Understanding supported self‐management for people living with a lower‐grade glioma: Implementation considerations through the lens of normalisation process theory

Abstract Background Supported self‐management can improve clinical and psychosocial outcomes in people with cancer; the considerations required to implement self‐management support (SMS) for people living with a lower‐grade glioma (LGG)—who often have complex support needs—are not known. We aimed to identify and understand these implementation considerations through the lens of normalisation process theory (NPT), from the perspectives of healthcare professionals (HCP) and people with LGG. Methods We conducted semistructured interviews with HCPs who support adults with brain tumours (n = 25; 12 different healthcare professions), and people with LGG who had completed primary treatment (n = 28; male n = 16, mean age 54.6 years, mean time since diagnosis 8.7 years), from across the United Kingdom. Interviews were transcribed and inductive open coding conducted, before deductively mapping to constructs of NPT. We first mapped HCP data, then integrated data from people with LGG to explore alignment in experiences and perspectives. Results We generated supporting evidence for all four NPT constructs and related subconstructs, namely: ‘Coherence’, ‘Cognitive participation’, ‘Collective action’ and ‘Reflexive monitoring’. Data from HCPs and people with LGG clearly demonstrated that effective SMS constitutes a collective activity. Key implementation considerations included: ensuring awareness of, and access to, support; building strong HCP‐support recipient relationships; and careful inclusion of close family and friends. We identified pertinent challenges, such as identifying support needs (influenced by the extent to which those with LGG engage in help‐seeking), resistance to support (e.g., technology literacy), training for HCPs and HCP cooperation. Conclusions This study demonstrates the collective nature of, and provides insight into the individual roles within, supported self‐management. We outline considerations to operationalise, sustain and appraise the implementation of SMS for people with LGG. Patient or Public Contribution People with brain tumours, and informal caregivers, were involved in the development of information materials and topic guides to ensure accessibility and pertinence. They also had opportunities to comment on interview findings.

expectancy of 5-15 years following diagnosis, 8,9 and can experience wide-ranging symptoms and impairments (e.g., fatigue, seizures, cognitive deficits) that adversely affect health-related quality of life. 10,11These impacts may persist long-term, particularly concerning fatigue and emotional impact. 12Consequently, people with LGG may have prolonged, multifaceted supportive care needs; it is, therefore, important to identify how they can be supported and empowered to self-manage their condition.

People with
LGG have shown a willingness to engage in selfmanagement, reporting the use of a diverse and extensive number of self-management strategies; the most common strategy type was 'using support' (e.g., receiving support from family). 13This complements the finding that people with brain tumours desire timely access to information and support from HCPs to help them self-manage (e.g., development of shared self-management care plans for support recipients and their family). 14However, little is known about how HCPs perceive their role in providing self-management support (SMS) for people with LGG.In a study of advanced cancer (which did not focus on brain tumours), HCPs differed in their practices, adopting varied instructive, collaborative or advisory approaches to SMS. 15 There was a recent 'call to action' for self-management in cancer care, calling for a shift in care culture from people being passive recipients to active partners in their care, to embed cocreated person-centred SMS. 16Therefore, attitudes towards, and the acceptability of SMS, are crucial implementation considerations 17 which need to be understood from both the HCP and support recipient perspective.Furthermore, for SMS to be successful, the barriers to implementation at the organisational and HCP level also need to be understood and overcome. 18 other cancers, the few available studies indicate that key HCP barriers to implementation of SMS included time, communication between HCPs and appropriate knowledge and training 19,20 ; in addition, lack of HCP confidence in providing SMS led to reduced motivation. 21A competency framework has been developed to inform SMS training for cancer nurses 22 ; however, healthcare organisations need to be ready and willing to implement SMS, which requires a process of change. 23For people with LGG specifically, the considerations required to implement SMS are poorly understood.
Normalisation process theory (NPT) 24 offers a generalisable framework outlining the generative mechanisms of social action and the considerations required to implement a new practice into routine care.NPT has been used in a diverse range of healthcare settings to explain the implementation processes of complex interventions. 25erefore, our study aimed, for the first time, to use the lens of NPT to identify and understand the considerations required to implement SMS for people living with an LGG, from the perspectives of HCPs and people with LGG.

| Design
This qualitative study, part of the wider Ways Ahead project, 26 generated data on HCPs' and people with LGGs' experiences of (supporting someone) living with an LGG; the present analysis focused on the considerations that may influence the implementation of SMS.Ways Ahead was reviewed and approved by the Wales Research Ethics Committee (REC ref: 20/WA/0118).

