Context,Mechanisms and Outcomes of Reasonable Adjustments Across Acute Hospital Settings for People With Intellectual Disabilities: A Scoping Review Protocol

Abstract

This is a protocol for a Campbell scoping review. The objective is to map the existing evidence on the implementation of reasonable adjustments in acute hospital settings for people with intellectual disabilities, using a realist lens. This involves examining how contextual factors interact with underlying mechanisms to influence outcomes related to equitable access, quality of care, and health experiences. In the context of healthcare for people with intellectual disabilities, reasonable adjustments can help bridge health inequities. There is a strong evidence base in the literature for reasonable adjustments, however there is little evidence of implementation across acute hospitals. Exploring this topic using a realist lens of context, mechanism and outcomes may help identify the underlying factors influencing implementation of reasonable adjustments in clinical practice. The review will follow the JBI scoping review methodology and will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Evidence sources examining reasonable adjustments implemented by healthcare staff to support people with intellectual disabilities in acute hospital settings will be included. A comprehensive search strategy will be applied across the following information sources: MEDLINE, CINAHL, Academic Search Complete, Embase, Scopus, Web of Science Core Collection, PsycINFO, JBI Evidence Synthesis, and The Cochrane Database of Systematic Review. Additionally, a rigorous search of grey literature will be conducted across defined databases, search engines and repositories. Sources will be limited to the English language, with no time limit imposed. Data will be extracted using a table designed for the review and following qualitative content analysis, results will be presented in tabular form with narrative summaries.

Keywords

context hospital implementation intellectual disability realism realist lens reasonable adjustments mechanism outcome

Background

Intellectual Disability

The global population is expected to continue growing over the next 50 years, and by 2080 it is estimated that people aged 65 or older will outnumber children under 18 (United Nations, 2024). A simultaneous rise in the prevalence of chronic disease means that more than half of the global population above 60 years of age have multimorbid conditions and complex health needs (Chowdhury et al., 2023). Healthcare systems need to be prepared to meet the health needs of future generations safely and effectively. These global demographic shifts also encompass people with intellectual disabilities who are living longer and experiencing higher rates of multimorbidity (Lee et al., 2024; Ryan et al., 2025). An estimated 1-3% of the population have an intellectual disability, with prevalence varying by region due to differences in diagnostic criteria, reporting practices and under-detection (Nair et al., 2022; WHO, 2022). Intellectual disability is a lifelong neurodevelopmental condition which occurs during the early developmental period of an individual’s life. It is characterised by significant limitations in intellectual functioning and in adaptive behaviours such as conceptual skills, social skills and practical skills (Schalock et al., 2021; World Health Organisation, 2022). Contemporary perspectives recognise that disability is not solely a reflection of an individual’s impairments but rather is shaped by their interactions with environmental and societal factors that either support or impede their everyday functioning (Toro et al., 2020). The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) affirms the human rights of people with intellectual disabilities, including their right to the highest attainable standard of health free from discrimination (article 25), and to healthcare that is accessible, inclusive and free from barriers or obstacles (article 9) (UNCRPD, 2006). Notwithstanding the UNCRPD, evidence indicates that people with intellectual disabilities continue to experience health inequities. They have higher rates of physical health conditions, greater multimorbidity, and require healthcare more frequently than their peers in the general population (Acosta et al., 2022; Lee et al., 2024; McMahon & Hatton, 2021). Considering that healthcare services are designed to meet the generic needs of large groups of people, a person who presents with diverse needs such as an intellectual disability or other cognitive disability (e.g., acquired-brain injury; dementia) may experience difficulties in accessing and using services, and thus a continued pattern of inequity endures (Bacherini et al., 2024; Sonderlund et al., 2024). To future-proof healthcare services, it is imperative that present-day inequities are addressed, and that healthcare systems evolve to meet the needs of the growing, aging and diversifying global population. However, addressing health inequities is complex (McConkey et al., 2020) and requires transformation of healthcare systems using multimodal approaches at multisystem levels (Ford et al., 2021).

