Socio‐healthcare for older people in the Mediterranean basin: an integrative review and quality appraisal

Public Health Nursing REVIEW SUMMARY Socio-Healthcare for Older People in the Mediterranean Basin: An Integrative Review and Quality Appraisal Ana María Porcel-Gálvez1Regina Allande-Cussó1Isotta Mac Fadden2Eleni Ferentinou3 Maria Zafiropoulou4Marta Lima-Serrano1 1Department of Nursing, University of Seville, Seville, Spain 2Department of Sociology and Communication, Univesrity of Salamanca, Salamanca, Spain 3Department of Medicine, University of Patras, Rion, Patras,, Greece 4Department of Humanities, Social Sciences and Economics, Hellenic Mediterranean University, Crete, Greece Correspondence: Regina Allande-Cussó (r[email protected]) Received: 2 October 2023 Revised: 24 August 2024 Accepted: 30 September 2024 Funding: This study was supported by the TEC-MED Project (A_A.3.2_0376) research project of the ENI CBC 2014-2020. Keywords: elderly population | integrated care | person-centered care | public health | socio-healthcare practices ABSTRACT Objectives: The aging Mediterranean Basin population presents complex challenges for healthcare systems, which require innovative care approaches. The study aimed to critically assess 19 socio-healthcare practices in the Mediterranean Basin that target the elderly population by analyzing their theoretical foundations, integration of care services, ethical considerations, gender-specific approaches, and use of technology. Design: An integrative literature review was conducted using a structured methodology. Sample: Diverse sources across multiple languages were searched, with the inclusion criteria focusing on the alignment of sociohealthcare practices with the components of the nursing metaparadigm, the incorporation of transversal values, and relevance to the elderly population. Results: The socio-healthcare practices exhibited common themes, such as person-centered care, interdisciplinary collaboration, and incorporation of technology for coordinated care delivery. Ethical principles of autonomy, dignity, and respect were central, with some socio-healthcare practices addressing gender-specific care needs. Evidence-based findings emphasized holistic care, integration, ethics, and innovation in elderly socio-healthcare. Conclusions: New eldercare frameworks should integrate these aspects, which offer a comprehensive approach to addressing the complex needs of elderly patients. Managers should design systems prioritizing patient well-being, whereas policymakers should develop equitable and high-quality care policies that collectively improve the well-being of the elderly population in the Mediterranean Basin. 1 Background Global life expectancy has continued to increase, with estimates projecting that the elderly population will have accounted for approximately 80% of the total population of low- to middleincome countries by 2050 (Rudnicka et al. 2020). Studies have observed that older individuals are at risk for social exclusion (Walsh, Scharf, and Keating 2017), which influences poverty, capabilities, quality of life, and vulnerability dimensions (Whelan, Layte, and Maître 2002). This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2024 The Author(s). Public Health Nursing published by Wiley Periodicals LLC. Public Health Nursing, 2024; 0:1–15 https://doi.org/10.1111/phn.13453 1of15 European social rights ensure sustainable social protection and access to essential services, including long-term care, fostering dignity and societal engagement (Garben 2019). However, Europe’s proximity to African and Asian Mediterranean countries has revealed shared shortfalls in the socio-ethical care of dependent elderly individuals (World Health Organization 2020). The increasing prevalence of frailty has challenged health policies and development (Brañas et al. 2018; Porcel-Gálvez et al. 2021). The healthcare continuum, shaped by determinants and resources, needs fresh paradigms that emphasize prevention (Pérez-Wilson et al. 2020). In line with this, the World Health Organization has advocated for holistic, patient-centered care (Statistical Office of the European Union 2020). Some contemporary care paradigms believe that health, a holistic entity intertwined with culture and economy, can be affected by social aspects (Braveman, Egerter, and Williams 2011;Dalsania et al. 2022). Models like Leininger’s Transcultural Nursing (Leininger 2002), Pender’s Health Promotion (Pender 2011), and Antonovsky’s salutogenic reflect these elements (Vinje, Langeland, and Bull 2017). Patient-centered care aligns with sociodemographic reality, integrating preferences, families, caregivers, prevention, and promotion (Ekman et al. 2011; McCormack and McCance 2006). The social determinants of the health paradigm recognize health as a product of not only biological factors but also social, economic, and