| Participants and recruitment
HCPs were eligible if they were a member of a relevant multidisciplinary team (MDT), involved in the care of adults with brain tumours (e.g., clinical nurse specialist); or were involved in the support of adults with brain tumours outside of National Health Service (NHS) care pathways (e.g., counsellors).
People with a diagnosis of grade 2 or 3 oligodendroglioma or grade 2 astrocytoma, based on histology or molecular features 27 were eligible if they were aged ≥18 years at diagnosis, resident in the United Kingdom, and were stable under observation, or had completed primary treatment; hereafter, we refer to these as people with LGG.
We identified potentially eligible HCPs and people with LGG through collaborating NHS sites and The Brain Tumour Charity networks.People with LGG require multidisciplinary management, so in addition to consultant clinical oncologists and neurosurgeons, there are clinical nurse specialists, and some services may have additional roles (e.g., Occupational Therapist, Clinical Neuropsychologist).Therefore, we used purposive sampling to ensure HCP recruitment comprised a range of healthcare professions, across the United Kingdom.Recruitment of people with LGG comprised of a range of ages, sex, diagnoses and time since diagnosis (1-5, 6-10, >10 years).
For NHS sites, HCPs within their respective MDTs, and people with LGG identified from medical records, were given an information sheet by the principal investigator or another HCP at the site.For The Brain Tumour Charity networks, B. R. linked the information sheet to a study advertisement, which was disseminated through the charity's newsletters.HCPs and people with LGG were asked to register their interest by calling or emailing the study team; B. R. called each interested person to answer any potential questions, then if confirmed as eligible and willing to participate, arranged a convenient date and time for interview.We conducted recruitment between August 2020 and May 2022; recruitment continued until we judged that reasonable data sufficiency was achieved. 28

| Data generation
B. R. and L. D., both trained and experienced in qualitative research, remotely conducted semistructured interviews, via a phone or video call (e.g., Zoom or Teams), as per interviewee preference.Immediately before each interview, audio-recorded consent was acquired, and demographic information was collected (e.g., from people with LGG: sex, age, diagnosis, treatment; from HCPs: profession, years working with people with brain tumours).
We used separate topic guides for HCP and people with LGG interviews (Files S1 and S2); each comprised open questions informed by the literature and expert knowledge.Both topic guides were reviewed by HCPs (J.L. and S. W.); the topic guide for people with LGG was also reviewed by a brain tumour Patient and Public Involvement panel and modified appropriately.Any new issues raised in an interview were added to the respective guide, to be explored in subsequent interviews.
For HCP interviews, participants were first asked to broadly reflect on their role in supporting people living with a brain tumour.
We then explored participants' views on the support needs of people with LGG, how these needs are identified, what support is available following treatment completion, including their perception of, and role in supporting, self-management and any challenges faced in providing support.
For interviews with people with LGG, participants were first asked to broadly reflect on life following their diagnosis.We then explored participants' views on how they had been impacted by the tumour and its treatment, how they had managed, their perceived support needs and whether support was received, including their experiences with seeking, receiving, and engaging with, healthcare support.People with LGG were offered a £20 voucher as a thank you for their time and given details of relevant charities and helplines on a postinterview sheet, which they could consult if they wanted further information or support.
Across both interview sets, we used probing questions to explore further, and all participants were afforded the opportunity to raise any additional issues of importance to them.We audio-recorded each interview; interviews lasted on average 72 min (48-93 min) for HCPs and 102 min (54-167 min) for people with LGG.

| Data analysis
Interviews were transcribed verbatim and anonymised; transcripts were checked for accuracy against the audio-recordings.The present analysis aimed to identify and understand what might influence the implementation of SMS for people with LGG.We commenced   sufficiency was reached when we judged that sufficient data had been generated to support and understand the implementation considerations for SMS. 28llowing this, we deductively mapped our codes to the four constructs of NPT, 24 1.Initial deductive coding included discussion with L. S. and T. F., who is an expert in NPT; the mapping of codes was then revised and finalised.Overall, we examined how our codes corresponded to each generative mechanism of social action in the context of implementing SMS for people with LGG.
As NPT is a theory more traditionally used to describe and explain implementation as the activity of professional providers, we started by mapping the HCP data to the NPT constructs, then interrogated each of these mappings with reference to the experiences and perspectives of the support recipients.We have explored and reported elsewhere the self-management strategies used by people with LGG. 13 Here, we wanted to explicitly explore the alignment (or otherwise) of the data from people with LGG with HCPs' experiences and perspectives relating to issues of SMS implementation.If data relevant to a particular (sub-)construct was seen amongst people with LGG, but had not been raised by HCPs, this was added to the analysis.Abbreviations: HCP, healthcare professional; LGG, lower-grade glioma.

