Assessing the health benefits of advice services: using research evidence and logic model methods to explore complex pathways

Alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B trial): protocol for a mixed-methods process evaluation of a randomised controlled trial

INTRODUCTION

An association between deep sedation and adverse short-term outcomes has been demonstrated although this evidence has been inconsistent. The A2B (alpha-2 agonists for sedation in critical care) sedation trial is designed to determine whether the alpha-2 agonists clonidine and dexmedetomidine, compared with usual care, are clinically and cost-effective. The A2B intervention is a complex intervention conducted in 39 intensive care units (ICUs) in the UK. Multicentre organisational factors, variable cultures, perceptions and practices and the involvement of multiple members of the healthcare team add to the complexity of the A2B trial. From our pretrial contextual exploration it was apparent that routine practices such as type and frequency of pain, agitation and delirium assessment, as well as the common sedative agents used, varied widely across the UK. Anticipated challenges in implementing A2B focused on the impact of usual practice, perceptions of risk, ICU culture, structure and the presence of equipoise. Given this complexity, a process evaluation has been embedded in the A2B trial to uncover factors that could impact successful delivery and explore their impact on intervention delivery and interpretation of outcomes.

METHODS AND ANALYSIS

This is a mixed-methods process evaluation guided by the A2B intervention logic model. It includes two phases of data collection conducted during and at the end of trial. Data will be collected using a combination of questionnaires, stakeholder interviews and routinely collected trial data. A framework approach will be used to analyse qualitative data with synthesis of data within and across the phases. The nature of the relationship between delivery of the A2B intervention and the trial primary and secondary outcomes will be explored.

ETHICS AND DISSEMINATION

All elements of the A2B trial, including the process evaluation, are approved by Scotland A Research Ethics Committee (Ref. 18/SS/0085). Dissemination will be via publications, presentations and media engagement.

TRIAL REGISTRATION NUMBER

NCT03653832.

A participatory evaluation of legal support in the context of health-focused peer advocacy with people who are homeless in London, UK

Legal problems can be cause and consequence of ill-health and homelessness, necessitating efforts to integrate responses to these challenges. How to respond to legal issues within the context of health services for people who are homeless is though unclear. Groundswell piloted providing legal support to peer advocates (who have current or past experience of homelessness) and clients currently homeless in addition to their health-focused work. A participatory action-research design evaluated the emerging programme. Groundswell staff, both researchers and those involved in service delivery, co-led the research alongside an external researcher. Qualitative methods were used to understand the experiences of legal support. We interviewed peer advocates and volunteers (n = 8), Groundswell clients (n = 3) and sector stakeholders (n = 3). Interviews were linked to regular reflective recorded meetings (n = 7) where Groundswell staff and researchers discussed the programme and the evaluation. Data were analysed thematically. The findings focus on three themes. First, peer advocates' and clients' legal needs involve an experience of being overwhelmed by system complexity. Second, the legal support to peer advocates aided in brokering and signposting to other legal support, in the context of a supportive organisational culture. Third, support to clients can be effective, although the complexity of legal need undermines potential for sustainable responses. In conclusion, legal support for peer advocates should be developed by Groundswell and considered by other similar agencies. Legal support to people who are currently street homeless requires significant resources and so health-focused third-sector organisations maybe unable to offer effective support. Other modes of integration should be pursued. Findings also have implications for how the third sector relates to the government agencies implicated in the legal challenges facing people who are homeless.

Maximising the health impacts of free advice services in the UK: A mixed methods systematic review

After a decade of austerity spending cuts and welfare reform, the COVID-19 pandemic has posed further challenges to the finances, health and wellbeing of working-age, low-income people. While advice services have been widely seen (and funded) as an income maximisation intervention, their health and well-being impact is less clear. Previous systematic reviews investigating the link between advice services and health outcomes have found a weak evidence base and cover the period up until 2010. This mixed methods review examined up to date evidence to help understand the health impacts of free and independent welfare rights advice services. We included evaluations of free to access advice services on social welfare issues for members of the public that included health outcomes. Through comprehensive searches of two bibliographic databases and websites of relevant organisations we identified 15 articles based on a mixture of study designs. The advice interventions evaluated were based in a range of settings and only limited information was available on the delivery and nature of advice offered. We undertook a convergent synthesis to analyse data on the effectiveness of advice services on health outcomes and to explain variation in these outcomes. Our synthesis suggested that improvements in mental health and well-being measures are commonly attributed to advice service interventions. However, there is little insight to explain these impacts or to inform the delivery of services that maximise health benefits. Co-locating services in health settings appears promising and embracing models of delivery that promote collaboration between organisations tackling the social determinants of health may help to address the inherent complexities in the delivery of advice services and client needs. We make recommendations to improve routine monitoring and reporting by advice services, and methods of evaluation that will better account for complexity and context.

