Attitudes, barriers and enablers to dysphagia management among healthcare professionals: a mixed-methods systematic review protocol

Myriam Chircop Galea; Dr Dominika Lisiecka; Dr Helen Kelly

doi:10.12688/hrbopenres.14404.1

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Study Protocol

Attitudes, barriers and enablers to dysphagia management among healthcare professionals: a mixed-methods systematic review protocol

[version 1; peer review: 1 approved with reservations]

Myriam Chircop Galea ¹, Dr Dominika Lisiecka², Dr Helen Kelly¹

PUBLISHED 30 Apr 2026

Author details Author details

¹ School of Clinical Therapies, University College Cork, Cork, County Cork, Ireland
² Department of Nursing and Hearing Sciences, Munster Technological University, Tralee, Ireland

Myriam Chircop Galea
Roles: Conceptualization, Data Curation, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Dr Dominika Lisiecka
Roles: Supervision, Validation, Writing – Review & Editing

Dr Helen Kelly
Roles: Supervision, Validation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Introduction

Dysphagia (swallowing difficulty) is a complex condition associated with adverse clinical outcomes, including malnutrition, dehydration, aspiration pneumonia, prolonged hospitalisation and reduced quality of life. Effective dysphagia management requires person-centred, evidence-informed care delivered through coordinated multidisciplinary service models across acute, rehabilitation, long-term care, and community settings. Healthcare professionals (HCPs) play a central role in dysphagia service delivery. However, variability in training, resources, interprofessional collaboration, and organisational structures may influence care quality. A comprehensive synthesis of HCPs’ attitudes, and perceived barriers and enablers to dysphagia management is needed to inform workforce development and service improvement.

Methods

This mixed-methods systematic review will be conducted using the Joanna Briggs Institute (JBI) convergent integrated approach. Six bibliographic databases (PubMed, CINAHL, Embase, PsycINFO, Web of Science, and the Cochrane Library) will be searched for primary studies published between 1 January 2012 and 1 June 2025. Studies published in English, Maltese, Italian, French, and Polish will be eligible. Targeted organisational reports from the Royal College of Speech and Language Therapists (RCSLT), American Speech-Language-Hearing Association (ASHA), National Institute for Health and Care Excellence (NICE), World Health Organization (WHO), and European Society for Swallowing Disorders (ESSD) will also be searched. Two reviewers will independently screen, extract, and appraise studies. Methodological quality will be assessed using the Mixed Methods Appraisal Tool (MMAT). Quantitative data will be transformed into textual descriptions and integrated with qualitative findings to produce synthesised themes.

Discussion

This review will provide an integrated understanding of professional-level and system-level influences on dysphagia service delivery. Findings are expected to inform workforce education, interprofessional collaboration, organisational policy, and person-centred care frameworks in dysphagia management.

Registration

PROSPERO CRD42024567890.

Keywords

Dysphagia; healthcare professionals; service delivery; barriers; enablers; mixed-methods systematic review; JBI convergent integrated approach

Corresponding author: Myriam Chircop Galea

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2026 Chircop Galea M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Chircop Galea M, Lisiecka DD and Kelly DH. Attitudes, barriers and enablers to dysphagia management among healthcare professionals: a mixed-methods systematic review protocol [version 1; peer review: 1 approved with reservations]. HRB Open Res 2026, 9:43 (https://doi.org/10.12688/hrbopenres.14404.1) First published: 30 Apr 2026, 9:43 (https://doi.org/10.12688/hrbopenres.14404.1) Latest published: 30 Apr 2026, 9:43 (https://doi.org/10.12688/hrbopenres.14404.1)

Introduction

Dysphagia is a multifactorial clinical condition that significantly affects nutritional status, respiratory health, and overall wellbeing.¹ It may arise from neurological disorders (e.g., stroke, Parkinson’s disease, multiple sclerosis), structural abnormalities, head and neck cancer and its treatment, and age-related physiological changes. Dysphagia management typically spans screening and early identification,² comprehensive assessment,^3,4 implementation of compensatory and rehabilitative strategies,^5–7 medical and nutritional interventions,^8,9 and ongoing monitoring.

Service delivery models for dysphagia vary across healthcare systems^10–14 due to differences in workforce structures, professional scope of practice, infrastructure, and policy environments.¹⁵ Management commonly involves speech and language therapists (SLTs),¹⁶ nurses,¹⁷ physicians,¹⁸ dietitians,¹⁹ occupational therapists,²⁰ physiotherapists²¹ and pharmacists.²² Effective dysphagia care depends not only on clinical competence but also on adequate training, access to instrumental assessments, interdisciplinary communication, governance structures, and organisational resources. Furthermore, person-centred decision-making is essential, particularly where recommendations for example texture-modified diets²³ or thickened liquids, may influence autonomy, quality of life, and patient experience.²⁴

To enhance dysphagia care, it is essential to explore the perceptions and experiences of HCPs who work collaboratively to support individuals living with dysphagia.²⁵ Given the collaborative nature of dysphagia management, it is critical to recognise the contributions of all HCPs involved in patient care.²⁶ Gaining insight into these perspectives will help identify current practices, existing gaps in practice, improve multidisciplinary care and underscore the evolving role of SLTs in addressing dysphagia service delivery. Moreover, it can provide valuable information to inform strategies that can improve care quality and efficiency. The knowledge and perspectives of these professionals will offer a comprehensive understanding of the factors that influence service delivery, highlighting both shared and discipline-specific challenges.

Understanding HCPs attitudes, as well as perceived barriers and enablers to dysphagia management, is essential to strengthening service delivery.²⁵ Mixed-methods synthesis enables integration²⁷ of quantitative evidence describing patterns and prevalence with qualitative evidence that captures contextual and experiential dimensions. By synthesising current evidence, this review aims to identify modifiable workforce and system-level factors influencing dysphagia service delivery.²⁸

Review question

What are the attitudes, barriers, and enablers influencing dysphagia management and service delivery among healthcare professionals working with individuals with dysphagia?