Reasonable Adjustments

In the context of healthcare provision for people with intellectual disabilities, reasonable adjustments are proposed to help bridge health inequities (Cashin et al., 2022; Wilson et al., 2022). Reasonable adjustments in healthcare can be described as changes or modifications to the environment, the service, and/or to routine practices, carried out with the intention of supporting the person with diverse needs to access and use services on an equitable basis (Cashin et al., 2022; Wilson et al., 2022; Wallace, 2024). Reasonable adjustments can be implemented at the macro, meso, and micro levels of healthcare. At the macro level (i.e., system or organisation), this may include hospital-wide accessibility policies, infrastructure and governance. At meso level (i.e., unit or department), adjustments may involve adapted clinical pathways, while at the micro level (i.e., individual), they may include personalised support such as tailored communication strategies or flexible appointment times. There is a strong evidence base in the literature for reasonable adjustments, with heterogeneous research studies from different stakeholder perspectives advocating their value and use in practice (Redley et al., 2019; McConkey et al., 2020; McCormick et al., 2021; Wilson et al., 2022; Wallace, 2024). However, despite this, there remains little evidence of actual implementation of reasonable adjustments in clinical practice (Moloney et al., 2021), which is unfortunate given that they have the potential to prevent or remove barriers that could otherwise impede a person from receiving equitable healthcare and treatment.

Realist Lens of Context, Mechanisms and Outcomes

Realism is an empirical scientific perspective concerned with understanding how observable phenomena produce outcomes in real world settings. Realism explores “what works, for who, in what conditions, and in what type of setting”, emphasising the interplay between context and mechanisms, which produce intended or unintended outcomes in real life situations (Pawson & Tilley, 1997; De Brún & McAuliffe, 2020; Greenhalgh & Manzano, 2022). A realist lens of context, mechanism and outcomes (CMO) is an effective approach for exploring causality in seeking to understand why complex interventions succeed or fail in real life settings (De Weger et al., 2020). While there is well-established evidence on reasonable adjustments from many heterogenous sources in the literature, none have reviewed the implementation perspective using a realist lens. The proposed scoping review addresses this knowledge gap and will offer insight into why a well-documented evidence-based approach to reducing health inequities (i.e., reasonable adjustments) are not implemented successfully and sustainably across acute hospitals. To strengthen the realist approach, this review draws on Normalization Process Theory (NPT) (May et al., 2009), which offers a framework for understanding the social processes involved in embedding complex interventions in practice. NPT identifies four constructs for generative mechanisms of social action (i.e., coherence, cognitive participation, collective action, and reflexive monitoring) which provide a useful lens for understanding the mechanisms that are often hidden in realist CMO explanations. Further descriptions of CMO relevant to this review are provided in the methods section 3.11 and in Table 1. A preliminary search of several databases was conducted (i.e., MEDLINE, JBI Evidence Synthesis, The Cochrane Database of Systematic Reviews, Prospero and Open Science Framework) and no current systematic reviews, scoping reviews or review protocols on the topic were identified. In response, this protocol aims to systematically address the topic and presents the objective and planned methods for a scoping review.

Table 1.

Description of Context (C) Mechanisms (M) and Outcomes (O)

CMO	Descriptions	Illustrative examples
Context	⁃ Context is the background to an intervention or programme with aspects such as social, economic, political, organisational structures, social and cultural norms and interrelationships. The context can enable or hinder mechanisms (De Weger et al., 2020). ⁃ Context can be conceptualised as what happens when an intervention, programme, or service is combined with a team, department or organization (Nilsen and Bernhardsson, 2019).	Illustrative examples to guide data extraction: ⁃ System-level factors (e.g., policy, legal, funding, governance, leadership) ⁃ Unit-level factors (e.g., environment, accessibility, physical resources, digital resources, time, staff training, role clarity) ⁃ Individual-level factors (e.g., patient characteristics, case complexity, health literacy, carer support and advocacy)
Mechanisms	⁃ Mechanisms refers to the processes which influence the behaviour of the participants. These are usually hidden, and are contingent on variations in context and lead to intended or unintended outcomes (De Weger et al., 2020) ⁃ Unobservable processes that occur in individuals minds due to the intervention or programme, which in turn influences the outcomes (De Brún & McAuliffe, 2020). ⁃ Interventions work through the reasoning and reactions (i.e., mechanisms) of its participants (Pawson and Tilly, 1997).	Illustrative examples to guide data extraction, informed by normalisation Process Theory (NPT) and other context-specific mechanisms: ⁃ Coherence ⁃ Cognitive participation ⁃ Collective action ⁃ Reflexive monitoring ⁃ Other context-specific mechanisms (e.g., intrinsic motivation, capabilities/skills, culture)
Outcomes	⁃ Intended or unintended consequences of an effort, these can be at micro-, meso-, or macro level (De Weger et al., 2020) ⁃ The results of the implementation of an intervention or programme, influenced by context and mechanisms (Pawson and Tilly, 1997).	Illustrative examples to guide data extraction may include short, medium or long-term outcomes: ⁃ System-level outcomes (e.g., service efficiency, improved service quality, patient safety and sustainability) ⁃ Unit-level outcomes (e.g., improved processes, staff competence and use of resources) ⁃ Individual-level outcomes (e.g., improved personal health outcomes, positive hospital experiences)