Preventing male suicide through a psychosocial intervention that provides psychological support and tackles financial difficulties: a mixed method evaluation

BACKGROUND

To help resolve high suicide rates in Bristol, North Somerset and South Gloucestershire, the charity Second Step was commissioned to roll-out the Hope service offering a psychosocial intervention for men, supporting them through acute distress and addressing financial difficulties. This study evaluated the impact of the Hope service on men at risk of suicide experiencing financial and other difficulties.

METHODS

Mixed methods study using: (i) a prospective cohort study design to compare depression, suicidal ideation and financial self-efficacy scores of men aged 30-64, referred to the service between October 2018 and July 2020, at baseline and 6 months follow-up and between low and moderate to high-intensity service users; and (ii) a qualitative interview study to evaluate the acceptability and impact of the Hope service to Hope service users.

RESULTS

There was a 49% reduction in depression score (mean reduction - 10.0, 95% CI - 11.7 to - 8.3) and in the proportion of service users with suicidal ideation (percent reduction - 52.5, 95% CI - 64.1% to - 40.9%) at 6 months follow-up compared to baseline. Financial self-efficacy scores increased by 26% (mean increase 2.9, 95% CI 1.8 to 3.9). Qualitative accounts illustrated how 'Hope saved my life' for several men interviewed; most respondents described being able to move forward and tackle challenges with more confidence following the Hope intervention. Professional advice to tackle financial and other difficulties such as housing helped to relieve anxiety and stress and enable practical issues to be resolved.

CONCLUSIONS

The Hope service offered practical and emotional support to men who have experienced suicidal feelings, redundancy, homelessness and poverty and occupies an important space between mental health and social care provision. Hope demonstrates the value of an intervention which cuts across traditional boundaries between psychiatric care and social advice agencies to provide, what is, in effect, an integrated care service.

A review of the effectiveness and experiences of welfare advice services co-located in health settings: A critical narrative systematic review

We conducted a narrative systematic review to assess the health, social and financial impacts of co-located welfare services in the UK and to explore the effectiveness of and facilitators and barriers to successful implementation of these services, in order to guide future policy and practice. We searched Medline, EMBASE and other literature sources, from January 2010 to November 2020, for literature examining the impact of co-located welfare services in the UK on any outcome. The review identified 14 studies employing a range of study designs, including: one non-randomised controlled trial; one pilot randomised controlled trial; one before-and-after-study; three qualitative studies; and eight case studies. A theory of change model, developed a priori, was used as an analytical framework against which to map the evidence on how the services work, why and for whom. All studies demonstrated improved financial security for participants, generating an average of £27 of social, economic and environmental return per £1 invested. Some studies reported improved mental health for individuals accessing services. Several studies attributed subjective improvements in physical health to the service addressing key social determinants of health. Benefits to the health service were also demonstrated through reduced workload for healthcare professionals. Key components of a successful service included co-production during service development and ongoing enhanced multi-disciplinary collaboration. Overall, this review demonstrates improved financial security for participants and for the first time models the wider health and welfare benefits for participants and for health service from these services. However, given the generally poor scientific quality of the studies, care must be taken in drawing firm conclusions. There remains a need for more high quality research, using experimental methods and larger sample sizes, to further build upon this evidence base and to measure the strength of the proposed theoretical pathways in this area.

Effectiveness of community interventions for protecting and promoting the mental health of working-age adults experiencing financial uncertainty: a systematic review

BACKGROUND

The COVID-19 pandemic has created a period of global economic uncertainty. Financial strain, personal debt, recent job loss and housing insecurity are important risk factors for the mental health of working-age adults. Community interventions have the potential to attenuate the mental health impact of these stressors. We examined the effectiveness of community interventions for protecting and promoting the mental health of working-age adults in high-income countries during periods of financial insecurity.