| Overview of findings
HCPs spoke about how the impact of the tumour and its treatment on people with LGG (e.g., cognitive deficits) created specific challenges for effective engagement in self-management for this population.The data we generated mapped extensively to all four NPT constructs and related subconstructs; some subconstructs were more supported by the data than others (Table 1).Our findings, described below by construct with supporting quotes throughout, outline the considerations required to operationalise, sustain and appraise the implementation of SMS for people with LGG.

| Coherence
Coherence encompassed HCPs' sense-making of self-management, and their perceived role and responsibilities in providing SMS.Most HCPs expressed an internalised perception of the importance of providing SMS; they highlighted the value of 'empowering' people with LGG to 'look after themselves' beyond the clinical care setting.
Self-management to me is about empowering somebody with the right information and resource, access to resource to be able to take more ownership on their health and wellbeing, and actually [the support recipient] is saying what they want done basically.

HCP39 (Clinical Nurse Specialist)
The key differentiation between self-management and other healthcare support was HCPs' perception that supporting selfmanagement is about promoting independence, so that people with LGG can 'take responsibility' for managing their condition.However, | 13 of 20 the desire to promote independence may not always be achievable; several people with LGG described how they experienced challenges with a loss of independence and reported having to be reliant on others (e.g., due to losing their driving licence), which was not always something they desired.
The loss of my licence and independence.I think loss of independence is probably the biggest [challenge].
I suppose having to rely on others to do a lot of things.Several HCPs spoke about a desire to build a shared understanding with people with LGG that self-management is not one individual's responsibility; they acknowledged the importance of a communal approach to self-management, with people with LGG assuming their own responsibilities, and close family and friends assuming support responsibilities in the home environment.Aligned with this, people with LGG recognised that the role and strength of their support networks influenced their ability to engage with self-management, for example, through the provision of practical support with housework and transport.

| Cognitive participation
Cognitive participation encompassed the relational work of HCPs and people with LGG to build and sustain a 'community' of supporting self-management.To initiate SMS, both HCPs and people with LGG outlined the importance of signposting to relevant information and available support.However, many people with LGG expressed that this was often lacking and that they had to proactively seek support.
Several HCPs conveyed that, due to a lack of insight (often because of the impairments that the tumour can cause) or desire not to be a burden, some people with LGG do not seek the help they need.
T A B L E 3 Lower-grade glioma participants' characteristics at the time of the interview.People with LGGs' initiation of self-management, and HCPs' perception of the amount of support required, was also influenced by the presence and strength of the support recipient's support network to collectively contribute to their self-management.For example, one person with LGG felt unable to go out in public without company, in case they had a seizure.
Several HCPs stated that the support available to which people with LGG could be signposted is poor in comparison to other cancers; where brain injury rehabilitation services were available, people with LGG were often excluded due to the progressive nature of their condition.HCPs and people with LGG similarly reported that access to support can also be influenced by the services available within the person's location.
Each area has different services, so we've still got that postcode lottery problem.HCP43 (Specialist allied health professional) HCPs spoke about how their perception of whether they could make a valid contribution to supporting self-management was influenced by challenges with the support recipient's acceptance.
This was corroborated by some people with LGG who described how they were struggling to process the consequences of their condition and were resistant to having an active role in their own self-management.
To collectively sustain engagement in (supporting) selfmanagement, HCPs and people with LGG acknowledged the importance of regular opportunities to report support needs to someone involved in their care (e.g., through a screening tool) and LGG to recognise needs and sustain SMS.Still, some HCPs outlined that there are people who seek support, but then resist the support that is offered.
You've got your patients who you just try and help, and you try and encourage, but they'll ring you up and they want help, but then they don't accept your advice or offers to signpost or whatever or refer to whatever.HCP33 (Clinical Nurse Specialist)