Objective

To map the existing evidence on the implementation of reasonable adjustments in acute hospital settings for people with intellectual disabilities, using a realist lens. This involves examining how contextual factors interact with underlying mechanisms to influence outcomes related to equitable access, quality of care, and health experiences.

Methods

Review Question

What is known about the implementation of reasonable adjustments for people with intellectual disabilities in acute hospital settings, and how do contexts and mechanisms influence outcomes?

Inclusion Criteria

The inclusion criteria were conceptualised using the PCC mnemonic – population, concept and context (Table 2) as recommended by Peters et al. (2020).

Table 2.

Inclusion Criteria

Criteria	Include	Exclude
P Population	Sources of evidence that focus on people with intellectual disabilities of any age group.	Any sources of evidence that do not focus on people with intellectual disabilities. People with other developmental or neurocognitive conditions (e.g., acquired-brain injury; dementia) are excluded.
C Concept	Implementation of reasonable adjustments in healthcare provision.	Any concept that is not implementation of reasonable adjustments in healthcare provision.
C Context	The context is the acute hospital setting. The review considers all patient encounters including inpatient care, outpatient services, and emergency department presentations irrespective of clinical specialty, presenting complaint, or geographical area.	Other healthcare settings that are not acute hospitals, for example GP clinics, primary care clinics
Language	English language	Other languages
Timeline	Any timeline	No restrictions
Type of sources	Primary research studies of any design (e.g., qualitative, quantitative or mixed methods). Secondary research studies (e.g., systematic reviews, scoping reviews, meta-analysis, narrative reviews). Published discussion papers, case studies, conference abstracts, dissertations, published or unpublished practice policies or guidelines.	Public-facing informational webpages, notes, letters, opinion pieces, blogs, informal websites.

Population

Sources of evidence that focus on people with intellectual disabilities of any age group will be included. While the concept of ‘reasonable adjustments’ in hospitals may be pertinent to a wide range of people with various developmental or neurocognitive conditions (e.g., acquired-brain injury; dementia), this scoping review focuses specifically on people with intellectual disabilities, as the research question and focus are specific to this population.

Concept

The concept is reasonable adjustments which are implemented by healthcare staff to help address the inequities experienced by people with intellectual disabilities in accessing healthcare.

Context

The context is the acute hospital setting. The review considers all patient encounters including inpatient care, outpatient services, and emergency department presentations, irrespective of clinical specialty, presenting complaint, or geographical area.

Types of Sources

This scoping review will include varied types of sources which meet the inclusion criteria. It will consider primary research studies of any design (e.g., qualitative, quantitative or mixed methods), as well as secondary research studies which meet the inclusion criteria (e.g., systematic reviews, scoping reviews, meta-analysis, narrative reviews). In keeping with the broad nature of a scoping review, published discussion papers, case studies and the wider grey literature will be included (e.g., conference abstracts, dissertations, published or unpublished practice guidelines). Public-facing informational webpages and informal media such as blogs and notes are excluded. While these sources may offer useful insights, they do not typically report implementation context, mechanisms, and outcomes with sufficient rigor to meet the evidence required for this review.

