{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T11:34:00Z","timestamp":1786361640983,"version":"build-2736575974"},"reference-count":53,"publisher":"National Institute for Health and Care Research","license":[{"start":{"date-parts":[[2026,8,1]],"date-time":"2026-08-01T00:00:00Z","timestamp":1785542400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000664","name":"Health Technology Assessment programme","doi-asserted-by":"publisher","award":["NIHR131023"],"award-info":[{"award-number":["NIHR131023"]}],"id":[{"id":"10.13039\/501100000664","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["journalslibrary.nihr.ac.uk"],"crossmark-restriction":false},"short-container-title":["Health Technol Assess"],"abstract":"<jats:sec id=\"abs1-1\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Pain during dressing changes is a major concern for individuals with chronic wounds, such as venous leg ulcers, diabetic foot ulcers and pressure sores. These procedures, often performed in community settings, can cause significant physical and emotional distress. Despite widespread recognition of this issue, there has been no comprehensive synthesis of evidence to guide effective pain management strategies during dressing changes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-2\">\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>This mixed-methods systematic review aimed to evaluate interventions designed to reduce pain during dressing changes for chronic wounds and to explore the experiences of patients and healthcare professionals.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-3\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Twenty-nine studies were included: 8 effectiveness studies, 11 surveys and 10 qualitative studies. Data were sourced from six electronic databases and analysed using a convergent segregated approach. Quantitative data were summarised using synthesis without meta-analysis guidance, while qualitative and survey data were analysed thematically. Findings were integrated using the preventing pain at dressing change pathway, a framework developed with stakeholder input to map interventions across the dressing change process.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-4\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Pain was found to be highly variable and influenced by wound type, healing stage and previous experiences. Non-adhesive and ibuprofen-releasing foam dressings consistently reduced pain, while gauze dressings were frequently associated with increased discomfort. Topical treatments, such as eutectic mixture of local anaesthetics cream and morphine gel, showed promise. Patients valued skilled, communicative nursing care and involvement in their own treatment. Distraction techniques and post-dressing pain relief were identified as important but under-researched. Pain assessment practices were inconsistent, and formal tools were rarely used.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-5\">\n                    <jats:title>Limitations<\/jats:title>\n                    <jats:p>The broad scope of eligible interventions increases the risk of missing relevant studies. Most studies were small and at moderate to high risk of bias.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-6\">\n                    <jats:title>Future work<\/jats:title>\n                    <jats:p>Future research should focus on evaluating underused interventions (e.g. distraction, patient involvement), improving pain assessment practices, and addressing equity gaps in pain management. Investment in nurse training and consistent care protocols is essential.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-7\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Effective pain management during dressing changes requires a holistic, patient-centred approach. While some interventions show promise, many commonly used strategies lack robust evidence. The preventing pain at dressing change pathway offers a practical framework for guiding future practice, research and policy development.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-8\">\n                    <jats:title>Funding<\/jats:title>\n                    <jats:p>This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR131023.