environmental factors. In this sense, culture is considered an asset for well-being given its contribution toward improving people’s health and well-being. This viewpoint has not been sufficiently addressed from the perspective of the elderly population and elder care, highlighting the importance of analyzing the care paradigm in the Mediterranean and its emphasis on promising and successful experiences that can be replicated in similar contexts (Butler-Jones 2012). Cultivating culturally sensitive research on social determinants is crucial for formulating effective interventions that enhance the health and well-being of older adults from diverse cultural backgrounds. Overcoming the hurdles hindering culturally sensitive research can guarantee that social care models incorporate successful strategies from previous research in this domain (Clark 2017). In this sense, the socio-healthcare approach has been selected to investigate promising strategies through which healthcare systems can be more responsive to the social needs of their patients. Hence, research has focused on the intersection between social care and healthcare (Alonso Morán et al. 2014). Integrated care coordinates professionals, patients, and families, adapting to improve health and quality of life (Van Kemenade and van der Vlegel-Brouwer 2019), and cultural shifts are crucial to promoting evidence-based person-centered care (Santana et al. 2018). Other contemporary care paradigms provide holistic healthcare for the person, not only biologically but also psychologically, socially, and spiritually (Santos, Lima-Basto, and Researcher 2014); attend to the culturally diverse backgrounds of patients (Lekas, Pahl, and Fuller Lewis 2020); and consider community- and telehealth-based care to provide more decentralized care closer to patients and families (Sharman 2014). In this context, the nursing discipline, as a care science grounded in its metaparadigm (Fawcett 2013), allows for the integration of all these care paradigms. The nursing metaparadigm comprises the person, the environment, health, and the nursing role. “Person” considers cultural contexts; “environment” includes cultural, social, and economic influences; “health” involves life processes; and “nursing role” corresponds to practice (Bahramnezhad et al. 2015). 1.1 Problem Identification Countries located within the Mediterranean Basin share cultural bonds and mutual challenges in the care of the elderly amid social and health crises. However, evidence has shown that multiculturality adds vulnerability (Grady 2009). Despite nurses engaging in socio-ethical care practices, a comprehensive review regarding such practices has been absent, hindering the analysis of promising practices aligned with contemporary care paradigms. Within the “Cross-Border Cooperation” initiative implemented by the European Union under the European Neighbourhood Instrument (ENI) 2014–2020, the TEC-MED project (Development of a Transcultural social-ethical-care model for dependent population in Mediterranean basin) (Porcel et al. 2019)aimsto create a cross-cultural ethical care model for vulnerable elderly populations in the Mediterranean. In line with this, Spain (Lead Beneficiary [LB]), Greece, Italy, Lebanon, Egypt, and Tunisia (Participant Partners) have been guided by the values of justice, privacy, equity, accessibility, community engagement, and the welfare state. In this complex context, an integrative review is one of the crucial phases before the TEC-MED model development. This review synthesizes evidence on promising socio-healthcare practices for dependent and socially excluded older people in the Mediterranean Basin from the viewpoint of defining the elements of the nursing metaparadigm. 2 Methods An integrative literature review was conducted following the methodology proposed by Whittemore and Knafl (2005). An integrative review is a specific review method that summarizes past empirical or theoretical literature to provide a more comprehensive understanding of a particular phenomenon or healthcare problem (Broome 2000). This approach has the potential to allow for diverse primary research methods to become a substantial part of evidence-based socio-healthcare practice (Whittemore and Knafl 2005). The integrative review followed the five suggested steps (1) problem identification stage (2) literature search stage, (3) data evaluation, (4) data analysis, and (5) presentation (Whittemore and Knafl 2005). 