METHODS

Eight electronic databases were systematically screened for experimental and observational studies published since 2000 measuring the effectiveness of community interventions on mental health outcomes. We included any non-clinical intervention that aimed to address the financial, employment, food or housing insecurity of participants. A review protocol was registered on the PROSPERO database (CRD42019156364) and results are reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

From 2326 studies screened, 15 met our inclusion criteria. Five categories of community intervention were identified: advice services colocated in healthcare settings; link worker social prescribing; telephone debt advice; food insecurity interventions; and active labour market programmes. In general, the evidence for effective and cost-effective community interventions delivered to individuals experiencing financial insecurity was lacking. From the small number of studies without a high risk of bias, there was some evidence that financial insecurity and associated mental health problems were amenable to change and differences by subpopulations were observed.

CONCLUSION

There is a need for well-controlled studies and trials to better understand effective ingredients and to identify those interventions warranting wider implementation.

Financial inclusion and physical health functioning among aging adults in the sub-Saharan African context: Exploring social networks and gender roles

BACKGROUND

It remains poorly understood how financial inclusion influences physical health functioning in later life in sub-Saharan African context and whether the association differs by gender and social relationships. We aim 1) to examine the associations of financial inclusion with functional impairment during older age in Ghana; and 2) to evaluate whether gender and social networks modify this association.

METHODS

The cross-sectional analyses are based on a sample (N = 1,201) of study participants aged 50 years and over (M = 66.5 years, SD = 11.9, 63.3% female) deriving from the 2016-2017 AgeHeaPsyWel-HeaSeeB Study. Ordinary least squares (OLS) regression analyses with interactions were performed to estimate the link between financial inclusion and functional health and how the association is modified by gender and older age social networks.

RESULTS

The mean financial inclusion score was 1.66 (SD = 1.74) in women and 2.33 (SD = 1.82) in men whilst mean activities of daily living (ADL) score was 13.03 (SD = 4.99) and 14.85 (SD = 5.06) in women and men respectively. We found that financial inclusion was associated with decreases in ADL (total sample: β = -.548, p < .001; women: β = -.582, p < .001; men: β = -1.082 p < .001) and instrumental ADL (IADL) (total sample: β = -.359, p = .034; women: β = -.445, p = .026 but not in men). Social networks significantly moderated the association of financial inclusion with ADL such that the financially included who were embedded in a stronger constellation of social networks were 6% less likely to report ADL impairment compared to those with weaker social networks (β = -.062, p = .025).

CONCLUSIONS

The study provides empirical evidence for a better understanding of the association between financial inclusion and physical health functioning in the context of later life social networks. Interventions for functional health through financial inclusion in sub-Saharan Africa should include improving interpersonal and social networks for older adult and also through gender lenses.

Study protocol for the Healthier Wealthier Families (HWF) pilot randomised controlled trial: testing the feasibility of delivering financial counselling to families with young children who are identified as experiencing financial hardship by community-based nurses

INTRODUCTION

Poverty and deprivation can harm children's future health, learning, economic productivity and societal participation. The Australian Healthier Wealthier Families project seeks to reduce the childhood inequities caused by poverty and deprivation by creating a systematic referral pathway between two free, community-based services: universal, well-child nursing services, which provide health and development support to families with children from birth to school entry, and financial counselling. By adapting the successful Scottish 'Healthier Wealthier Children' model, the objectives of this Australian pilot are to test the (1) feasibility of systematising the referral pathway, and (2) short-term impacts on household finances, caregiver health, parenting efficacy and financial service use.