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3310\/gjrc0808","type":"journal-article","created":{"date-parts":[[2025,8,8]],"date-time":"2025-08-08T06:51:27Z","timestamp":1754635887000},"page":"1-57","update-policy":"https:\/\/doi.org\/10.3310\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Interventions to reduce pain at dressing change of chronic wounds: a mixed-methods systematic review"],"prefix":"10.3310","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4141-8863","authenticated-orcid":true,"given":"Fiona","family":"Campbell","sequence":"first","affiliation":[{"name":"Centre for Evidence and Implementation Science, University of Birmingham, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4536-4794","authenticated-orcid":true,"given":"Ruth","family":"Wong","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8800-3596","authenticated-orcid":true,"given":"Georgina","family":"Wilkins","sequence":"additional","affiliation":[{"name":"Centre for Evidence and Implementation Science, University of Birmingham, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-3130-0574","authenticated-orcid":true,"given":"Menghan","family":"Wang","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-6688-560X","authenticated-orcid":true,"given":"Katie","family":"Twentyman","sequence":"additional","affiliation":[{"name":"Institute of Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5110-0384","authenticated-orcid":true,"given":"Richard","family":"Cooper","sequence":"additional","affiliation":[{"name":"Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8455-8786","authenticated-orcid":true,"given":"Andrew","family":"Kirkcaldy","sequence":"additional","affiliation":[{"name":"Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"6221","published-online":{"date-parts":[[2026,8]]},"reference":[{"key":"key2026081014082100_ref1-bib1","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1111\/wrr.12683","article-title":"The humanistic and economic burden of chronic wounds: a systematic review","volume":"27","author":"Olsson","year":"2018","journal-title":"Wound Repair Regen"},{"key":"key2026081014082100_ref2-bib2","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1111\/apm.13344","article-title":"Single cells and bacterial biofilm populations in chronic wound infections","volume":"132","author":"Lichtenberg","year":"2023","journal-title":"APMIS"},{"key":"key2026081014082100_ref3-bib3","doi-asserted-by":"crossref","first-page":"292","DOI":"10.12968\/jowc.2017.26.6.292","article-title":"The health economic burden that acute and chronic wounds impose on an average clinical commissioning group\/health board in the UK","volume":"26","author":"Guest","year":"2017","journal-title":"J Wound Care"},{"key":"key2026081014082100_ref4-bib4","first-page":"8","article-title":"Chronic wounds: magnitude, socioeconomic burden and consequences","volume":"4","author":"Gupta","year":"2021","journal-title":"Wounds Asia"},{"key":"key2026081014082100_ref5-bib5","doi-asserted-by":"crossref","first-page":"1543","DOI":"10.3390\/pharmaceutics13101543","article-title":"Extracellular vesicles as therapeutic tools for the treatment of chronic wounds","volume":"13","author":"Bray","year":"2021","journal-title":"Pharmaceutics"},{"key":"key2026081014082100_ref6-bib6","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1111\/j.1742-481X.2012.00947.x","article-title":"Wound infection, dressings and pain, is there a relationship in the chronic wound?","volume":"10","author":"Cutting","year":"2012","journal-title":"Int Wound J"},{"key":"key2026081014082100_ref7-bib7","doi-asserted-by":"crossref","first-page":"399","DOI":"10.2147\/JPR.S281876","article-title":"Measures and effects of pain management for wound dressing change in outpatient children in Western China","volume":"14","author":"Wu","year":"2021","journal-title":"J Pain Res"},{"key":"key2026081014082100_ref8-bib8","doi-asserted-by":"crossref","first-page":"e2107","DOI":"10.1002\/nop2.2107","article-title":"Effects of non\u2010pharmacological interventions on pain in wound patients during dressing change: a systematic review","volume":"11","author":"Ma","year":"2024","journal-title":"Nurs Open"},{"key":"key2026081014082100_ref9-bib9","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: an updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"key2026081014082100_ref10-bib10","doi-asserted-by":"crossref","first-page":"2108","DOI":"10.11124\/JBISRIR-D-19-00169","article-title":"Methodological guidance for the conduct of mixed methods systematic reviews","volume":"18","author":"Stern","year":"2020","journal-title":"JBI Evid Synthesis"},{"key":"key2026081014082100_ref11-bib11","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1111\/iwj.12996","article-title":"Chronic wounds in Australia: a systematic review of key epidemiological and clinical parameters","volume":"16","author":"McCosker","year":"2018","journal-title":"Int Wound