Describing pre‐appointment written materials as an intervention in the context of children’s NHS therapy services: A national survey

Abstract Context Pre‐appointment written materials, including letters and leaflets, are commonly used by healthcare organisations to deliver professional‐patient interactions. The written materials potentially change patients’ knowledge and behaviour as part of a healthcare intervention but have received little investigation. Objective To describe the content of pre‐appointment written materials through a behaviour change intervention perspective. Design Mixed methods study with an online questionnaire about pre‐appointment written materials and an analysis of actual materials. Questionnaire data were analysed descriptively and pre‐appointment materials by qualitative framework analysis. Setting and participants Children's community/outpatient occupational therapy, physiotherapy and/or speech and language therapy services across the UK. Service managers/clinical leads provided data. Intervention Pre‐appointment written materials. Results Questionnaire responses were received from n = 110 managers/clinical leads from n = 58 NHS organisations. Written materials (n = 64) were received from n = 24 organisations. Current materials are used by therapy services as a conduit to convey the therapy service's expectations related to: accessing the service, decision‐making about care and help‐giving. The materials enrol the parent and child to the therapy services’ expectations by behaviour change techniques. The materials configure the parent/child expectations, knowledge and behaviour towards the therapy services’ operational procedures. Conclusion Pre‐appointment written materials configure patients to organisations’ operational procedures. The written materials currently lack support for parent/child empowerment, shared decision‐making and self‐management to improve health. Patient Contribution Four parents of children accessing therapy services were involved in the study. The parents shared their experiences to highlight the importance of the topic and contributed to the final research design and methods.


| INTRODUC TI ON
National Health Service (NHS) Trusts in the UK each spend an estimated £12 000-£87 000 per month to post between 48 000 and 800 000 letters to patients. 1 Many of these letters will be delivered pre-appointment to inform patients about the appointment and the service being offered. Pre-appointment written materials are a form of healthcare interaction, an intervention that takes place before the initial face-to-face appointment. 2 Pre-appointment written materials represent a significant investment in written interactions on the part of NHS organisations, but their potential role in supporting patient health is poorly understood. 2 Little is known about current pre-appointment written materials and how they contribute to quality of care and patient health.
In public health, pre-appointment letters inviting patients to screening programmes have been developed by drawing on behavioural theory, principles and techniques to enhance letter content and formatting. In the UK, Sallis et al 3 enhanced invitation letters to the NHS Health Check by: simplification (shortened content, improved readability and reduced complexity); behavioural specificity using behavioural instruction and concrete statements; personal salience, using formatting techniques and lexical choices; and behaviour change techniques of action planning and prompts. 3 Similarly, ten Hoor et al 4 enhanced invitation letters to chlamydia testing in the Netherlands by increased personal relevance of informational content to bolster patients' motivation, simplified content to increase patients' ability to process the information, and information tailored to patients' risk perception, attitude, moral norms, social influence and response efficacy and self-efficacy 4 found in previous research.
Both studies tested the interventions in randomised controlled trials but with opposing results. Sallis et al 3 found the enhanced letters were significantly associated with increased patient attendance at NHS Health Checks but ten Hoor et al 4 found no differences in uptake of chlamydia testing between those receiving the enhanced and standard letters. Differences in the health context between the two studies, that is cardiovascular health 3 and sexual health 4 and target behaviours, that is attending an appointment 3 and requesting, using and returning a test kit 4 may account for differences in findings but it remains unclear if theory-informed pre-appointment written materials can positively impact on health behaviours. The above studies specifically focus on patient letters despite the letters being only one part of a package of materials sent to participants. Leaflets 3 and websites 4 were also included in the package of materials but were not enhanced. Developing the whole package of written materials into an active health intervention may increase the likelihood of positive behaviour change and health outcomes.
Our study explores current pre-appointment written materials in children's therapy services in the UK, including, but not limited to, letters. Following the Medical Research Council's guidance on intervention development, 5 our study aims to characterise the materials as an intervention, including delineation of key intervention components and mechanisms, and to describe the context of children's therapy services in the UK in which these interventions are situated. 6 A detailed description of current materials is an important step towards developing pre-appointment written materials into a targeted health intervention to deliver high-quality care and target health outcomes.

| ME THODS
A mixed methods study of children's NHS therapy services in the UK was conducted. The study was approved by the Health Research Inclusion criteria for participants were as follows: managers or leaders of (a) NHS provider/commissioned community and/or outpatient services that (b) included occupational therapy, physiotherapy and/or speech and language therapy (c) for children in the UK. Multi-professional services (eg wheelchair services, child and adolescent mental health services) were included if they included an occupational therapist, physiotherapist, or speech and language therapist. Exclusion criteria were as follows: adult-only (16 years +) services; services without at least one of the eligible therapy professions; and inpatient therapy services. The HRA approved participant information sheet was provided to participants online prior Patient Contribution: Four parents of children accessing therapy services were involved in the study. The parents shared their experiences to highlight the importance of the topic and contributed to the final research design and methods.