Methods

Study reporting and registration

This protocol was developed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P)²⁹ statement. The completed PRISMA-P checklist and search strategies will be made available on OSF repository.

The systematic review is registered with PROSPERO (CRD42022323414). PROSPERO registration constitutes a registry record and does not represent publication or peer review.

Review design

A mixed-methods systematic review (MMSR) will be conducted using the Joanna Briggs Institute (JBI) convergent-integrated approach.²⁷ This approach is appropriate where the review question can be addressed by both qualitative and quantitative evidence and where integrated findings are required.

Eligibility criteria

Eligibility criteria were informed by the Population–Phenomenon of Interest–Context (PICo) framework.

Inclusion criteria

Studies will be included if they:

• Are primary research (quantitative, qualitative, or mixed-methods);
• Include HCPs involved in dysphagia management;
• Report HCPs’ attitudes, perceived barriers, and/or enablers related to dysphagia management or service delivery;
• Are published after 1 January 2012
• Are available in English, Maltese, Italian, French, or Polish.

The eligibility window was selected to ensure relevance to contemporary dysphagia service delivery models, evolving professional roles, and current healthcare systems.

Exclusion criteria

Studies will be excluded if they are:

• Reviews, overviews of reviews, editorials, letters, commentaries, or opinion pieces;
• Animal studies;
• Studies including only students;
• Studies focusing exclusively on patients or family caregivers without reporting HCP data;
• Studies not addressing attitudes, barriers, or enablers to dysphagia management.

Information sources and search strategy

The following databases will be searched:

• PubMed
• CINAHL
• Embase
• PsycINFO
• Web of Science
• Cochrane Library

Search strategies will combine controlled vocabulary and free-text terms related to dysphagia, healthcare professionals, attitudes, barriers, enablers, and service delivery.

In addition to bibliographic databases, targeted organisational reports will be searched to reduce publication bias and capture practice-relevant evidence. These will include resources and reports from:

• Royal College of Speech and Language Therapists (RCSLT)
• American Speech-Language-Hearing Association (ASHA)
• National Institute for Health and Care Excellence (NICE)
• World Health Organization (WHO)
• European Society for Swallowing Disorders (ESSD)

Reference lists of included studies will be screened for additional eligible records.

Study selection

All identified records will be imported into Rayyan³⁰ for screening. Two reviewers will independently screen titles and abstracts, followed by full-text screening. Disagreements will be resolved through discussion or consultation with a third reviewer. A PRISMA flow diagram will summarise the selection process.

Data extraction

A standardised extraction form will be developed and piloted. Extracted data will include:

• Study characteristics (author, year, country)
• Healthcare profession(s) and setting
• Study design and methods
• Sampling approach
• Key findings related to attitudes, barriers, and enablers
• Organisational and service delivery context

Data extraction will be conducted independently by two reviewers, with discrepancies resolved by consensus.

Risk of bias and quality assessment

Risk of bias and methodological quality will be assessed using the Mixed Methods Appraisal Tool (MMAT),³¹ which enables the appraisal of qualitative, quantitative, and mixed-methods studies. Appraisal will be conducted at the study level. Two reviewers will independently assess methodological quality, with disagreements resolved through discussion or consultation with a third reviewer where necessary.

Quality appraisal results will be presented in tables and summarised narratively. Studies will not be excluded based on methodological quality. However, risk of bias assessments will inform interpretation of findings and the strength of conclusions drawn from the integrated synthesis, consistent with the JBI convergent integrated approach.

Meta-Bias (es)

Potential meta-biases will be addressed through comprehensive search strategies across multiple databases and screening of reference lists of included studies. Grey literature will be considered where appropriate to reduce publication bias. Studies published in English, Maltese, Italian, French, and Polish will be included to minimise language bias. Selective reporting within studies will be considered as part of the methodological quality appraisal using the MMAT. Transparency in study selection and reporting will follow PRISMA guidance.

Data synthesis and integration

The review will follow the JBI convergent-integrated approach.³²

Qualitative findings will be synthesised using thematic synthesis.³³ Quantitative findings will be transformed into textual descriptions (“qualitised”) to enable integration with qualitative evidence.²⁷ Integrated themes will be generated through iterative coding and collaborative review among the research team.

Synthesised findings will be organised to reflect individual, team-level, organisational, and system-level influences on dysphagia service delivery where supported by the data.

Confidence in cumulative evidence

Confidence in the cumulative evidence will be assessed narratively, considering methodological quality (MMAT appraisal), consistency of findings across studies, and richness of qualitative and quantitative evidence contributing to each theme. Due to the mixed-methods design, formal grading approaches such as GRADE are not considered fully appropriate. Greater confidence will be attributed to findings supported by multiple studies of higher methodological quality and consistent evidence across study designs.

Amendments

Any protocol amendments will be documented and justified in the final review publication and updated in PROSPERO where applicable.

Discussion

This protocol describes a mixed-methods systematic review to synthesise HCPs attitudes, and perceived barriers and enablers to dysphagia management across care settings. The review will generate an integrated understanding of workforce, organisational, and system-level determinants influencing dysphagia service delivery, as well as contextual factors shaping implementation within healthcare environments. A distinctive contribution is the application of the JBI convergent-integrated approach to combine qualitative and quantitative evidence, enabling identification of multi-level influences and theoretically informed insights that may guide evidence-based service improvement and implementation strategies in dysphagia care.

Strengths and contributions

This review will provide the first comprehensive mixed-methods synthesis of HCPs attitudes, barriers, and enablers to dysphagia management across disciplines and care settings. Using the JBI convergent-integrated approach, it adopts a systems-oriented perspective to examine how individual, team, organisational, and structural factors influence dysphagia service delivery.