METHODS AND ANALYSIS

This pilot randomised controlled trial will run in three sites across two Australian states (Victoria and New South Wales), recruiting a total of 180 participants. Nurses identify eligible caregivers with a 6-item, study-designed screening survey for financial hardship. Caregivers who report one or more risk factors and consent are randomised. The intervention is financial counselling. The comparator is usual care plus information from a government money advice website. Feasibility will be evaluated using the number/proportion of caregivers who complete screening, consent and research measures, and access financial counselling. Though powered to assess feasibility, impacts will be measured 6 months post-enrolment with qualitative interviews and questionnaires about caregiver-reported income, loans and costs (adapted from national surveys, for example, the Household, Income and Labour Dynamics in Australia Survey); health (General Health Questionnaire 1, EuroQol five-dimensional questionnaire, Depression, Anxiety, Stress Scale short-form); efficacy (from the Longitudinal Study of Australian Children); and financial service use (study-designed) compared between arms.

ETHICS AND DISSEMINATION

Ethics committees of the Royal Children's Hospital (HREC/57372/RCHM-2019) and South West Sydney Local Health District (2019/ETH13455) have approved the study. Participants and stakeholders will receive results through regular communication channels comprising meetings, presentations and publications.

TRIAL REGISTRATION NUMBER

ACTRN12620000154909; prospectively registered. Pre-results.

International Evidence on the Impact of Health-Justice Partnerships: A Systematic Scoping Review

Background: Health-justice partnerships (HJPs) are collaborations between healthcare and legal services which support patients with social welfare issues such as welfare benefits, debt, housing, education and employment. HJPs exist across the world in a variety of forms and with diverse objectives. This review synthesizes the international evidence on the impacts of HJPs.

Methods: A systematic scoping review of international literature was undertaken. A wide-ranging search was conducted across academic databases and grey literature sources, covering OECD countries from January 1995 to December 2018. Data from included publications were extracted and research quality was assessed. A narrative synthesis approach was used to analyze and present the results.

Results: Reported objectives of HJPs related to: prevention of health and legal problems; access to legal assistance; health improvement; resolution of legal problems; improvement of patient care; support for healthcare services; addressing inequalities; and catalyzing systemic change. There is strong evidence that HJPs: improve access to legal assistance for people at risk of social and health disadvantage; positively influence material and social circumstances through resolution of legal problems; and improve mental wellbeing. A wide range of other positive impacts were identified for individuals, services and communities; the strength of evidence for each is summarized and discussed.

Conclusion: HJPs are effective in tackling social welfare issues that affect the health of disadvantaged groups in society and can therefore form a key part of public health strategies to address inequalities.

Financial Inclusion, Health-Seeking Behavior, and Health Outcomes Among Older Adults in Ghana

PURPOSE

This study examines the associations between financial inclusion, health-seeking behavior, and health-related outcomes in older persons in Ghana.

METHOD

Employing data from a 2016/2017 Aging, Health, Psychological Well-Being and Health-Seeking Behavior Study (N = 1,200; mean age = 66.2 years [standard deviation = 11.9], we estimated regression models of self-rated health (SRH), psychological distress (PD), and health-care use (HCU) on a variable representing compositional characteristics of financial inclusion.

RESULTS

Multivariate logistic and generalized Poisson models showed that financial inclusion is positively associated with SRH (β = .104, standard error [SE] = .033, p < .001) but inversely related to both PD (β = .038, SE = .032, p < .005) and HCU (β = -.006, SE = .009, p < .05) independent of other factors. However, after adjusting for socioeconomic and health-related factors, the associations were tempered and the effect of SRH decreased by 0.094 and PD increased by 0.065 points but HCU became statistically insignificant (β = -.020, SE = .0114, p > .05).

CONCLUSIONS

Financial services inclusion profoundly appears to buffer against and retard health-related challenges in later life. Social and health policies targeted at improving the health outcomes of older people should include and build on the growing recognition of the importance of inclusive financial services and strategies.