2.1 Problem Identification Stage The initial step of any review involves identifying the problem and purpose. The current integrative review was guided by 2of15 Public Health Nursing,2024 15251446, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/phn.13453 by Readcube (Labtiva Inc.), Wiley Online Library on [16/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TABLE 1 Search strategy. "Home Care Services"[Mesh] OR “community care”[tiab] OR “Social services” [Mesh] OR “Social support” [Mesh] OR “primary care”[tiab] OR “Home care services”[tiab] OR “Home care service”[tiab] OR “Domiciliary care”[tiab] OR “Formal home care”[tiab] OR “district nursing”[tiab] OR “home care”[tiab] OR “domestic health care”[tiab] OR “domiciliary care”[tiab] OR "home care agencies"[MeSH Terms] OR “home care agencies”[tiab] OR "Home Care Services/organization and administration"[Mesh] OR "Home Health Aides/organization and administration"[Mesh] OR “long term care”[tiab] OR “Apps”[tiab] OR “Social Media Groups”[tiab] OR “Arts”[tiab] OR “Social inclusion”[Mesh] OR “Social care module” AND "aged"[Mesh] OR "aged, 65 and over"[Mesh] OR "aged"[tiab] OR "aged, 65and over"[tiab] OR “frail elderly”[tiab] OR “oldest old”[tiab] OR “older people”[tiab] OR “senior”[tiab] OR elder*. the following research question: “In older individuals and/or those at risk of social exclusion, what promising socio-healthcare attention practices have the most impact on outcomes?” On the first level of analysis, the selected health and social care practices covered the components of the nursing metaparadigm (person, environment, health, and nursing role/caregiving), focused on older people; on the second level of analysis, it was identified how health and social care practices incorporated transversal values (i.e., development of digital care platforms, ethics, gender, and transcultural aspects). 2.2 Literature Search Stage 2.2.1 Search and Identification A systematic search was conducted to identify scientific and gray literature. The search strategy was agreed upon by the whole team- Leader Beneficiary and Participant Partners (Table 1). Then, following an agreed flow diagram (Figure 1), the Leader Beneficiary searched English scientific literature and English gray documents and for gray literature in Spanish. At the same time, Participant Partners searched the rest of the national languages (i.e., Italian, Greek, Arabic, and French) for gray literature. Concerning the scientific literature the Cochrane Library was searched followed by Scopus, Web of Science, and PubMed. Grey literature was accessed through various platforms, such as Open Grey, Google Scholar Database, ProQuest, and local/national authority websites. 2.2.2 Inclusion and Exclusion Criteria The current study considered original research articles, case studies, systematic reviews, and theoretical studies published from 2000 to 2019 in English, Spanish, French, Italian, Greek, and Arabic. Gray literature describing specific socio-healthcare practices for older, dependent, and socially excluded individuals was included. Practices are needed to explain the nursing metaparadigm components and consider transversal values. No exclusion criteria were defined. 2.3 Screening, Data Analysis, and Synthesis The registers obtained from the searches were inserted into a shared Excel document. Following the PRISMA guidelines (Page et al. 2021) (Supporting Material 1), two different reviewers did the screening and data extraction. Once this process was completed, all researchers reached a consensus regarding which studies to include in the analysis during an online meeting. A flowchart was designed to graphically represent the process of selecting final studies (Figure 2). Among the 9481 documents from official databases and 833 from other sources/grey literature, a total of 19 studies had ultimately been included in the integrative review. The final set of selected studies was presented in a table containing the following categories: country, source type, theoretical basis, cross-sectional values, and aspects of the nursing metaparadigm addressed. The synthesis approach used was a deductive method based on the framework of nursing discipline (Fawcett 2013). Thus, as a first level of analysis, we identified those socio-health practices that respond to the components of the nursing metaparadigm: person, health, environment, and nursing/provision of care. On the other hand, at a second level of analysis, it was identified how the selected sociohealthcare practices considered the transversal values of ethics, gender, use of new technologies, and transcultural aspects (Table 2). 2.3.1 Critical Appraisal The LB reviewers evaluated the quality and level of evidence of the included studies according to the Johns Hopkins Institute of Medicine guidelines (Dang and Dearholt 2017). The evaluation focused on the quality of methodological practice development. The documents identified for each socio-healthcare practice corresponded to one of the following four typologies: 1. Published article: A written research study or analysis officially published in a journal or publication. 2. Program report: A comprehensive document detailing the activities, goals, outcomes, and processes of a specific program or project. 