By integrating qualitative and quantitative evidence, the review will identify both the prevalence of reported determinants and the contextual mechanisms shaping practice. It recognises that dysphagia management is embedded within interconnected systems, including clinician knowledge and beliefs, interprofessional collaboration, organisational capacity, and broader policy environments.

Synthesising evidence across these levels will help identify priority targets for service improvement and inform theoretically grounded implementation strategies that are responsive to contextual variation across healthcare systems.

Implications for practice and policy

Findings from this review will extend beyond descriptive reporting of barriers and enablers to inform system service development. By mapping determinants across workforce, organisational, and structural domains, the review may support the design of implementation strategies that align with integrated care principles.

At the workforce level, findings may inform competency frameworks, targeted continuing professional development, and interprofessional education models that strengthen shared understanding of dysphagia risk management and person-centred decision-making.

At the organisational level, the review may identify modifiable structural factors, such as referral pathways, access to instrumental assessment, documentation standards, communication protocols, and governance mechanisms that influence service consistency and accountability.

At a policy level, findings may contribute to identifying enabling conditions for sustainable dysphagia service delivery, including protected clinical time, workforce planning, equitable resource distribution, and integration across acute and community care interfaces.

By situating dysphagia management within broader implementation and integrated care frameworks, the review may generate insights relevant to health system strengthening and quality improvement initiatives.

Future research

This synthesis will highlight key gaps in both theory and evidence. Future research may build on these findings by applying implementation science frameworks, such as the Consolidated Framework for Implementation Research (CFIR)³⁴ or the Theoretical Domains Framework (TDF),^35,36 to design and evaluate context-sensitive strategies aimed at strengthening dysphagia service delivery.

Subsequent studies may incorporate mixed-methods or prospective designs to examine the relationship between professional attitudes and measurable patient-level outcomes, including safety indicators, nutritional status, hospital utilisation, and patient-reported experience. Comparative international research may further clarify how contextual factors and underlying mechanisms interact to influence dysphagia management across different healthcare systems.

Conclusion

Dysphagia management is embedded within complex healthcare systems characterised by interprofessional interdependence, organisational constraints, and changing policy contexts. By synthesising healthcare professionals’ attitudes, barriers, and enablers through a theoretically informed mixed-methods approach, this review aims to generate actionable, system-sensitive insights that support implementation of consistent, person-centred, and equitable dysphagia service delivery.

Data availability statement

Underlying data

No datasets are associated with this article at this stage. Data generated during the systematic review, including extracted study data, screening decisions, methodological quality appraisal outcomes (MMAT), and data underpinning tables and figures, will be made openly available via OSF with the assigned DOI upon completion of the review, in accordance with F1000’s Open Data policy.

Extended data

Open Science Framework. Attitudes, Barriers and Enablers to Dysphagia Management: Systematic Review Protocol. DOI: https://doi.org/10.17605/OSF.IO/VB9U2.³⁷