Methodology

This is a scoping review protocol which describes the rationale, objective and planned methods for a scoping review. The protocol is registered with Campbell Systematic Reviews and is reported in line with the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) 2015 checklist (Moher et al., 2015). The scoping review will be conducted using the JBI Scoping Review methodology (Peters et al., 2020). This methodology was chosen as it offers a systematic and rigorous approach to mapping the available evidence on a topic. The results of the review will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018).

Search Strategy

The search strategy was developed by the research team who have expertise in conducting reviews, searching databases, and in the field of intellectual disability. The strategy drew on methodological guidance, including the approach outlined by MacDonald et al. (2024) for Campbell systematic reviews. Multiple consultations were held with an academic librarian to inform the search strategy development, resulting in several iterative revisions. Additional consultation with the academic librarian is planned to implement the search strategy during the full review phase. The search aims to identify published and unpublished sources of evidence and will involve a three-step process of preliminary search, full search, and a final reference list search. An initial preliminary search of MEDLINE and Scopus was undertaken to identify sources of evidence relevant to the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the sources aided in developing a full search strategy which will be used with Boolean operators to combine or expand searches as outlined in Supplemental File 1. The full search strategy will be applied in the following information sources: MEDLINE, CINAHL, Academic Search Complete, Embase, Scopus, Web of Science Core Collection, PsycINFO, JBI Evidence Synthesis, and The Cochrane Database of Systematic Review (Supplemental File 2). For grey literature, a replicable search strategy will be conducted in line with guidance from Hoffecker (2020) across several databases, search engines and repositories (Supplemental File 2). Finally, for robustness the reference list of all included sources of evidence will be screened for additional studies. There will be no timeframe imposed on the literature search as the concept of reasonable adjustments has evolved in more recent years in tandem with an increasing focus on health equity. Sources of evidence in the English language only will be included as this is the first language of the research team and time and cost limitations exist in relation to translations.

Source of Evidence Selection

Following the final search, all identified sources of evidence will be collated and uploaded to an online management tool for systematic reviews (Covidence) and duplicates removed. Two independent reviewers will conduct title/abstract screening, followed by full text review. Reasons for exclusion of sources of evidence at full text will be recorded and reported. To ensure consistency in selection, inter-reviewer agreement will be assessed and reported using Cohen’s kappa, calculated within Covidence. Any disagreements that arise during the selection process will be resolved through discussion, or through consensus with a third reviewer. The full results will be reported in the final scoping review and presented in the PRISMA flow diagram (Page et al., 2021).

Data Extraction

Data extraction will be conducted using a data extraction table designed specifically for this review (Supplemental File 3). As advocated by Arksey and O'Malley (2005), the data extraction table will be piloted by two members of the research team using five to ten sources of evidence and modified if needed to ensure the necessary information is being extracted, any modifications to the final table will be reported in the final scoping review. Data extraction will be an iterative process, however at this protocol point, it is anticipated that information to be extracted will include title, authors, year, country of publication, type of evidence source, aim, methods (for research studies), key findings and recommendations. Furthermore, information relevant to the realist perspective of context, mechanisms and outcomes presented or discussed in the sources will be extracted, as this will be crucial data for meeting the review objective. Descriptions and illustrative examples of context, mechanisms and outcomes (CMO) are provided in Table 1 and are intended to guide data extraction, while allowing for inductive identification of additional CMO where relevant. Contextual factors defined as social, economic, political, organisational structures, social and cultural norms, and interrelationships (De Weger et al., 2020), will be systematically extracted from all included studies where relevant. Following this, the extraction will focus on mechanisms, defined as the underlying processes or interactions that generate outcomes. As mechanisms are inherently unobservable and often unreported in empirical studies, it is our intention to ‘infer potential mechanisms’ by drawing on contextual details, intervention descriptions and reported outcomes within the included sources of evidence. As previously mentioned, data interpretations will be anchored in established theory such as the Normalization Process Theory (May et al., 2009) and in the available empirical evidence on mechanisms for example Dalkin et al. (2015), Lacouture et al. (2015) and Long et al. (2022). Additional context-dependent mechanisms, not captured by NPT constructs, will also be extracted as they emerge in the data. Consequently, the inferential nature of the data extraction for mechanisms will be acknowledged in the final review as a limitation of the research. Outcomes will also be systematically extracted and are conceptualised as the ‘intended’ or ‘unintended’ effects of the intervention, i.e., the reasonable adjustment. Outcomes are anticipated to occur across multiple levels, including macro-level (i.e., system), meso-level (i.e., unit) and micro-level (i.e., individual). Data extraction will be conducted independently by two reviewers with strategies to ensure consistency, including the use of a standardised data extraction table (Supplemental File 3), operational definitions (Table 1) and a pilot extraction of the first five to ten sources of evidence to establish agreement. Any discrepancies will be resolved through discussion between the two reviewers and a third consulted if necessary.