Exposing the impact of intensive advice services on health: A realist evaluation

Attention has turned to welfare advice as a potential health and social care intervention. However, establishing direct evidence of health impact has proven difficult. This is compounded by the need to understand both the facilitative contexts and mechanisms through which this impact occurs. This study investigated if, how and in which circumstances an intensive advice service had an impact on stress and well-being (as precursors to health impacts), for clients attending a branch of Citizens Advice, located in the North East of England. A mixed methods realist evaluation of three intensive advice services offered by Citizens Advice (CA) was operationalised in five phases: (a) Building programme theories, (b) refining programme theories, (c) Development of a data recording tool, (d) Testing programme theories with empirical data, (e) Impact interviews. This paper focuses on phase 4. The Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) and Perceived Stress Scale (PSS) were completed by 191 clients, with a 91% follow-up rate (data collected: February 2016 to March 2017). Twenty-two CA clients participated in interviews (data collected: October 2015 to November 2016). The PSS indicated a significant decrease in stress from initial consultation to approximately 4-6 weeks post advice from 31.4 to 10.3 (p < 0.001) and the WEMWBS indicated a significant increase in client well-being from a mean of 26.9 to 46.5 (p < 0.001). Nine refined programme theories are presented which combine the qualitative and quantitative analysis; they are underpinned by three abstract theories: Capabilities model, The Decision to Trust Model, and Third Space. An explanatory framework is presented covering the micro, meso, and macro levels of CA. Use of a stress and well-being lens has allowed insight into the precursors of health in those receiving intensive advice. Using these measures whilst explaining contextual and mechanistic properties, begins to build a complex and real picture of how advice services impact on health.

Randomised controlled trial with economic and process evaluations of domiciliary welfare rights advice for socioeconomically disadvantaged older people recruited via primary health care (the Do-Well study)

Background

Welfare rights advice services are effective at maximising previously unclaimed welfare benefits, but their impact on health has not been evaluated.

Objective

To establish the acceptability, cost-effectiveness and effect on health of a domiciliary welfare rights advice service targeting older people, compared with usual practice.

Design

A pragmatic, individually randomised, parallel-group, single-blinded, wait-list controlled trial, with economic and process evaluations. Data were collected by interview at baseline and 24 months, and by self-completion questionnaire at 12 months. Qualitative interviews were undertaken with purposive samples of 50 trial participants and 17 professionals to explore the intervention’s acceptability and its perceived impacts.

Setting

Participants’ homes in North East England, UK.

Participants

A total of 755 volunteers aged ≥ 60 years, living in their own homes, fluent in English and not terminally ill, recruited from the registers of 17 general practices with an Index of Multiple Deprivation within the most deprived two-fifths of the distribution for England, and with no previous access to welfare rights advice services.

Interventions

Welfare rights advice, comprising face-to-face consultations, active assistance with benefit claims and follow-up as required until no longer needed, delivered in participants’ own homes by a qualified welfare rights advisor. Control group participants received usual care until the 24-month follow-up, after which they received the intervention.

Main outcome measures

The primary outcome was health-related quality of life (HRQoL), assessed using the CASP-19 (Control, Autonomy, Self-realisation and Pleasure) score. The secondary outcomes included general health status, health behaviours, independence and hours per week of care, mortality and changes in financial status.

Results

A total of 755 out of 3912 (19%) general practice patients agreed to participate and were randomised (intervention,n = 381; control,n = 374). In the intervention group, 335 participants (88%) received the intervention. A total of 605 (80%) participants completed the 12-month follow-up and 562 (75%) completed the 24-month follow-up. Only 84 (22%) intervention group participants were awarded additional benefits. There was no significant difference in CASP-19 score between the intervention and control groups at 24 months [adjusted mean difference 0.3, 95% confidence interval (CI) –0.8 to 1.5], but a significant increase in hours of home care per week in the intervention group (adjusted difference 26.3 hours/week, 95% CI 0.8 to 56.1 hours/week). Exploratory analyses found a weak positive correlation between CASP-19 score and the amount of time since receipt of the benefit (0.39, 95% CI 0.16 to 0.58). The qualitative data suggest that the intervention was acceptable and that receipt of additional benefits was perceived by participants and professionals as having had a positive impact on health and quality of life. The mean cost was £44 per participant, the incremental mean health gain was 0.009 quality-adjusted life-years (QALYs) (95% CI –0.038 to 0.055 QALYs) and the incremental cost-effectiveness ratio was £1914 per QALY gained.

Conclusions

The trial did not provide sufficient evidence to support domiciliary welfare rights advice as a means of promoting health among older people, but it yielded qualitative findings that suggest important impacts on HRQoL. The intervention needs to be better targeted to those most likely to benefit.

Future work

Further follow-up of the trial could identify whether or not outcomes diverge among intervention and control groups over time. Research is needed to better understand how to target welfare rights advice to those most in need.