• PRISMA-P checklist
• Search strategy

Data is available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

References

1. George RG, Jagtap M: Impact of Swallowing Impairment on Quality of Life of Individuals with Dysphagia. Indian J Otolaryngol Head Neck Surg Off Publ Assoc Otolaryngol India. 2022 Dec; 74(Suppl 3): 5473–5477. PubMed Abstract | Publisher Full Text | Free Full Text
2. Brodsky MB, Suiter DM, González-Fernández M, et al.: Screening Accuracy for Aspiration Using Bedside Water Swallow Tests: A Systematic Review and Meta-Analysis. Chest. 2016 Jul; 150(1): 148–163. PubMed Abstract | Publisher Full Text | Free Full Text
3. Lim S, Lee N, Zakeri K, et al.: Can the Risk of Dysphagia in Head and Neck Radiation Therapy Be Predicted by an Automated Transit Fluence Monitoring Process During Treatment? A First Comparative Study of Patient Reported Quality of Life and the Fluence-Based Decision Support Metric. Technol. Cancer Res. Treat. 2021 Jun 30; 20. Located at: WOS:000688069400001. Publisher Full Text
4. Warnecke T, Labeit B, Schroeder J, et al.: Neurogenic Dysphagia. Neurology. 2021 Feb 9; 96(6): e876–e889. Publisher Full Text
5. Chung SJ, Lee JH, Soh Y: Compensatory strategies of dysphagia after anterior cervical spinal surgery: A case report. Medicine (Baltimore). 2024 Jul 19; 103(29): e39016. PubMed Abstract | Publisher Full Text | Free Full Text
6. Schindler A, Pizzorni N, Cereda E, et al.: Consensus on the treatment of dysphagia in Parkinson’s disease. J. Neurol. Sci. 2021 Nov 15; 430. Located at: WOS:000708680400009. Publisher Full Text
7. Simning I, Simning A: Severe Idiopathic Dysphagia in an Acute Hospital Setting: Assessment, Management, and Outcome. J Med Speech-Lang Pathol. 2013 Sep; 21(3): 3. PubMed Abstract | Free Full Text
8. Ito H, Nagao A, Maeda S, et al.: Clinical Significance of Surgical Intervention to Restore Swallowing Function for Sustained Severe Dysphagia. J. Clin. Med. 2023 Aug 26; 12(17): 5555. PubMed Abstract | Publisher Full Text | Free Full Text
9. Manabe T, Masaki Y, Yamamoto Y, et al.: Association of Nutritional Support with Survival Time in Hospitalized Older Patients with Dysphagia: A Retrospective Study. Ann. Nutr. Metab. 2022; 78(5): 281–286. PubMed Abstract | Publisher Full Text
10. Chang YW, Chang YJ: The relationship between oral feeding and cardiorespiratory regulation of premature infants. Hu Li Za Zhi. 2008 Jun; 55(3): 5–10. PubMed Abstract
11. Estupiñán Artiles C, Regan J, Donnellan C: Dysphagia screening in residential care settings: A scoping review. Int. J. Nurs. Stud. 2021 Feb; 114: 103813. PubMed Abstract | Publisher Full Text
12. Jayes M, Palmer R, Enderby P: Giving voice to people with communication disabilities during mental capacity assessments. Int. J. Lang. Commun. Disord. 2021 Jan; 56(1): 90–101. PubMed Abstract | Publisher Full Text
13. Speyer R, Sandbekkbråten A, Rosseland I, et al.: Dysphagia Care and Management in Rehabilitation: A National Survey. J. Clin. Med. 2022 Sep 27; 11(19): 5730. PubMed Abstract | Publisher Full Text | Free Full Text
14. Ward EC, Raatz M, Marshall J, et al.: Telepractice and Dysphagia Management: The Era of COVID-19 and Beyond. Dysphagia. 2022 Dec 1; 37(6): 1386–1399. Publisher Full Text
15. Rajati F, Ahmadi N, Naghibzadeh ZA s, et al.: The global prevalence of oropharyngeal dysphagia in different populations: a systematic review and meta-analysis. J. Transl. Med. 2022 Apr 11; 20: 175. PubMed Abstract | Publisher Full Text | Free Full Text
16. Clark S, Ebersole B: Understanding the role of speech language pathologists in managing dysphagia. Nursing Lond. 2018 Dec; 48(12): 42–46. PubMed Abstract | Publisher Full Text
17. Donovan NJ, Daniels S, Edmiaston J, et al.: Dysphagia Screening: State of the Art: Invitational Conference Proceeding From the State-of-the-Art Nursing Symposium, International Stroke Conference 2012.2012 [cited 2025 Mar 24]. Dysphagia Screening: State of the Art|Stroke. Publisher Full Text
18. Bakhtiyari J, Ghorbani R, Salmani M, et al.: Physicians’ Perspective on a Multidisciplinary Approach to Dysphagia Management. Iran J Otorhinolaryngol. 2019 May; 31(104): 141–146. PubMed Abstract | Free Full Text
19. Dietitians Of Canada null: Defining the Role of the Dietitian in Dysphagia Assessment and Management. Can J Diet Pract Res Publ Dietit Can Rev Can Prat Rech En Diet Une Publ Diet Can. 2015 Jun; 76(2): 100. PubMed Abstract | Publisher Full Text
20. Holmgren N, Hatlevig J: Dysphagia management and OT’s role: A unique perspective|AOTA.June 2023 2023 [cited 2025 Mar 24]; 28(6): Pp. 18–21. Reference Source
21. Kalimkhan A, Singhvi H, Heroor A: J Head Neck Physicians Surg. 2022 Jun 28; 10: 61–67. 5085 111910.
22. Blaszczyk A, Brandt N, Ashley J, et al.: Crushed Tablet Administration for Patients with Dysphagia and Enteral Feeding: Challenges and Considerations. Drugs Aging. 2023 Oct; 40(10): 895–907. PubMed Abstract | Publisher Full Text | Free Full Text
23. Hadde EK, Chen J: Texture and texture assessment of thickened fluids and texture-modified food for dysphagia management. J. Texture Stud. 2021; 52(1): 4–15. PubMed Abstract | Publisher Full Text
24. Yee J, Musson N, Rogus-Pulia N: Multisite Implementation of the VA Intensive Dysphagia Treatment Program. Arch. Phys. Med. Rehabil. 2021; 102(10): e17. Located at: Embase. Publisher Full Text
25. Nakamori M, Ortega Fernandez O, Kayashita J, et al.: Editorial: New approaches to evaluation and management of dysphagia in neurological disease. Front. Neurol. 2024; Vol. 15: 15. Publisher Full Text
26. Groher M: The Historical role of the SLP in dysphagia management. The Historical Role of SLPs in dysphagia.2016 Sep 1 [cited 2025 Mar 25]. Reference Source
27. Stern C, Lizarondo L, Carrier J, et al.: Methodological guidance for the conduct of mixed methods systematic reviews. JBI Evid Synth. 2020 Oct; 18(10): 2108–2118. Publisher Full Text
28. Higgins I, Parker V, Keatinge D, et al.: Doing clinical research: the challenges and benefits. Contemp. Nurse. 2010 Jun; 35(2): 171–181. PubMed Abstract | Publisher Full Text
29. Page MJ, McKenzie JE, Bossuyt PM, et al.: The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29; 372: n71. PubMed Abstract | Publisher Full Text | Free Full Text
30. Ouzzani M, Hammady H, Fedorowicz Z, et al.: Rayyan-a web and mobile app for systematic reviews. Syst. Rev. 2016 Dec; 5(1): 210. Free Full Text Publisher Full Text | Free Full Text
31. Hong QN, Pluye P, Fàbregues S, et al.: Improving the content validity of the mixed methods appraisal tool: a modified e-Delphi study. J. Clin. Epidemiol. 2019 Jul 1; 111: 49–59.e1. Publisher Full Text
32. Lizarondo L, Stern C, Carrier J, et al.: Mixed methods systematic reviews.Aromataris E, Lockwood C, Porritt K, et al., editors. JBI Manual for Evidence Synthesis. JBI; 2024 [cited 2025 Mar 24]. Publisher Full Text Reference Source
33. Thomas J, Harden A: Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med. Res. Methodol. 2008 Jul 10; 8(1): 45. Publisher Full Text
34. Damschroder LJ, Reardon CM, Widerquist MAO, et al.: The updated Consolidated Framework for Implementation Research based on user feedback. Implement. Sci. 2022 Oct 29; 17(1): 75. PubMed Abstract | Publisher Full Text | Free Full Text
35. Cane J, O’Connor D, Michie S: Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement. Sci. 2012 Apr 24; 7: 37. PubMed Abstract | Publisher Full Text | Free Full Text
36. Michie S, Johnston M, Abraham C, et al.: Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Healthc. 2005 Feb; 14(1): 26–33. PubMed Abstract | Publisher Full Text | Free Full Text
37. Chircop Galea M: Search strategy and data extraction template for: Attitudes, barriers and enablers to dysphagia management among healthcare professionals: a mixed methods systematic review protocol. Open Science Framework. 2026. Publisher Full Text