K E Y W O R D S
behaviour change, children's therapy, health service delivery, written materials to the questionnaire and consent was inferred from questionnaire completion.
Data on the use of pre-appointment written materials in children's therapy services were collected through an online questionnaire based on the domains of the Template for Intervention Description and Replication (TIDieR). 8 Initial question items and response options were developed by two authors (SA and NK) from clinical experience and a review of published evidence related to pre-appointment interventions. 9 The questionnaire was further refined by a process of peer review and piloting until a final set of items and response options related to ten TIDieR domains were agreed 7 (see Appendix S1). The final questionnaire was administered online using Qualtrics © , 10 with a link to the questionnaire provided in an email invitation to participate. Data were collected from October 2018 to February 2019.
The online questionnaire included a section on the characteristics of the responding therapy services, comprising: the number of therapists in the team, whole time equivalent staff, number of children known to the service, number of referrals per month, number of weeks wait for an initial appointment and non-attendance rates.
Data on current pre-appointment written materials were collected by requesting samples of actual, currently in use materials from the participating services. Participants submitted the samples by email. Written comments or additional information related to the materials that participants submitted in their email correspondence with the documents was retained and included in analysis.
The questionnaire data were transferred from Qualtrics© 10 to Statistical Package for Social Sciences (SPSS, version 25)©. 11 Data cleaning and data entry were completed following a data dictionary and analysis plan. 7 Univariate descriptive analysis was completed.
Questionnaire data were primarily categorical ( inspection of the distribution of values. The median, interquartile range (IQR) and range were therefore used to represent continuous variable data (Table 1b).
The samples of pre-appointment written materials were analysed in two stages, using an adapted framework analysis. 12 The initial framework was developed inductively. All sample documents were read, and all content identified and labelled. Labels representing similar content were given a descriptive heading in the framework and corresponding content was categorised under the headings. Headings changed and developed to represent broader conceptual categories as documents were re-read and analysis developed (eg see Table 2). Comments and note taking were documented in the framework to track changing categories and headings.
All documents were re-read until the conceptual headings held and all content was represented. TR reviewed the framework throughout analysis and conceptual categories and headings were discussed and agreed between SA and TR. Categories containing large volumes of, and conceptually rich, content were prioritised for further in-depth analysis. Research memos 13 were used to prioritise categories and explore conceptual ideas, with 'expectations' found to be a central concept in the materials (see Table 3). Enrolment, 14,15 defined in the sociology of translation [14][15][16] as the negotiation of interrelated roles and actions to expected identities and roles, became conceptually important to understand expectations in the materials. The sociology of translation [14][15][16] was subsequently used to inform the analytical framework and further in-depth analysis and interpretation.
Data were subsequently framed from the theoretical perspective of the sociology of translation. Changes included re-defining categories to represent specific entities 14

| RE SULTS
Of the n = 112 NHS provider organisations approached, data were returned for n = 58 organisations (response rate 51.7%) by n = 110 service managers and/or clinical leads. A flowchart of participating organisations and therapy services is presented in Figure 1. Sample characteristics are provided in Table 1a text message (n = 40, 25.8%) was also common.
The remainder of this section focuses on the qualitative data analysis and the enrolment that begins with pre-appointment written materials. Quantitative data are further integrated into results where it adds context to the findings.

| Players and layers
Pre-appointment written materials were found to present a complex network of people and interactions related to children's therapy. Most of the content in the materials related directly to the child, the parent and the therapist. However, they also introduced numerous other individuals and groups of people including teachers, special educational needs coordinators, headteachers, Trust chair and chief executives, patient advice and liaison advocates and, occasionally, public bodies, for example the National Institute for Health and Care Excellence.
The therapy service was typically placed at the centre of the network, as a connector that introduces and links individuals and groups to the therapy context and establishes associations with children's therapy.
The written materials contained varied and multiple layers of content, all relating to the operational context of the therapy service.
The core layer of content was pragmatic with a focus on the logistics of the appointment, that is the date, time and location, and the therapy service, that is profession(s) and contact details. This core content was often built upon with increasing layers of detail about the specific aspects of the appointment (eg what to bring, who will be there), the therapy service (eg opening times and team members), the organisation (eg smoking policy and parking) and the help available (eg treatments and groups).
Pre-appointment written materials were found to enrol 14,15 the child, the parent, and the therapist to identities, roles and actions that align with the therapy service's notion of therapy and subsequently constructed service operations and procedures.
Enrolment 15 is by means of techniques (eg instruction on how to perform the behaviour 17 ) that target parents' capabilities, social opportunities and motivation 21 (see Table 4) to align parental behaviour with the behavioural expectations of the therapy service.
Lexical choices are used alongside the techniques to add salience to actions, all of which can be found in the varied layers of content. The materials, by attempting to modify behaviours, can be considered an intervention and from survey findings a common intervention. The child, the parent and the therapist are enrolled to follow the service's operational systems and procedures related to accessing the service, decision-making about care and help-giving.