Critical Appraisal

Critical appraisal of the included sources of evidence will be conducted. The objective is to map all available evidence on the implementation of reasonable adjustments regardless of quality; however, the critical appraisal will offer additional insight into the methodological quality of the included sources and will inform the interpretation of results.

Data Analysis and Presentation of Results

The extracted data will be analysed using Burnard (2011) framework for qualitative content analysis, and results will be mapped descriptively using headings and subheadings. Tables and diagrams will be used as appropriate to illustrate results, accompanied by narrative summaries. All results will align with the review objective and offer insight into what is known on the implementation of reasonable adjustments using the realist lens of context, mechanism and outcomes. The number and type of evidence sources will be reported, mapping the heterogeneous methodologies used to conduct research on this topic, as well as the evidence available in the grey literature. Data specifically relating to context, mechanisms and outcomes will be reported under subheadings with tables and narrative summaries, making connections between the CMO contingencies in the individual sources of evidence and collectively across the review.

Public and Patient Involvement

This scoping review protocol was developed with public and patient involvement (PPI) to ensure it reflected the priorities, experiences and perspectives of people with intellectual disabilities, their families and/or carers. The PPI group reviewed the draft protocol and provided feedback on the clarity and relevance of the research objective. The PPI resulted in minor edits and the addition of further clarity around context, mechanism and outcomes (i.e., addition of Table 1). It is anticipated that the findings of this review will be a foundation for further work by the research team, where engaging further PPI will be a priority to promote research inclusivity and ensure real world applicability and impact of findings.

Supplemental Material

Supplemental Material - Context, Mechanisms and Outcomes of Reasonable Adjustments Across Acute Hospital Settings for People With Intellectual Disabilities: A Scoping Review Protocol

Supplemental Material for Context, Mechanisms and Outcomes of Reasonable Adjustments Across Acute Hospital Settings for People With Intellectual Disabilities: A Scoping Review Protocol by Mairead Moloney, Laurence Taggart, Owen Doody in Campbell Systematic Reviews

Supplemental Material

Supplemental Material - Context, Mechanisms and Outcomes of Reasonable Adjustments Across Acute Hospital Settings for People With Intellectual Disabilities: A Scoping Review Protocol

Supplemental Material

Supplemental Material - Context, Mechanisms and Outcomes of Reasonable Adjustments Across Acute Hospital Settings for People With Intellectual Disabilities: A Scoping Review Protocol

Footnotes

Acknowledgements

Thank you to the PPI group who reviewed this protocol.

Author Contributions

All authors (MM, LT, OD) contributed equally to the conception, design and drafting of the scoping review protocol. All authors (MM, LT, OD) have content, methodological, statistical and informational retrieval expertise.

Content: Mairead Moloney, Owen Doody, Laurence Taggart

Review methods: Mairead Moloney, Owen Doody, Laurence Taggart

Information retrieval: Mairead Moloney, Owen Doody, Laurence Taggart

Funding

The authors received no financial support for the research, authorship, and/or publication of this article. We got open access funding from the University of Limerick. As per the national institutional open access agreements.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Preliminary timeframe

Approximate date of submission for the scoping review is one-year after protocol approval.

Plans for Updating this Review

The review will be updated by the authors in 2–4 years depending on the volume of new evidence that is published on the topic in the interim. This review is concerned with understanding the factors affecting implementation (i.e., context, mechanisms and outcomes) of an evidence-based intervention (i.e., reasonable adjustments), therefore it would be useful to update this review as new evidence of actual implementation in clinical practice emerges in the literature.

Supplemental Material

Supplemental material for this article is available online.

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