3. Statutes of the organization: Formal written rules and regulations outlining the structure, purpose, and governance of an organization. 4. Annual activity report: A summary document that outlines the activities, achievements, and challenges of an organization or program over the course of a year 3of15 15251446, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/phn.13453 by Readcube (Labtiva Inc.), Wiley Online Library on [16/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TABLE 2 The most promising socio-healthcare practices. Nursing metaparadigm (first analysis level) Transversal values (second analysis level) Initiative Country Source type Person Health Environment Nursing/health delivery Technology/ eHealth Ethics Gender Transcultural aspects Quality appraisal 1 Sustainable tailored integrated care for older people in Europe- SUSTAIN (de Bruin et al. 2018; Lette et al. 2020; Reynolds et al. 2021; Stoopetal.2019) Austria, Belgium, Estonia, Germany, Ireland, Norway, Spain, Netherlands, United Kingdom Published article Patient, family, and caregivers (older people) Autonomy and wellbeing Thehomecare and community services Multiprofessional support. Holistic and interdisciplinary approach. Person-centered care Undeveloped Dignity and safety Non-specified Non-specified IIIB 2Benchmarking integrated care for better management of chronic and age-related conditions in Europe- INTEGRATE (Borgermans and Devroey 2017; Cash-Gibson and Rosenmoller 2014) Spain, Sweden, Netherlands Germany Published articles Patients (older people) Autonomy, well-being, and social integration (integrated care) Different management levels Multiprofessional support. Holistic and interdisciplinary approach. Person-centered care. Empowerment of older people Clinical information systems assessed Non-specified Non-specified Cultural sensibility VA 3Providingintegrated health and social care for older persons-issues, problems, and solutions- PROCARE (Leichsenring 2004; Leichsenring and Alaszewski 2004) Austria, Denmark, Finland, France, Germany, Greece, Italy, the Netherlands, and the United Kingdom Published article and book Patients (older people and disabled people) Autonomy, well-being, and social integration (integrated care) Different management levels: exploring the coordination between social and health systems Multiprofessional support. Holistic and interdisciplinary approach. Person-centered care. Empowerment of older people Non-specified Dignity Non-specified Non-specified VB (Continues) 4of15 Public Health Nursing,2024 15251446, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/phn.13453 by Readcube (Labtiva Inc.), Wiley Online Library on [16/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TABLE 2 (Continued) Nursing metaparadigm (first analysis level) Transversal values (second analysis level) Initiative Country Source type Person Health Environment Nursing/health delivery Technology/ eHealth Ethics Gender Transcultural aspects Quality appraisal 4CareWellProject (Mateo-Abad et al. 2020,Mateo-Abadetal. 2020) Spain, Croatia, Poland, Italia, United Kingdom Published article Patients and caregivers (older people) Autonomy and mental health. Home-based care Multiprofessional support. Holistic and interdisciplinary approach. Person-centered care. ICT tools: Electronic prescription, Messaging clinicians and Patients, Electronic Health Record, Call Center, Virtual Conference, Personal Health Folder, Nurse Information System, Educational Platform Patient and caregiver empowerment Non-specified Non-specified IIA 5 Sustainable integrated care models for multi-morbidity: delivery, financing, and performance- SELFIE (Leijten et al. 2018) Netherlands, Germany, Austria, Norway, Hungary, United Kingdom, Croatia, Spain Published article Patient and informal caregivers (older people and frail people) Autonomy and mental health Housing and social network, community Multiprofessional support. Holistic and interdisciplinary approach. Person-centered care. Empowerment of older people Shared information systems Risk management and consideration of personal preferences or needs Non-specified Non-specified VA 6 BUURTZORG (Buurtzorg 2023) The Netherlands Program report Patient and family (older people) Autonomy and wellbeing Networks in the neighborhood Home care nurse-led program. Person-centered care. Empowerment of older people Web-based care platform to support the Buurtzorg program: research-based, standardized taxonomy for healthcare; assessment, interventions, and outcomes Based on universal human values Non-specified Active in 24 countries and has a small international team to support VB (Continues) 5of15 15251446, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/phn.13453 by Readcube (Labtiva Inc.), Wiley Online Library on [16/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TABLE 2 (Continued) Nursing metaparadigm (first analysis