| Accessing the service
In their most basic form, the materials provide instructions on how to access the service. Instructions include how to make or change  'Regular attendance is essential to the progress and effectiveness of your child's treatment' 'At the end of the assessment, the therapist will discuss your child's difficulty with you and indicate the level of therapy needed. However, some children will not require any further appointments.' 'Supporting children in this way has been shown to make a significant difference to their communication skills' 'Follow the advice and practise any home exercises your therapist suggests. These are designed to help your child's condition' 'During the course of therapy, you may be given activities to practice with your child. These will form a vital a part of your child's therapy.' Cognitive and interpersonal skills n/a n/a n/a None Memory attention and decision processes n/a n/a n/a None Behavioural regulation n/a n/a n/a 'Failure to do so will count as DNA (did not attend) and may result in discharge from the service' 'If you are unable to attend on more than one occasion and do not inform us before the appointment you will be discharged.' 'If you should fail to be available for this appointment, without notifying us, we will assume that you no longer require an appointment and your child will be discharged' Emotion n/a n/a n/a None Bold text denotes increased dose of the technique through formatting.
a Denotes lexical choices to add salience to the technique.
an appointment, when and where to turn up for an appointment, or how to address specific needs identified in the referral before an appointment will be offered. Service users are instructed to contact the service if the specific conditions set out in the materials, for example attending the appointment at the time specified, cannot be met. Such instructions are primarily targeted at the parent. Only one NHS child and adolescent mental health service instructed adolescent patients directly on how to access the service. All the materials were found to use behavioural instructions to educate 22 primarily the parent about the social transactions needed for successful access to the service.
In rare cases, written materials contained only such core instructions as outlined above. Most commonly, even in their most basic forms, written materials stated the consequences of following, or not following, the instructions. Vicarious consequences, 17  The withdrawal of access to the therapy service, in the form of the child's discharge, was frequently framed as an explicit consequence of the parent not following the instructions. Scheduling a consequence 17 for not doing as instructed (ie not attending the appointment or contacting the service), whilst theoretically a punishment for performing unwanted behaviours 17 was sometimes stated to be based on the assumption that the appointment, or treatment, was no longer needed or there were no longer 'any concerns', and access to therapy was therefore withdrawn. In rare cases, the threat of 'further action' being taken by the child's referring professional as a consequence of not attending the appointment was used to inform of potential future punishment 17 for not accessing the service as instructed. Scheduled and/or future punishments were commonly used to reinforce 22 the expected behaviours to parents.
The pre-appointment written materials primarily enrolled parents to access the service as expected by increasing parental knowledge. 22 Some materials used additional techniques to educate, persuade and coerce 22 the parent to do as expected (see Table 4).
Accessing the service as instructed and expected provided a gateway for decisions to be made about the child's future care.

| Decision-making about care
In the materials, the appointment is typically rendered as a highly structured and scheduled event at which the therapist will decide about the child's future care. The structure and schedule for the appointment support the therapist's decision-making by providing opportunities for the therapist to observe and test the child, ask questions and elicit information that will allow a decision to be made.
Pre-appointment written materials provide the parent with information about the structure and schedule of the appointment: First you will meet the therapist for a discussion … Your child will have the opportunity to explore the daily activities … At the end of the session you will receive practical strategies….
(community occupational therapy service) The materials also provide instructions on how parents and children should prepare for the appointment, for example what to bring (eg a drink, consent form, child's red health book), what to wear (specifically by the child eg vest and shorts), and topics for discussion (eg activities of daily living, the child's communication). Occasionally, the materials may also inform and instruct the parent about the decision-making process at the appointment: Once the initial consultation is complete you will be asked to wait in the waiting area for a short time while the team meet together in order to consider possible management options for your situation. You will then be invited back into the consulting room where the treatment plan will then be explained and discussed in detail with you (outpatient multidisciplinary therapy service) The use of pre-appointment questionnaires sometimes provided an opportunity for the parent to contribute information and their views for use in the decision-making process. Pre-appointment materials instructed the parent to fill in forms, tick or circle difficulties on a questionnaire, discuss difficulties with the child or teacher and write them down, and chronicle the child's skill development to contribute information and views. The parent's information and views were always constricted to the skills, activities or actions of interest to the therapy service, for example gross motor skills, dressing, writing, bike riding, swallowing or speech, and to the child's difficulties and/or differences. Difficulties and/or differences were key to the therapist's decision-making and most often identified by comparing the child to peers or to age-or performance-based norms. Differences were sometimes, but rarely, considered in the form of goal setting 22 that represented the differences the parent wished to see in the future. Some materials instructed the child to identify their own difficulties and/or differences by completing a questionnaire or thinking about goals but such interactive elements for children were not commonly found in Decision-making was portrayed as a process whereby the therapist matched the child's difficulties and/or differences to the help-giving practices available from the service to propose a management plan. Some materials did provide the opportunity for the parent and the child to identify goals for therapy, enabling, to some degree, self-management. 23 None of the materials suggested opportunities for the parent and/or the child to share decision-making with the therapist nor choose the help-giving practices that might be best suited to them, from the range of help-giving available.