| Collective action
Collective action encompassed the considerations required to operationalise the implementation of SMS, to 'make it work' in practice.Several HCPs highlighted the importance of coordination between HCPs for them to become aware of someone with support needs; this was particularly important for allied HCPs offering a specific service (e.g., occupational therapy).People with LGG expressed that communication between HCPs was often not streamlined, with information getting lost as they were 'passed around'.Some HCPs echoed this sentiment and suggested that quality of care would improve with improved HCP cooperation, rather than dealing with each support need as a 'separate entity'.
Most HCPs expressed the value of building a good rapport with their support recipients to facilitate effective communication about their support needs.People with LGG appreciated when HCPs showed strong social skills; this generated trust and helped them feel reassured.
I'm sure that all [healthcare professionals] are medically highly skilled, but obviously that's not the only bit of the job is it.You have to understand people.
Understand how they're feeling.Know how to speak to them.Make them feel reassured at what is a very frightening period in their life.Pa28 (aged 66, male, grade 2 astrocytoma) Still, some HCPs spoke about how there is a 'fine line' in these relationships; some HCPs wanted people with LGG to assume more responsibility in the decision making concerning desired support.
Both HCPs and people with LGG outlined the value of including close family and friends in support to ensure they understood the condition and its consequences, and how they can be involved in supporting self-management.Particularly, both groups identified | 15 of 20 challenges with cognitive deficits that mean additional assistance in the home environment can be beneficial.
It's very hard to self-manage if a memory deficit is there because at the end of the day a prompt is needed to set the prompt.Because she couldn't write the list herself or couldn't set the phone reminders reliably.So, I think if you're truly isolated, that has a massive impact on how successful you are going to be.HCP28 (Consultant Clinical Oncologist) Both HCPs and people with LGG outlined the implications of poor technology literacy on access to, and engagement with, support, acknowledging that 'some people won't [access the support] if they've got to do it online'.Several HCPs identified their own training needs to deliver support, linking this to the need for cooperation between HCPs; they noted that if they were not trained to provide particular types of support, or not aware that support could be provided for particular problems beyond their expertise, this would often be missing from their service.
If you are managing or leading a service, you sometimes lead to your strengths, just as I am doing.
And our support, unknowingly, has been missing out on a few key aspects because that's not within my expertise.HCP17 (Macmillan centre manager) All HCPs stressed the impact of resources on the execution of support provision.This largely encompassed financial constraints within the service, and time; the lack of availability and flexibility of HCPs meant several HCPs felt unable to 'benchmark against other centres' to improve their services or maintain the desired continuity of care.Most people with LGG expressed additional concerns, primarily with transport challenges to attend support, and their own financial resources to acquire equipment.

| Reflexive monitoring
Reflexive monitoring encompassed HCPs' appraisal of the worth and effectiveness of implementing SMS.Several HCPs acknowledged the need to avoid information overload when providing SMS, as sharing too much information at once could be overwhelming for the recipient.Similarly, people with LGG reflected on the importance of appropriately timed information sharing, and the need to consider the time it takes to accept their condition; they suggested it would be most effective to have access 'at your fingertips' for when it is required.
HCPs determined that implementing SMS was useful for empowering people with LGG to take an active role in their care.
An important element of this was managing the expectations of people with LGG to help them work towards realistic goals.
With a lot of the brain tumour patients we've got to help them to be quite realistic and support that as an ongoing thing.So, I guess it's important to address that although support might help them, it's not going to fix all of their problems but help them manage their problems themselves.HCP36 People with LGG can have complex, multi-faceted supportive care needs. 10Amongst people with cancer, clinical and psychosocial outcomes can be improved through effective engagement in selfmanagement 29 ; this requires support from HCPs, family, and friends. 4e considerations required to implement SMS for people with LGG are poorly understood.We aimed to identify and understand these implementation considerations, through the lens of NPT, from the perspectives of HCPs and people with LGG.
We generated extensive supporting evidence for all four NPT In our findings, HCPs recognised the value of their role in selfmanagement.This included providing the information and support to promote independence and empower people to confidently engage in self-management.Integrating the perspective of people with LGG highlighted that independence can be difficult to maintain or achieve.
This, in turn, emphasises a need for sustained support over time.
There are potential organisational constraints with HCP time and flexibility in relation to being able to assess individual's support needs, and maintain SMS provision, over the longer-term.HCPs emphasised that participation goes both ways, requiring help seeking from the support recipient, so that HCPs can identify and maintain awareness of supportive care needs.This may be influenced by the possibility that people with LGG could underestimate, and thus not seek help for, cognitive, psychological or social changes. 30Still, people with LGG outlined the importance of building trust in their relationships with HCPs and expressed difficulties with reporting needs within the opportunities provided, as these are often focused on the treatment for the tumour.Particularly, psychological support is a challenging aspect of SMS to implement and embed for support providers, as this is an area that people reported to be especially difficult to seek and access help for.
Our findings also highlight the critical importance of interaction between HCPs to operationalise SMS provision.indicates the importance of appropriately timed information sharing, so that people can access support when they are ready. 34However, a 2021 environmental scan found that most online self-management resources concern active treatment, with few specifically directed at people with brain tumours, particularly those with LGG, living longerterm. 35Our findings also outlined further challenges with accessibility, due to technology literacy and cognitive deficits; hence, online support may be lacking, not preferred, or require support to access. 36 outline, from both perspectives, the pivotal role of a person's support network in bridging the gap between provision of SMS from the HCP, to the implementation of self-management strategies in the home environment; this was particularly important for those with cognitive deficits.Thus, available support may be a key determinant of successful self-management for people with LGG.In further analyses from the Ways Ahead project, to be reported elsewhere, we have found from interviews with informal caregivers that family and friends provide wide-ranging support (e.g., practical, emotional, cognitive) for people with LGG.Nonetheless, the data reported in the current paper suggests that including informal caregivers in SMS requires careful consideration to ensure self-management remains person-centred.Informal caregivers may have their own perspectives of what is, or should be, important to the support recipient, and these should not dominate the priorities of the people with LGG themselves.Moreover, informal caregivers may have their own supportive care needs, particularly related to emotional burden, 37,38 and, while they are important, how these can best be met requires further consideration.For example, informal caregivers of people with a brain tumour desire stronger connections with HCPs to help them feel able to provide support. 39While we acknowledged the value of this in our findings, we would concur with HCPs in our study who stressed the importance of permission from the support recipient to ensure inclusion of informal caregivers into SMS is appropriately managed.