level) Transversal values (second analysis level) Initiative Country Source type Person Health Environment Nursing/health delivery Technology/ eHealth Ethics Gender Transcultural aspects Quality appraisal 7 KAPI- open care centers for older people “Health pro Elderly” (Pavlova et al. 2017; Sourtzi et al. 2008) Greece (partners: Austria, Czech Republic, Germany, Italy, Netherlands, Poland, Slovenia, Slovakia, Spain, and the United Kingdom) Program report Patients (older people) Quality of life, physical and mental health Open care centers Multiprofessional support. Holistic and interdisciplinary approach. Person-centered care Undeveloped Universal socio-health support Non-specified Universal socio-health support IIIB 8WEDO (Social Care Wales 2023) Wales Statutes of the organization Patient, family, and caregivers (older people) Social integration and wellbeing Work in the community Social workers and healthcare workers. Person-centered care. Empowerment of older people Thematic reports and case studies to show the progress towards realizing its vision on the webpage Organizational values: equality, accessibility, and inclusion Non-specified The prevention of discrimination, the promotion of equality and diversity VB 9 Takaful and Karama (World Bank Group 2023) Egypt Statutes of the organization Patients (older people) Social integration, autonomy Foster homes Multiprofessional support. Holistic and interdisciplinary approach. Person-centered care Undeveloped Organization value: dignity Promoting Egyptian Women’s Empowerment Non-specified VB 10 Sekem (SEKEM Initiative 2018) Egypt Statutes of the organization Patient and caregiver (older people) Functional ability, physical and mental health Home cares Multiprofessional support. Holistic and interdisciplinary approach. Person-centered care A platform for collecting clinical data and analyzing results Organization value: empowerment Non-specified Diversity support VB (Continues) 6of15 Public Health Nursing,2024 15251446, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/phn.13453 by Readcube (Labtiva Inc.), Wiley Online Library on [16/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TABLE 2 (Continued) Nursing metaparadigm (first analysis level) Transversal values (second analysis level) Initiative Country Source type Person Health Environment Nursing/health delivery Technology/ eHealth Ethics Gender Transcultural aspects Quality appraisal 11 COMUNITÀ MONTANA GRAND PARADIS (Unité des Communes Valdôtaines Grand-Paradis 2023) Italy Statutes of the organization Patients and caregivers (older people) Active aging and wellbeing Residential structure and home care Multiprofessional support. Training programs for caregivers. Holistic and interdisciplinary approach. Person-centered care Undeveloped Non-specified Non-specified Transnational cooperation programs VB 12 COMMUNITÀ DI SANT ‘EGIIDIO (Community of Sant’Egidio—Ministry of Health in Italy 2023) Italy Statutes of the organization Patients (older people) Social integration, autonomy, and mental health Street, home care,carecenter, and home-sharing Multiprofessional support and volunteers. Holistic and interdisciplinary approach. Person-centered care Telemedicine program Organizational values: dignity and integrity Non-specified Minority support programs such as gypsy VB 13 IDRAAC Institute for Development, Research, Advocacy, andAppliedCare (IDRAAC 2023) Lebanon Statutes of the organization Patients (children, adults, older people) Mental health and social integration The research center, clinic center, workshops Multiprofessional support. Holistic and interdisciplinary approach. Person-centered care A platform for communication between users and with the organization’s professionals Non-specified Specific training programs on gender issues Non-specified VB 14 SANAD Home Hospice Care (SANAD 2020) Lebanon Statutes of the organization Patient and family (older people) Mental health, wellbeing Hospice care center Multiprofessional support. Training for the healthcare professional. Holistic and interdisciplinary approach. Person-centered care Undeveloped Respect for the beliefs, values, and practices of the patient and his family Non-specified Respect for the beliefs, values, and practices of the patient and his family VB 15 The Lebanese Center for Palliative Care- Balsam (Lebanese Ministry of Interior 2017) Lebanon Annual activity report Patient and family (adults and older people) Autonomy, well-being, and mental health Home cares Multiprofessional support. Holistic and interdisciplinary approach. Person-centered care Undeveloped Organization value: Dignity Inclusive care, considering gender, religion, and sexual orientation Inclusive cares: considering gender, religion, and sexual orientation VB (Continues) 7of15 15251446, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/phn.13453 by Readcube (Labtiva Inc.), Wiley