J"},{"key":"key2026081014082100_ref12-bib12","doi-asserted-by":"crossref","first-page":"1193","DOI":"10.1111\/iwj.12443","article-title":"Estimating the costs associated with the management of patients with chronic wounds using linked routine data","volume":"13","author":"Phillips","year":"2015","journal-title":"Int Wound J"},{"key":"key2026081014082100_ref14-bib14","doi-asserted-by":"crossref","first-page":"100600","DOI":"10.1016\/j.puhip.2025.100600","article-title":"EQUALSS GUIDE multiple: a novel framework for equity-focused evidence synthesis","volume":"9","author":"McCann","year":"2025","journal-title":"Public Health Pract"},{"key":"key2026081014082100_ref15-bib15","doi-asserted-by":"crossref","first-page":"l4898","DOI":"10.1136\/bmj.l4898","article-title":"RoB 2: a revised tool for assessing risk of bias in randomised trials","volume":"366","author":"Sterne","year":"2019","journal-title":"BMJ"},{"key":"key2026081014082100_ref16-bib16","doi-asserted-by":"crossref","first-page":"i4919","DOI":"10.1136\/bmj.i4919","article-title":"ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions","volume":"355","author":"Sterne","year":"2016","journal-title":"BMJ"},{"key":"key2026081014082100_ref17-bib17","doi-asserted-by":"crossref","first-page":"e011458","DOI":"10.1136\/bmjopen-2016-011458","article-title":"Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS)","volume":"6","author":"Downes","year":"2016","journal-title":"BMJ Open"},{"key":"key2026081014082100_ref18-bib18","volume-title":"CASP (Qualitative Studies) Checklist","author":"CASP","year":"2023"},{"key":"key2026081014082100_ref19-bib19","doi-asserted-by":"crossref","first-page":"l6890","DOI":"10.1136\/bmj.l6890","article-title":"Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline","volume":"368","author":"Campbell","year":"2020","journal-title":"BMJ"},{"key":"key2026081014082100_ref20-bib20","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1177\/1403494820987466","article-title":"The Gender Pain Gap: gender inequalities in pain across 19 European countries","volume":"50","author":"Bimpong","year":"2022","journal-title":"Scand J Public Health"},{"key":"key2026081014082100_ref21-bib21","doi-asserted-by":"crossref","first-page":"1770","DOI":"10.1016\/j.ajem.2019.06.014","article-title":"Racial and ethnic disparities in the management of acute pain in US emergency departments: meta-analysis and systematic review","volume":"37","author":"Lee","year":"2019","journal-title":"Am J Emerg Med"},{"key":"key2026081014082100_ref22-bib22","doi-asserted-by":"crossref","first-page":"1187","DOI":"10.1016\/j.jpain.2009.10.002","article-title":"Racial and ethnic disparities in pain: causes and consequences of unequal care","volume":"10","author":"Anderson","year":"2009","journal-title":"J Pain"},{"key":"key2026081014082100_ref24-bib24","first-page":"A36","article-title":"Treatment of painful skin ulcers with a biocellulose dressing containing lidocaine","volume":"18","author":"Alvarez","year":"2006","journal-title":"Wounds"},{"key":"key2026081014082100_ref25-bib25","first-page":"4","article-title":"Effect of an ibuprofen-releasing foam dressing on wound pain: a real-life RCT","volume":"342","author":"Palao i Domenech","year":"2008","journal-title":"J Wound Care"},{"key":"key2026081014082100_ref26-bib26","doi-asserted-by":"crossref","first-page":"123","DOI":"10.1186\/s40814-018-0312-6","article-title":"Eutectic mixture of local anaesthetics (EMLA R) as a primary dressing on painful chronic leg ulcers: a pilot randomised controlled trial","volume":"4","author":"Purcell","year":"2018","journal-title":"Pilot Feasibility Stud"},{"key":"key2026081014082100_ref27-bib27","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1111\/j.1742-481X.2007.00308.x","article-title":"A pilot (real-life) randomised clinical evaluation of a pain-relieving foam dressing: (ibuprofen-foam versus local best practice)","volume":"4","author":"Sibbald","year":"2007","journal-title":"Int Wound J"},{"key":"key2026081014082100_ref28-bib28","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1097\/01.ASW.0000394027.82702.16","article-title":"Reduction of bacterial burden and pain in chronic wounds using a new polyhexamethylene biguanide antimicrobial foam dressing-clinical trial results","volume":"24","author":"Sibbald","year":"2011","journal-title":"Adv Skin Wound Care"},{"key":"key2026081014082100_ref29-bib29","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1111\/j.1742-481X.2011.00901.x","article-title":"Topical morphine gel in the treatment of painful leg ulcers, a double\u2010blind, placebo\u2010controlled clinical trial: a pilot