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Version 1

VERSION 1 PUBLISHED 30 Apr 2026

Author details Author details

¹ School of Clinical Therapies, University College Cork, Cork, County Cork, Ireland
² Department of Nursing and Hearing Sciences, Munster Technological University, Tralee, Ireland

Myriam Chircop Galea
Roles: Conceptualization, Data Curation, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Dr Dominika Lisiecka
Roles: Supervision, Validation, Writing – Review & Editing

Dr Helen Kelly
Roles: Supervision, Validation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (1)

version 1

Published: 30 Apr 2026, 9:43

https://doi.org/10.12688/hrbopenres.14404.1

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© 2026 Chircop Galea M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Chircop Galea M, Lisiecka DD and Kelly DH. Attitudes, barriers and enablers to dysphagia management among healthcare professionals: a mixed-methods systematic review protocol [version 1; peer review: 1 approved with reservations]. HRB Open Res 2026, 9:43 (https://doi.org/10.12688/hrbopenres.14404.1)

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Reviewer Report 29 May 2026

Cornelius J. Werner, RWTH Aachen University, Aachen, North Rhine-Westphalia, Germany

Approved with Reservations

https://doi.org/10.21956/hrbopenres.15867.r55517

Summary
This manuscript is a protocol for a mixed-methods systematic review examining the attitudes, perceived barriers, and enablers to dysphagia management among healthcare professionals across acute, rehabilitation, long-term care, and community settings. The review will follow the JBI convergent-integrated ... Continue reading

Summary
This manuscript is a protocol for a mixed-methods systematic review examining the attitudes, perceived barriers, and enablers to dysphagia management among healthcare professionals across acute, rehabilitation, long-term care, and community settings. The review will follow the JBI convergent-integrated approach, searching six bibliographic databases and five targeted organisational sources for primary studies published from January 2012 onward in five languages. Dual independent screening, extraction, and MMAT-based quality appraisal are planned, with quantitative findings qualitised and integrated with qualitative evidence through thematic synthesis. The protocol is PRISMA-P compliant and prospectively registered on PROSPERO, with extended materials deposited on OSF. As this is a protocol, no datasets are yet associated with the article.

Rationale and objectives
The rationale is clearly and adequately developed. The clinical and organisational importance of dysphagia is well established, the multidisciplinary nature of service delivery is appropriately motivated, and the gap addressed (an absence of integrated cross-disciplinary synthesis of professional-level and system-level determinants) is plausible and clearly stated. The review question is explicit and properly scoped using the PICo framework. No revision is required here.

Study design
The design is appropriate to the question. A mixed-methods systematic review is well matched to a question that spans measurable patterns (prevalence of reported barriers) and contextual, experiential dimensions, and the JBI convergent-integrated approach is a defensible and recognised framework for this purpose. The decision not to apply GRADE, with narrative confidence assessment in its place, is reasonable for an integrated mixed-methods synthesis and is justified in the text. No revision is required here.

Sufficiency of methods for replication
Several elements are specified to a replicable standard: databases, the publication window, eligibility criteria, the screening and adjudication workflow, the appraisal instrument, and the synthesis approach. However, the methods fall short of full replicability in specific, correctable ways, which is the basis for a "Partly" rating.

The following points should be addressed:

The full search strategy is not presented in the manuscript and is deferred to OSF. At least one fully reproduced database strategy, with controlled vocabulary, free-text terms, Boolean structure, and any filters, should be included in the protocol or its appendix so that the search can be appraised and reproduced as published.
The search window is reported inconsistently. The abstract specifies a closed window ending 1 June 2025, whereas the inclusion criteria state only "published after 1 January 2012" with no upper bound. The authors should reconcile these and state the intended search execution date and any date limits applied.
The qualitisation procedure is under-specified. The protocol commits to transforming quantitative findings into textual descriptions but does not state how quantitative magnitude (for example, the proportion of respondents endorsing a given barrier) will be preserved during this conversion. A brief description of how effect direction and magnitude will be retained rather than flattened into thematic prose would materially improve reproducibility.
The mechanism by which MMAT appraisal modulates confidence is not operationalised. Studies will be appraised but not excluded, and confidence is assessed narratively; the authors should specify concretely how methodological quality will influence the weight given to a finding, beyond the general statement that greater confidence attaches to higher-quality, consistent evidence.
No inter-rater agreement metric is pre-specified. For a review whose principal output is interpretive coding, a planned reliability measure for screening (for example, a calibration exercise and a reported agreement statistic) should be stated.

Datasets
This item is rated Not applicable. The manuscript is a protocol and correctly states that no datasets are yet associated with the article. The data availability statement appropriately commits to depositing extracted data, screening decisions, and appraisal outcomes on OSF on completion, consistent with the journal's open data policy. The extended data (PRISMA-P checklist, search strategy) are deposited under a clear licence.