| Strengths and limitations
The overarching strength of our study was the novel contribution A key limitation of our study, however, was that people with LGG with more limited capacity may have been discouraged from taking part, due to the expected interview length (approximately 90 min).
This means those with greater support needs or challenges engaging with self-management, may have been missed; multiple, shorter interviews could be considered in future research to mitigate risk of fatigue.Moreover, although telephone interviews have previously been shown to be effective for discussing sensitive issues, 44 in this context, in-person interviews may have helped the interviewer to better gauge the impairment of the participant.
Our eligibility criteria included people with grade 3 oligodendrogliomas; while such diagnoses would not necessarily be considered low-grade, we included them because they have a similar prognosis to those with low-grade brain tumours. 8The people with LGG were up to 18 years postdiagnosis.Molecular assessment of tumours became routine after some of the participants were diagnosed, and for that reason, we included participants with either eligible molecular features or a diagnosis based on histology only.
Recruitment across the United Kingdom and through The Brain Tumour Charity networks means that HCPs and people with LGG involved in this study could be in different services; hence, some instances where people with LGG provided contrasting experiences to the practice described by HCPs might be because their local services did not include the elements, or did not operate in the way, described by the interviewed HCPs.Further, HCPs often spoke more widely about the services provided for people with brain tumours rather than focusing only on LGG.Those with different types of brain tumours may share similar experiences of impairments, functional limitations, and reduced life expectancy. 45Therefore, our findings are likely to also have relevance for SMS provision for people with other types of brain tumours.

| CONCLUSION
Continues) analysis with an inductive, open coding approach; B. R. and M. B., both trained in qualitative analysis, independently generated initial codes following familiarisation with a subset of transcripts of people with LGG (n = 6 of 28) and HCPs (n = 5 of 25).The coding frame was refined following discussion between the researchers; the remaining transcripts were then coded by B. R. As coding progressed, findings and uncertainties were discussed with M. B. and L. S. Data namely: 'Coherence', 'Cognitive participation', 'Collective action' and 'Reflexive monitoring'.Each construct has four related subconstructs that were used to guide the deductive mapping (e.g., 'Cognitive participation' encompasses initiation, enrolment, legitimation, and activation); construct descriptions are provided in Table