study","volume":"9","author":"Bastami","year":"2012","journal-title":"Int Wound J"},{"key":"key2026081014082100_ref30-bib30","doi-asserted-by":"crossref","first-page":"409","DOI":"10.12968\/jowc.2004.13.10.27268","article-title":"The importance of pain reduction through dressing selection in routine wound management: the MAPP study","volume":"13","author":"Meaume","year":"2004","journal-title":"J Wound Care"},{"key":"key2026081014082100_ref31-bib31","doi-asserted-by":"crossref","first-page":"209","DOI":"10.12968\/jowc.2012.21.5.209","article-title":"The impact of atraumatic vs conventional dressings on pain and stress","volume":"21","author":"Upton","year":"2012","journal-title":"J Wound Care"},{"key":"key2026081014082100_ref32-bib32","doi-asserted-by":"crossref","first-page":"S4, S6, S8 passim","DOI":"10.12968\/bjon.2010.19.Sup4.48418","article-title":"The assessment and treatment of wound pain at dressing change","volume":"19","author":"Bell","year":"2010","journal-title":"Br J Nurs"},{"key":"key2026081014082100_ref33-bib33","article-title":"Il dolore durante il cambio della medicazione nei pazienti con ulcera agli arti inferiori","volume":"5","author":"Bouvet","year":"2016","journal-title":"Pain Nurs Magazine"},{"key":"key2026081014082100_ref34-bib34","doi-asserted-by":"crossref","first-page":"333","DOI":"10.12968\/jowc.2006.15.8.26941","article-title":"Patients\u2019 perceptions of the impact of treatments and products on their experience of leg ulcer pain","volume":"15","author":"Briggs","year":"2006","journal-title":"J Wound Care"},{"key":"key2026081014082100_ref35-bib35","first-page":"318","article-title":"Chronic ulcers and everyday living: patients\u2019 perspective in the United Kingdom","volume":"21","author":"Fagervik-Morton","year":"2009","journal-title":"Wounds"},{"key":"key2026081014082100_ref36-bib36","doi-asserted-by":"crossref","first-page":"369","DOI":"10.12968\/jowc.2000.9.8.26282","article-title":"Nurses\u2019 views about pain and trauma at dressing changes: results of a national survey","volume":"9","author":"Hollinworth","year":"2000","journal-title":"J Wound Care"},{"key":"key2026081014082100_ref37-bib37","doi-asserted-by":"crossref","first-page":"76","DOI":"10.12968\/jowc.2002.11.2.26676","article-title":"Nurses\u2019 views about pain and trauma at dressing changes: a central European perspective","volume":"11","author":"Kammerlander","year":"2002","journal-title":"J Wound Care"},{"key":"key2026081014082100_ref38-bib38","doi-asserted-by":"crossref","first-page":"862","DOI":"10.1590\/S0104-07072012000400017","article-title":"Assessment of pain during leg ulcers\u2019 dressing change","volume":"21","author":"Oliveira","year":"2012","journal-title":"Texto Contexto-Enfermagem"},{"key":"key2026081014082100_ref39-bib39","article-title":"Dressing-related pain in patients with chronic wounds: an international patient perspective","volume":"159","author":"Price","year":"2008","journal-title":"Int Wound J"},{"key":"key2026081014082100_ref40-bib40","first-page":"115","article-title":"Description of pressure ulcer pain at rest and at dressing change","volume":"26","author":"Szor","year":"1999","journal-title":"J Wound Ostomy Continence Nurs"},{"key":"key2026081014082100_ref41-bib41","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1097\/WON.0000000000001059","article-title":"Assessment of wound-related pain experiences of patients with chronic wounds: a multicenter cross-sectional study in eastern China","volume":"51","author":"Wei","year":"2024","journal-title":"J Wound Ostomy Continence Nurs"},{"key":"key2026081014082100_ref42-bib42","doi-asserted-by":"crossref","first-page":"1975","DOI":"10.1111\/jocn.12858","article-title":"Unravelling nocebo effect: the mediating effect of anxiety between anticipation and pain at wound dressing change","volume":"24","author":"Woo","year":"2015","journal-title":"J Clin Nurs"},{"key":"key2026081014082100_ref43-bib43","doi-asserted-by":"crossref","first-page":"1373","DOI":"10.14393\/BJ-v32n1a2016-32738","article-title":"Perceptions of elderly living with leg ulcer","volume":"32","author":"Buso","year":"2016","journal-title":"Biosci J"},{"key":"key2026081014082100_ref44-bib44","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1080\/15360288.2018.1527801","article-title":"A preliminary study of pain relieving dressings for older adults with chronic leg ulcers from the provider\u2019s perspective: a qualitative study","volume":"32","author":"Docking","year":"2018","journal-title":"J Pain Palliat Care Pharmacother"},{"key":"key2026081014082100_ref45-bib45","doi-asserted-by":"crossref","first-page":"235","DOI":"10.1046\/j.1471-6712.2001.00018.x","article-title":"Elderly