Additional points the authors should address
A registration metadata error must be corrected. The abstract metadata reports PROSPERO CRD42024567890, which is incorrect; that number is associated in the published literature with an unrelated review. The authentic registration, confirmed in the Methods text and via the OSF deposit, is CRD42022323414. The metadata field must be corrected so that the abstract, body, PROSPERO, and OSF are mutually consistent.
The Discussion, Implications, and Future research sections are disproportionately long and assertive for a protocol and at times read as conclusions of a completed review. Claims regarding the review's capacity to inform competency frameworks, referral pathways, protected clinical time, and health system strengthening presuppose findings that do not yet exist. These should be reframed in conditional terms, and a brief explicit limitations subsection should be added, acknowledging the constraints of qualitisation, the non-weighting of low-quality studies, and the likely predominance of English-language evidence.
Minor: the reference list should be audited. Reference 10 (premature-infant cardiorespiratory regulation, 2008) is off-topic for a review of HCP attitudes and predates the stated eligibility window; reference 21 is incompletely formatted. The 2012 lower bound would also benefit from an explicit justification.

Points that must be addressed to make the article scientifically sound
Correct the PROSPERO number in the abstract metadata to the single valid registration. Reconcile the search-window end date between the abstract and the inclusion criteria. Provide at least one full database search strategy. Specify how quantitative magnitude is preserved during qualitisation and how MMAT appraisal concretely modulates confidence in synthesised findings. The remaining points (inter-rater reliability, tempering of the discussion, reference audit) are important for quality but are not prerequisites for scientific soundness.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: neurogenic dysphagia, frailty, aphasia

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Cornelius J. Werner, RWTH Aachen University, Aachen, Germany

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Reviewer Report

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29 May 2026 | for Version 1

Cornelius J. Werner, RWTH Aachen University, Aachen, North Rhine-Westphalia, Germany

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Approved With Reservations

Summary
This manuscript is a protocol for a mixed-methods systematic review examining the attitudes, perceived barriers, and enablers to dysphagia management among healthcare professionals across acute, rehabilitation, long-term care, and community settings. The review will follow the JBI convergent-integrated approach, searching six bibliographic databases and five targeted organisational sources for primary studies published from January 2012 onward in five languages. Dual independent screening, extraction, and MMAT-based quality appraisal are planned, with quantitative findings qualitised and integrated with qualitative evidence through thematic synthesis. The protocol is PRISMA-P compliant and prospectively registered on PROSPERO, with extended materials deposited on OSF. As this is a protocol, no datasets are yet associated with the article.

Rationale and objectives
The rationale is clearly and adequately developed. The clinical and organisational importance of dysphagia is well established, the multidisciplinary nature of service delivery is appropriately motivated, and the gap addressed (an absence of integrated cross-disciplinary synthesis of professional-level and system-level determinants) is plausible and clearly stated. The review question is explicit and properly scoped using the PICo framework. No revision is required here.

Study design
The design is appropriate to the question. A mixed-methods systematic review is well matched to a question that spans measurable patterns (prevalence of reported barriers) and contextual, experiential dimensions, and the JBI convergent-integrated approach is a defensible and recognised framework for this purpose. The decision not to apply GRADE, with narrative confidence assessment in its place, is reasonable for an integrated mixed-methods synthesis and is justified in the text. No revision is required here.

Sufficiency of methods for replication
Several elements are specified to a replicable standard: databases, the publication window, eligibility criteria, the screening and adjudication workflow, the appraisal instrument, and the synthesis approach. However, the methods fall short of full replicability in specific, correctable ways, which is the basis for a "Partly" rating.

The following points should be addressed:

The full search strategy is not presented in the manuscript and is deferred to OSF. At least one fully reproduced database strategy, with controlled vocabulary, free-text terms, Boolean structure, and any filters, should be included in the protocol or its appendix so that the search can be appraised and reproduced as published.
The search window is reported inconsistently. The abstract specifies a closed window ending 1 June 2025, whereas the inclusion criteria state only "published after 1 January 2012" with no upper bound. The authors should reconcile these and state the intended search execution date and any date limits applied.
The qualitisation procedure is under-specified. The protocol commits to transforming quantitative findings into textual descriptions but does not state how quantitative magnitude (for example, the proportion of respondents endorsing a given barrier) will be preserved during this conversion. A brief description of how effect direction and magnitude will be retained rather than flattened into thematic prose would materially improve reproducibility.
The mechanism by which MMAT appraisal modulates confidence is not operationalised. Studies will be appraised but not excluded, and confidence is assessed narratively; the authors should specify concretely how methodological quality will influence the weight given to a finding, beyond the general statement that greater confidence attaches to higher-quality, consistent evidence.
No inter-rater agreement metric is pre-specified. For a review whose principal output is interpretive coding, a planned reliability measure for screening (for example, a calibration exercise and a reported agreement statistic) should be stated.

Datasets
This item is rated Not applicable. The manuscript is a protocol and correctly states that no datasets are yet associated with the article. The data availability statement appropriately commits to depositing extracted data, screening decisions, and appraisal outcomes on OSF on completion, consistent with the journal's open data policy. The extended data (PRISMA-P checklist, search strategy) are deposited under a clear licence.

Additional points the authors should address
A registration metadata error must be corrected. The abstract metadata reports PROSPERO CRD42024567890, which is incorrect; that number is associated in the published literature with an unrelated review. The authentic registration, confirmed in the Methods text and via the OSF deposit, is CRD42022323414. The metadata field must be corrected so that the abstract, body, PROSPERO, and OSF are mutually consistent.
The Discussion, Implications, and Future research sections are disproportionately long and assertive for a protocol and at times read as conclusions of a completed review. Claims regarding the review's capacity to inform competency frameworks, referral pathways, protected clinical time, and health system strengthening presuppose findings that do not yet exist. These should be reframed in conditional terms, and a brief explicit limitations subsection should be added, acknowledging the constraints of qualitisation, the non-weighting of low-quality studies, and the likely predominance of English-language evidence.
Minor: the reference list should be audited. Reference 10 (premature-infant cardiorespiratory regulation, 2008) is off-topic for a review of HCP attitudes and predates the stated eligibility window; reference 21 is incompletely formatted. The 2012 lower bound would also benefit from an explicit justification.