Online Library on [16/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TABLE 2 (Continued) Nursing metaparadigm (first analysis level) Transversal values (second analysis level) Initiative Country Source type Person Health Environment Nursing/health delivery Technology/ eHealth Ethics Gender Transcultural aspects Quality appraisal 16 Matia Foundation (Fundación MATIA 2023) Spain Annual activity report Patient and family (older people) Autonomy and adaptation Hospitals, daycare centers, long-term centers, home cares Multiprofessional support. Training programs for caregivers and health professionals. Holistic and interdisciplinary approach Undeveloped Beneficence, justice, autonomy; dignity Non-specified Non-specified VB 17 Aging Lab Foundation (Ageing Lab Foundation 2020) Spain Annual activity report Patient and family (older people) Active Aging Creation of research and professional networks Research projects to implement their results in real life. Empowerment of older people Some projects are related to caring platform development Beneficence, justice, autonomy Non-specified Non-specified IV 18 Saint John of God (San Juan de Dios 2021) Spain Annual activity report Patients (older people, disabled people, frailty people) Autonomy, holistic conception, and Integration in society Hospitals, daycare centers, long-term centers, home cares Multiprofessional support. Holistic and interdisciplinary approach. Empowerment of older people Undeveloped Beneficence, justice, autonomy Non-specified Consideration of cultural and religious values VB 19 Pilares Foundation (Fundación PILARES 2021 Spain Annual activity report and book Patients (older people) Autonomy, community participation. Improvement in health quality Hospitals, daycare centers, long-term centers, home cares, community centers Multiprofessional support. Holistic and interdisciplinary approach. Person-centered care. Empowerment of older people Undeveloped Beneficence, justice, autonomy; dignity Non-specified Non-specified VB 8of15 Public Health Nursing,2024 15251446, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/phn.13453 by Readcube (Labtiva Inc.), Wiley Online Library on [16/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License FIGURE 1 Systematic Literature (scientific and gray literature) review flowchart. PP, Participant Partner; WP, Work Package. [Color figure can be viewed at wileyonlinelibrary.com] 3Results 3.1 Descriptive Analysis and Quality Appraisal A total of 9432 records were obtained from the initial literature search. Among them, 19 socio-healthcare practices were finally selected: two from Egypt, four from Spain, three from Lebanon, two from Italy, one from the Netherlands, one from Wales, and six from a consortium of countries across Europe. All socio-healthcare practices were published in English, except for those from Italy and Spain, which were published in Italian and Spanish, respectively. According to source type, we found five published articles, two program reports, seven organization statutes, and four annual activity reports. A summary of the 19 most promising socio-healthcare practices is shown in Table 2. Following the recommendations of the Johns Hopkins Institute of Medicine (Dang and Dearholt 2017), the quality of the scientific evidence for the design of all socio-healthcare practices included in our study was evaluated. Among the 19 socio-healthcare practices identified as promising, 16 obtained a VB quality level. Only Sustain (de Bruin et al. 2018; Lette et al. 2020; Reynolds et al. 2021; Stoop et al. 2019) and KAPI (Pavlova et al. 2017; Sourtzi et al. 2008) obtained a IIIB and Care Well IIA quality level. Among the selected socio-healthcare practices, only Sustain, Integrate (Borgermans and Devroey 2017; Cash-Gibson and Rosenmoller 2014), Procare (Leichsenring 2004; Leichsenring and Alaszewski 2004), Care Well (Mateo-Abad et al. 2020,Mateo-Abadetal.2020), Selfie (Leijten et al. 2018), and KAPI had scientific publications in journals. The remaining socio-healthcare practices belonged to associations or foundations that have not conducted secondary studies with scientific publications. Only two of the six sociohealthcare practices that have been published in scientific article format (e.g., Sustain and Care Well) demonstrated a higher level of evidence than the rest (Figure 3). 3.2 Analysis Levels 3.2.1 First Level: Nursing Metaparadigm The analysis, on the first level, is based on each component of the nursing metaparadigm. Figure 4summarizes the main characteristics of the most promising health and social care practices described below regarding the person, health, environment, and nursing and health delivery. 9of15 15251446, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/phn.13453 by Readcube (Labtiva Inc.), Wiley Online Library on [16/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License