persons\u2019 experiences of living with venous leg ulcer: living in a dialectal relationship between freedom and imprisonment","volume":"15","author":"Ebbeskog","year":"2001","journal-title":"Scand J Caring Sci"},{"key":"key2026081014082100_ref46-bib46","doi-asserted-by":"crossref","first-page":"S5","DOI":"10.12968\/bjon.2003.12.Sup2.11327","article-title":"Why patients do not comply with compression bandaging","volume":"12","author":"Edwards","year":"2003","journal-title":"Br J Nurs"},{"key":"key2026081014082100_ref47-bib47","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1111\/j.1365-2648.2006.04007.x","article-title":"Patient stories of living with a pressure ulcer","volume":"56","author":"Hopkins","year":"2006","journal-title":"J Adv Nurs"},{"key":"key2026081014082100_ref48-bib48","first-page":"21","article-title":"A focus group study into patients\u2019 perception of chronic wound pain","volume":"4","author":"Mudge","year":"2008","journal-title":"Wounds UK"},{"key":"key2026081014082100_ref49-bib49","doi-asserted-by":"crossref","first-page":"51","DOI":"10.12968\/jowc.2003.12.2.26469","article-title":"How living with a leg ulcer affects people\u2019s daily life: a nurse-led study","volume":"12","author":"Rich","year":"2003","journal-title":"J Wound Care"},{"key":"key2026081014082100_ref50-bib50","doi-asserted-by":"crossref","first-page":"494","DOI":"10.1111\/j.1365-2648.2006.04140.x","article-title":"Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives","volume":"57","author":"Spilsbury","year":"2007","journal-title":"J Adv Nurs"},{"key":"key2026081014082100_ref51-bib51","doi-asserted-by":"crossref","first-page":"1092","DOI":"10.1111\/j.1365-2648.1995.tb03110.x","article-title":"Living with a venous leg ulcer: a descriptive study of patients\u2019 experiences","volume":"22","author":"Walshe","year":"1995","journal-title":"J Adv Nurs"},{"key":"key2026081014082100_ref52-bib52","doi-asserted-by":"crossref","first-page":"103774","DOI":"10.1016\/j.ijnurstu.2020.103774","article-title":"Venous leg ulcer management in Australian primary care: patient and clinician perspectives","volume":"113","author":"Weller","year":"2021","journal-title":"Int J Nurs Stud"},{"key":"key2026081014082100_ref53-bib53","first-page":"S1","article-title":"Holistic management of wound-related pain: an overview of the evidence and recommendations for clinical practice","volume":"25","author":"Holloway","year":"2024","journal-title":"J Wound Manag"},{"key":"key2026081014082100_ref54-bib54","article-title":"Topical agents or dressings for pain in venous leg ulcers","volume":"11","author":"Briggs","year":"2012","journal-title":"Cochrane Database Syst Rev"},{"key":"key2026081014082100_ref55-bib55","doi-asserted-by":"crossref","first-page":"1346","DOI":"10.1186\/s12912-025-03984-z","article-title":"The effect of virtual reality on patients\u2019 experiences of pain during painful wound care procedure: a systematic review and meta-analysis of randomized controlled trials","volume":"24","author":"\u00c7etinkaya \u00d6zdemir","year":"2025","journal-title":"BMC Nurs"}],"container-title":["Health Technology Assessment"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/njl-admin.nihr.ac.uk\/document\/download\/2051758","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.journalslibrary.nihr.ac.uk\/sites\/journalslibrary\/files\/journal_data\/GJRC0808\/GJRC0808.xml","content-type":"text\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/njl-admin.nihr.ac.uk\/document\/download\/2051758","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T11:14:03Z","timestamp":1786360443000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.journalslibrary.nihr.ac.uk\/hta\/GJRC0808"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8]]},"references-count":53,"alternative-id":["10.3310\/GJRC0808"],"URL":"https:\/\/doi.org\/10.3310\/gjrc0808","relation":{},"ISSN":["2046-4924"],"issn-type":[{"value":"2046-4924","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8]]},"assertion":[{"value":"This content has been made freely available to all.","name":"free","label":"Free to read"},{"value":"04-2021","name":"contractual_start_date","label":"contractual_start_date","group":{"name":"article_history","label":"Article History"}},{"value":"05-2025","name":"editorial_review_begun","label":"editorial review begun","group":{"name":"article_history","label":"Article History"}},{"value":"10-2025","name":"accepted_for_publication","label":"Accepted for publication","group":{"name":"article_history","label":"Article History"}}]}}