Optimising contextual factors in the practitioner-patient encounter in the management of osteoarthritis

Ismail, Ayah (2023) Optimising contextual factors in the practitioner-patient encounter in the management of osteoarthritis. PhD thesis, University of Nottingham.

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Contextual factors (CFs) related to the patient, healthcare practitioners, and their therapeutic relationship are integral to the overall treatment effect of any given intervention. In osteoarthritis (OA), around 75% of the treatment effect is directly attributable to CFs. Identifying and understanding the role of CFs may encourage healthcare practitioners to develop and enhance the contextual aspects of care, and thus enhance the overall treatment benefit.


The overall aim of this research project is to develop a contextual enhancement package (CEP) that can be used to optimise the management of OA. To achieve this aim, the studies in this thesis aimed to realise the following objectives: [1] to identify and evaluate the current evidence for modifiable CFs that can improve clinical outcomes using quantitative systematic review and meta-analysis of randomised controlled trials (RCTs); [2] to explore and understand the experience and perspectives of patients and health practitioners about contextual enhancers in consultations for OA using qualitative systematic review and meta-aggregation; and [3] to obtain views and perspectives from clinicians, researchers, and public and patients on the identified CFs using an online survey and Public and Patient Involvement and Evaluation (PPI/E) meetings.


Quantitative systematic review: A systematic search was carried out, up until April 18th, 2019, on the following databases: MEDLINE via Ovid, EMBASE, AMED, PsycINFO and Cochrane library. RCTs comparing contextual enhanced interventions versus non-enhanced control in adults for any health conditions were searched. The outcomes included both self-reported outcomes and objectively measured outcomes. The effect size and 95% confidence interval were calculated using the standardised mean difference. Risk of bias was evaluated using the modified Cochrane tool. The random effects model was used to pool the results. The GRADE approach was used to assess the confidence in the body of evidence for each outcome assessed.

Qualitative systematic review: A systematic search was conducted between March 15 and May 18, 2020, on the following databases: MEDLINE via Ovid, EMBASE, AMED, PsycINFO and CINAHL. The search for unpublished studies included ProQuest Dissertations and Google Scholar. The search was not limited to any language or publication year. The Joanna Briggs Institute (JBI) methodology for quality assessment, study selection, data extraction and synthesis were used. Findings were assessed for credibility, categorised based on similarity in meaning and subjected to a meta-aggregation. The ConQual approach was used to assess the confidence of the synthesised findings.

Stakeholders’ involvement: An online survey was conducted using Microsoft Forms software. The responses to the survey were collected between September 20 and October 15, 2021. Results were tabulated and analysed utilising Microsoft Excel. The study sought anonymous stakeholders’ ratings and opinions. The survey involved a Likert scale question to rate the importance of each of the eight contextual factors identified in this project and an optional open-ended question about additional contextual factors related to practitioner-patient interaction that need to be considered.

PPI/E meetings: The PPI/E process in this research project took two forms of involvement. In the early stages of the project, in November 2019, the in-person PPI/E meeting aimed to consider the relevance of the research topic to the public and patients. The meeting communicated the research information (i.e., research question and topic) to patients with OA. Whereas, at the later stage of the research, in September 2021, patients exchanged information and participated by providing their opinion and input on the research outcomes in the online meeting.


Quantitative systematic review: Of 3928 records generated from the systematic search, 25 trials (5632 participants) met the inclusion criteria, and 20 were included in this meta-analysis. Conditions studied included musculoskeletal [6], cardiovascular [3], asthma [2], irritable bowel syndrome [1], diabetes [1], chronic pain [1], acute pain [3], gynaecological conditions requiring day-care surgery [1], postoperative nausea [1], and in GP or hospital-based patients [6]. Three CFs were identified from these trials: empathy, patient involvement and positive communication. All were found to be effective for patient experience (i.e., satisfaction) (SMD 0.34; 95% CI 0.27, 0.42). Positive communication was also effective for symptoms (SMD 0.17, 95%CI 0.06, 0.28) but not objective outcomes (SMD 0.10, 95%CI -0.14, 0.34). According to the GRADE guidelines for assessing confidence in the findings of systematic reviews of interventions, the certainty of the evidence was rated low for symptoms and objective outcomes and very low for patient experience outcomes.

Qualitative systematic review: Of 1808 records generated from the systematic search of databases and grey literature, eight studies were included in the meta-aggregation. All included papers were moderate to high quality based on the JBI qualitative critical appraisal tool. Meta-aggregation generated three synthesised findings. According to the ConQual criteria for assessing confidence in qualitative review findings, all the synthesised findings' level of evidence was rated as moderate. The key, potentially modifiable, factors identified were empathy and positive communication; clear and relevant information provided by the health practitioner; patient expectation concerning their outcome and the consultation experience; active involvement of the patient in the consultation; sufficient consultation time; easy access to consultations; and health providers confidence.

Stakeholder’s involvement: Fifty healthcare providers from various professions and four patients with OA responded to the online survey. The healthcare providers’ professions included physicians, physiotherapists, health researchers, and podiatrist. All the respondents answered the Likert scale question, and 39 answered the optional open-ended question. The stakeholders’ importance rating for each of the eight contextual factors identified from the quantitative and qualitative systematic reviews was high. Healthcare providers and patients with OA considered all factors essential and expanded their responses about how important these factors are in the open-ended question.

PPI/E meetings: The first meeting confirmed the importance and relevance of the research topic to a group of OA patients. Also, the PPI suggested some CFs (i.e., regular follow-up and referral) that were considered later in developing the search strategy for the qualitative systematic review. The second meeting obtained the PPI inputs on the CFs identified from previous reviews in the research project. The PPI/E supported the delivery of all the factors and suggested tailoring the factors to patient needs.


Eight contextual factors have been identified according to their therapeutic effects, clinical importance and stakeholders’ perspectives. They are ready to be integrated to form a CEP. Further studies will be undertaken to develop an educational programme, test the feasibility of delivering CEP, and assess the clinical effectiveness and cost-effectiveness of CEP in people with osteoarthritis at the first instance.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: Zhang, Weiya
Doherty, Michael
Hall, Michelle
Keywords: osteoarthritis; contextual factors; contextual enhancers; placebo
Subjects: W Medicine and related subjects (NLM Classification) > WE Muscoskeletal system
Faculties/Schools: UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID: 74042
Depositing User: Ismail, Ayah
Date Deposited: 31 Jul 2023 04:41
Last Modified: 31 Jul 2023 04:41
URI: https://eprints.nottingham.ac.uk/id/eprint/74042

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