Points that must be addressed to make the article scientifically sound
Correct the PROSPERO number in the abstract metadata to the single valid registration. Reconcile the search-window end date between the abstract and the inclusion criteria. Provide at least one full database search strategy. Specify how quantitative magnitude is preserved during qualitisation and how MMAT appraisal concretely modulates confidence in synthesised findings. The remaining points (inter-rater reliability, tempering of the discussion, reference audit) are important for quality but are not prerequisites for scientific soundness.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

neurogenic dysphagia, frailty, aphasia

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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[1] 1. George RG, Jagtap M: Impact of Swallowing Impairment on Quality of Life of Individuals with Dysphagia. Indian J Otolaryngol Head Neck Surg Off Publ Assoc Otolaryngol India. 2022 Dec; 74(Suppl 3): 5473–5477. PubMed Abstract | Publisher Full Text | Free Full Text

[2] 2. Brodsky MB, Suiter DM, González-Fernández M, et al.: Screening Accuracy for Aspiration Using Bedside Water Swallow Tests: A Systematic Review and Meta-Analysis. Chest. 2016 Jul; 150(1): 148–163. PubMed Abstract | Publisher Full Text | Free Full Text

[3] 3. Lim S, Lee N, Zakeri K, et al.: Can the Risk of Dysphagia in Head and Neck Radiation Therapy Be Predicted by an Automated Transit Fluence Monitoring Process During Treatment? A First Comparative Study of Patient Reported Quality of Life and the Fluence-Based Decision Support Metric. Technol. Cancer Res. Treat. 2021 Jun 30; 20. Located at: WOS:000688069400001. Publisher Full Text

[4] 4. Warnecke T, Labeit B, Schroeder J, et al.: Neurogenic Dysphagia. Neurology. 2021 Feb 9; 96(6): e876–e889. Publisher Full Text

[5] 5. Chung SJ, Lee JH, Soh Y: Compensatory strategies of dysphagia after anterior cervical spinal surgery: A case report. Medicine (Baltimore). 2024 Jul 19; 103(29): e39016. PubMed Abstract | Publisher Full Text | Free Full Text

[6] 6. Schindler A, Pizzorni N, Cereda E, et al.: Consensus on the treatment of dysphagia in Parkinson’s disease. J. Neurol. Sci. 2021 Nov 15; 430. Located at: WOS:000708680400009. Publisher Full Text

[7] 7. Simning I, Simning A: Severe Idiopathic Dysphagia in an Acute Hospital Setting: Assessment, Management, and Outcome. J Med Speech-Lang Pathol. 2013 Sep; 21(3): 3. PubMed Abstract | Free Full Text

[8] 8. Ito H, Nagao A, Maeda S, et al.: Clinical Significance of Surgical Intervention to Restore Swallowing Function for Sustained Severe Dysphagia. J. Clin. Med. 2023 Aug 26; 12(17): 5555. PubMed Abstract | Publisher Full Text | Free Full Text

[9] 9. Manabe T, Masaki Y, Yamamoto Y, et al.: Association of Nutritional Support with Survival Time in Hospitalized Older Patients with Dysphagia: A Retrospective Study. Ann. Nutr. Metab. 2022; 78(5): 281–286. PubMed Abstract | Publisher Full Text

[10] 10. Chang YW, Chang YJ: The relationship between oral feeding and cardiorespiratory regulation of premature infants. Hu Li Za Zhi. 2008 Jun; 55(3): 5–10. PubMed Abstract

[11] 11. Estupiñán Artiles C, Regan J, Donnellan C: Dysphagia screening in residential care settings: A scoping review. Int. J. Nurs. Stud. 2021 Feb; 114: 103813. PubMed Abstract | Publisher Full Text

[12] 12. Jayes M, Palmer R, Enderby P: Giving voice to people with communication disabilities during mental capacity assessments. Int. J. Lang. Commun. Disord. 2021 Jan; 56(1): 90–101. PubMed Abstract | Publisher Full Text

[13] 13. Speyer R, Sandbekkbråten A, Rosseland I, et al.: Dysphagia Care and Management in Rehabilitation: A National Survey. J. Clin. Med. 2022 Sep 27; 11(19): 5730. PubMed Abstract | Publisher Full Text | Free Full Text

[14] 14. Ward EC, Raatz M, Marshall J, et al.: Telepractice and Dysphagia Management: The Era of COVID-19 and Beyond. Dysphagia. 2022 Dec 1; 37(6): 1386–1399. Publisher Full Text

[15] 15. Rajati F, Ahmadi N, Naghibzadeh ZA s, et al.: The global prevalence of oropharyngeal dysphagia in different populations: a systematic review and meta-analysis. J. Transl. Med. 2022 Apr 11; 20: 175. PubMed Abstract | Publisher Full Text | Free Full Text

[16] 16. Clark S, Ebersole B: Understanding the role of speech language pathologists in managing dysphagia. Nursing Lond. 2018 Dec; 48(12): 42–46. PubMed Abstract | Publisher Full Text

[17] 17. Donovan NJ, Daniels S, Edmiaston J, et al.: Dysphagia Screening: State of the Art: Invitational Conference Proceeding From the State-of-the-Art Nursing Symposium, International Stroke Conference 2012.2012 [cited 2025 Mar 24]. Dysphagia Screening: State of the Art|Stroke. Publisher Full Text

[18] 18. Bakhtiyari J, Ghorbani R, Salmani M, et al.: Physicians’ Perspective on a Multidisciplinary Approach to Dysphagia Management. Iran J Otorhinolaryngol. 2019 May; 31(104): 141–146. PubMed Abstract | Free Full Text

[19] 19. Dietitians Of Canada null: Defining the Role of the Dietitian in Dysphagia Assessment and Management. Can J Diet Pract Res Publ Dietit Can Rev Can Prat Rech En Diet Une Publ Diet Can. 2015 Jun; 76(2): 100. PubMed Abstract | Publisher Full Text

[20] 20. Holmgren N, Hatlevig J: Dysphagia management and OT’s role: A unique perspective|AOTA.June 2023 2023 [cited 2025 Mar 24]; 28(6): Pp. 18–21. Reference Source

[21] 21. Kalimkhan A, Singhvi H, Heroor A: J Head Neck Physicians Surg. 2022 Jun 28; 10: 61–67. 5085 111910.