| Help-giving
The final layer of content in some of the materials related to helpgiving practices of the therapy service. The nature and form of help-giving was described as: advice (eg on ways to help the child, children's skills were used to provide information about health consequences, 17 and the parent's and child's actions in the context of the help-giving were framed/re-framed 17 as a vital part of the child's therapy. Specific lexical choices, for example appointments being described as 'essential' and 'compulsory', were also found to add salience to specific aspects of help-giving.
The materials that contained content about help-giving also informed parents of an end to the help, and often specified the number of sessions or other key factors that would signify the end of help-giving.

| Configuring the child, parent and therapist to the therapy service
Pre-appointment written materials seek to configure the child, parent and therapist to the therapy service. That is to define the identity, roles and future actions of the child, parent and therapist 16 as part of a delineation of the therapy scenario. 16

| D ISCUSS I ON
The findings from our study support a key criticism of current preappointment materials used in healthcare more broadly, that the ma-  [30][31][32][33] related to health and treatment options, rather than children's difficulties and differences, may support shared decision-making from the start of the therapist-parent-child relationship during pre-appointment written interactions.
Finally, our study found that, commonly, patients' who do not follow the series of transactions specified in current pre-appointment written materials risk discharge from the therapy service based on common assumptions that the parent no longer has concerns, or the therapy is no longer needed. Smith 34 has argued that, in public services, an interpersonal view of human behaviour, rather than a transactional view, is required. Such transactions, whilst believed to be key to efficient services, do not work for people and the inevitable variation in public services. 34 Adopting a more interpersonal view of human behaviour 34,35 may lead to a different set of assumptions whereby those who do not follow the transactions specified may be the families most in need, or in crisis, who require more relational care 35 and suspension of the 'rules' for a more personalised pathway to change. 34 Changing the assumptions upon which the content of pre-appointment materials is based requires system-level change, driven through organisational policy and culture. Only through more adaptable healthcare systems will high quality, effective care, optimum health outcomes and meaningful service efficiency be realised. 34

| Limitations
Our sampling strategy successfully captured a breadth of data from across the UK using a first-of-its-kind explicit sampling frame of children's therapy services, 7 and resulted in a reasonable survey response rate (see Figure 1). However, the possibility remains that those who responded were more engaged with pre-appointment materials than those who did not take part. Our study found wide variation in questionnaire results for variables related to the therapy service context. It may be that the variation reflects respondent characteristics rather than true variation between therapy services.
For example, data variation may reflect the managerial level of the respondent, for example manager of a single therapy team versus manager of all therapy services within the organisation, rather than the true variation of the construct. Due to the potential sensitivity of some questionnaire variables which reflect the services' performance against national standards, for example waiting times, the threat of reporting bias was considered. However, our findings are consistent with other data in this area 36 increasing confidence in the reliability of performance-based data. Eighty-four (86.6%) survey respondents participating in our study reported delivering preappointment interventions using different modes of delivery, that is telephone call, text message and emails. These alternative modes of intervention delivery are not captured in this study, limiting the generalisability of the results.

| CON CLUS ION
Our study has identified intervention techniques and processes used in current pre-appointment materials. The findings suggest that services could consider using a broader range of behaviour change techniques in pre-appointment materials to more effectively support health-related actions and enable outcomes. Core assumptions and beliefs, for example about 'effective' child-parent-therapist healthcare interactions that underpin the content of current materials need to be challenged to support change in the discourse and the materials. Research focused on system-level factors, for example organisational policies and routine care 'pathways', that drive discourse and behaviour in health care is needed to progress meaningful implementation of national policy such as personalised care.

ACK N OWLED G M ENTS
The research team acknowledges the support of the National Institute for Health Research Clinical Research Network (NIHR CRN).

CO N FLI C T O F I NTE R E S T S
The authors have no conflict of interests to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are openly avail-