Pa22 (aged 43 ,
female, grade 2 astrocytoma) Most HCPs outlined an understanding of the specific role and responsibilities they have in supporting self-management, working with the person's own realities and preferences to provide personalised support.This included: appropriate signposting to information and support; providing tools (i.e., suggesting specific self-management strategies) to empower both people with LGG and families; and listening to individual's needs to co-develop goals.It's very much listening and knowing the patient, knowing where they're at in terms of their journey, their pathway and unpicking what sort of things can be put in.So, it's not just a psychological thing, physical thing, it's all of them basically.HCP39 (Clinical Nurse Specialist) However, some people with LGG felt that the support received was focused on 'what they can do to treat your tumour, not treat you as a person'.
constructs and related subconstructs, namely: 'Coherence', 'Cognitive participation', 'Collective action' and 'Reflexive monitoring'.Overall, our findings demonstrate the ways that SMS for people with LGG should be understood as a collective and collaborative activity.We offer important insights into: (1) how people with LGG can both be supported and enabled to support themselves effectively through service provision; and (2) the challenges that need to be addressed to facilitate implementation of SMS.
Overall, we have an advanced understanding of the mechanisms of SMS implementation by demonstrating and emphasising the collective nature of SMS for people with LGG.Due to the importance of engagement from HCPs, people with LGG, and informal caregivers, it is crucial that SMS is seen as a collective activity, requiring the kinds of interactions and communications that support effective selfmanagement for people with LGG.Improved partnership working between HCPs and people with LGG also needs to recognise the importance of the autonomy, agency, and capacity of the support recipient.This closer partnership might be facilitated by providing HCPs with the skills and confidence to work with peoples' concerns that are 'non-treatment focused'.Co-created with service users to develop more personalised models of care, the Bridges approach to SMS emphasises the collaborative nature of SMS and involves training practitioners to use language and other techniques as part of everyday practice.40In stroke and neurorehabilitation across 24 UK NHS Trusts, successful implementation and integration of the Bridges approach to supported self-management demonstrated increased skills and confidence in providing SMS.Still, a key distinction between care pathways for stroke patients and people with LGG is the incurable nature and likelihood of progression in people with LGG, which may influence the approach to rehabilitation.Viewed as collective activity, SMS must be acceptable and feasible for all stakeholders.This underlines the need for a detailed understanding of the desired support and design preferences for SMS from the perspective of each stakeholder.For example, support groups may appear to be a valuable platform for sharing advice and experiences; however, functional challenges (e.g.location, timing) and issues with heterogeneity across people with LGG, may preclude engagement, which has potential implications for the scope of providing group support.Ultimately, future development of supported self-management interventions for people with LGG26 should include comprehensive co-design with all stakeholders, to acknowledge and look to overcome the challenges and constraints highlighted in our findings.In other research guided by NPT, Mäkelä et al.41 demonstrated the feasibility of co-designing SMS approaches with people with traumatic brain injury (TBI) and showed promise in addressing implementation challenges related to complex service pathways for people with TBI.
to a very limited evidence base concerning the implementation of SMS for people with LGG.This was underpinned by several methodological strengths, including: (1) our application of NPT, which provided a deeper understanding of the mechanisms of social action, that underpin implementation processes 42 ; (2) involvement of multiple stakeholders (HCPs and people with LGG), which allowed us to understand SMS implementation considerations from the perspectives of service providers and support recipients 43 ; (3) inclusion of a wide range of healthcare professions, which helped us capture the challenges faced by different roles within SMS provision and (4) inclusion of HCPs from numerous regions across the United Kingdom, which provided diverse experiences with implementation challenges from within different provider settings, representing different levels of organisation readiness to support self-management.
This study provided, for the first time, a comprehensive insight into the collective nature of, and individual roles within, supported selfmanagement and outlined the considerations required to operationalise, sustain and appraise the implementation of SMS for people with LGG, through the lens of NPT.This provides a crucial first step towards creating a shift in care culture to embed co-created SMS, by shedding light on factors influencing implementation that need to be overcome at the organisation, HCP and support recipient levels.Our findings can inform the development of supported self-management interventions for people with LGG, ensuring these have a line of sight to future implementation into routine care.AUTHOR CONTRIBUTIONS Ben Rimmer: Writing-original draft; investigation; methodology; writing-review and editing; project administration; formal analysis.Tracy Finch: Conceptualisation; funding acquisition; writing-review Coherence-The sense-making work that people do individually and collectively when they are faced with the problem of operationalising some set of practices Healthcare professional participants' characteristics at the time of the interview.
31consideration of a SMS training programme could be beneficial.Such a programme has improved confidence in SMS provision for HCPs in other cancers.31In the United Kingdom, the Tessa Jowell Academy Programme connects brain tumour centres and provides a space to tackle challenges 32 ; this is an example of a platform that could help support emergent training interdisciplinary awareness of what support is needed by, and what has already been provided for, the support recipient.Altogether, these considerations would help ensure SMS is more integrated and holistic enabling people to be more effectively supported to selfmanage.Further, our findings also acknowledge that HCPs may have training needs, and support provision may be influenced by locally available expertise; hence