[22] 22. Blaszczyk A, Brandt N, Ashley J, et al.: Crushed Tablet Administration for Patients with Dysphagia and Enteral Feeding: Challenges and Considerations. Drugs Aging. 2023 Oct; 40(10): 895–907. PubMed Abstract | Publisher Full Text | Free Full Text

[23] 23. Hadde EK, Chen J: Texture and texture assessment of thickened fluids and texture-modified food for dysphagia management. J. Texture Stud. 2021; 52(1): 4–15. PubMed Abstract | Publisher Full Text

[24] 24. Yee J, Musson N, Rogus-Pulia N: Multisite Implementation of the VA Intensive Dysphagia Treatment Program. Arch. Phys. Med. Rehabil. 2021; 102(10): e17. Located at: Embase. Publisher Full Text

[25] 25. Nakamori M, Ortega Fernandez O, Kayashita J, et al.: Editorial: New approaches to evaluation and management of dysphagia in neurological disease. Front. Neurol. 2024; Vol. 15: 15. Publisher Full Text

[26] 26. Groher M: The Historical role of the SLP in dysphagia management. The Historical Role of SLPs in dysphagia.2016 Sep 1 [cited 2025 Mar 25]. Reference Source

[27] 27. Stern C, Lizarondo L, Carrier J, et al.: Methodological guidance for the conduct of mixed methods systematic reviews. JBI Evid Synth. 2020 Oct; 18(10): 2108–2118. Publisher Full Text

[28] 28. Higgins I, Parker V, Keatinge D, et al.: Doing clinical research: the challenges and benefits. Contemp. Nurse. 2010 Jun; 35(2): 171–181. PubMed Abstract | Publisher Full Text

[29] 29. Page MJ, McKenzie JE, Bossuyt PM, et al.: The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29; 372: n71. PubMed Abstract | Publisher Full Text | Free Full Text

[30] 30. Ouzzani M, Hammady H, Fedorowicz Z, et al.: Rayyan-a web and mobile app for systematic reviews. Syst. Rev. 2016 Dec; 5(1): 210. Free Full Text Publisher Full Text | Free Full Text

[31] 31. Hong QN, Pluye P, Fàbregues S, et al.: Improving the content validity of the mixed methods appraisal tool: a modified e-Delphi study. J. Clin. Epidemiol. 2019 Jul 1; 111: 49–59.e1. Publisher Full Text

[32] 32. Lizarondo L, Stern C, Carrier J, et al.: Mixed methods systematic reviews.Aromataris E, Lockwood C, Porritt K, et al., editors. JBI Manual for Evidence Synthesis. JBI; 2024 [cited 2025 Mar 24]. Publisher Full Text Reference Source

[33] 33. Thomas J, Harden A: Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med. Res. Methodol. 2008 Jul 10; 8(1): 45. Publisher Full Text

[34] 34. Damschroder LJ, Reardon CM, Widerquist MAO, et al.: The updated Consolidated Framework for Implementation Research based on user feedback. Implement. Sci. 2022 Oct 29; 17(1): 75. PubMed Abstract | Publisher Full Text | Free Full Text

[35] 35. Cane J, O’Connor D, Michie S: Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement. Sci. 2012 Apr 24; 7: 37. PubMed Abstract | Publisher Full Text | Free Full Text

[36] 36. Michie S, Johnston M, Abraham C, et al.: Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Healthc. 2005 Feb; 14(1): 26–33. PubMed Abstract | Publisher Full Text | Free Full Text

[37] 37. Chircop Galea M: Search strategy and data extraction template for: Attitudes, barriers and enablers to dysphagia management among healthcare professionals: a mixed methods systematic review protocol. Open Science Framework. 2026. Publisher Full Text

Attitudes, barriers and enablers to dysphagia management among healthcare professionals: a mixed-methods systematic review protocol

Abstract

Introduction

Methods

Discussion

Keywords

Introduction

Review question

Methods

Study reporting and registration

Review design

Eligibility criteria

Inclusion criteria

Exclusion criteria

Information sources and search strategy

Study selection

Data extraction

Risk of bias and quality assessment

Meta-Bias (es)

Data synthesis and integration

Confidence in cumulative evidence

Amendments

Discussion

Strengths and contributions

Implications for practice and policy

Future research

Conclusion

Data availability statement

Underlying data

Extended data

References

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Attitudes, barriers and enablers to dysphagia management among healthcare professionals: a mixed-methods systematic review protocol

Abstract

Introduction

Methods

Discussion

Keywords

Introduction

Review question

Methods

Study reporting and registration

Review design

Eligibility criteria

Inclusion criteria

Exclusion criteria

Information sources and search strategy

Study selection

Data extraction

Risk of bias and quality assessment

Meta-Bias (es)

Data synthesis and integration

Confidence in cumulative evidence

Amendments

Discussion

Strengths and contributions

Implications for practice and policy

Future research

Conclusion

Data availability statement

Underlying data

Extended data

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

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Reviewer Reports

Comments on this article

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