Trial registration

Current Controlled Trials ISRCTN37380518.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 7, No. 3. See the NIHR Journals Library website for further project information. The authors also received a grant of £28,000 from the North East Strategic Health Authority in 2012 to cover the costs of intervention delivery and training as well as other non-research costs of the study.

The help for people with money, employment or housing problems (HOPE) intervention: pilot randomised trial with mixed methods feasibility research

Background

Job loss, austerity measures, financial difficulties and house repossession contribute to the risk of self-harm and suicide during recessions. Navigating the benefits system and accessing sources of welfare and debt advice is a difficult experience for vulnerable people, further contributing to their distress. Whilst there is some evidence that advice-type interventions can lead to financial gain, there is mixed evidence for their effectiveness in improving mental health in those experiencing financial difficulties. There have been no interventions targeting those who have self-harmed due to economic hardship.

Methods

Our aim was to determine the feasibility and acceptability of a brief psychosocial intervention (the ‘HOPE’ service) for people presenting to hospital emergency departments (ED) following self-harm or in acute distress because of financial, employment or welfare (benefit) difficulties. Nineteen people consented to random allocation to the intervention or control arm on a 2:1 basis. Participants randomised to the intervention arm (n = 13) received up to six sessions of 1:1 support provided by community support staff trained in Motivational Interviewing (MI). Control participants (n = 6) received a one-off session signposting them to relevant support organisations. Fourteen participants were followed up after 3 months. Participants and mental health workers took part in qualitative interviews. The acceptability of outcome measures including the PHQ-9, GAD-7, repeat self-harm, EQ5D-5 L and questions about debt, employment and welfare benefits were explored.

Results

Interviews indicated the main benefits of the service as the resolution of specific financial problems and receiving support when participants were feeling most vulnerable. Randomisation was acceptable to most participants although not always fully understood and control participants could be disappointed. Recruitment was slow (1–2 per month). The outcome measures were acceptable and appeared sensitive to change.

Discussion

The HOPE intervention is feasible and acceptable. There was evidence of need and it is a relatively inexpensive intervention. Refining aspects of the intervention would be straightforward. A full-scale RCT would be feasible, if broadened eligibility criteria led to increased recruitment and improvements were made to staff training and support.

Trial registration

ISRCTN58531248.

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0365-6) contains supplementary material, which is available to authorized users.

Understanding new models of integrated care in developed countries: a systematic review

Background

The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.

Objectives

The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.

Design

The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.

Setting

Any setting.

Participants

Patients receiving a health-care service and/or staff delivering services.

Interventions

Changes to service delivery that increase integration and co-ordination of health and health-related services.

Main outcome measures

Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.

Study design

Empirical work of a quantitative or qualitative design.

Data sources

We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.

Review methods

The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.

Results

We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.

Limitations

Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.

Conclusions

There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.

Future work

Links between elements of new models and outcomes require further study, together with research in a wider variety of populations.

Study registration

This study is registered as PROSPERO CRD37725.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Searching for the Impact of Participation in Health and Health Research: Challenges and Methods

Internationally, the interest in involving patients and the public in designing and delivering health interventions and researching their effectiveness is increasing. Several systematic reviews of participation in health research have recently been completed, which note a number of challenges in documenting the impact of participation. Challenges include working across stakeholders with different understandings of participation and levels of experience in reviewing; comparing heterogeneous populations and contexts; configuring findings from often thin descriptions of participation in academic papers; and dealing with different definitions of impact. This paper aims to advance methods for systematically reviewing the impact of participation in health research, drawing on recent systematic review guidance. Practical examples for dealing with issues at each stage of a review are provided based on recent experience. Recommendations for improving primary research on participation in health are offered and key points to consider during the review are summarised.

Cochrane Qualitative and Implementation Methods Group guidance series-paper 2: methods for question formulation, searching, and protocol development for qualitative evidence synthesis

This paper updates previous Cochrane guidance on question formulation, searching, and protocol development, reflecting recent developments in methods for conducting qualitative evidence syntheses to inform Cochrane intervention reviews. Examples are used to illustrate how decisions about boundaries for a review are formed via an iterative process of constructing lines of inquiry and mapping the available information to ascertain whether evidence exists to answer questions related to effectiveness, implementation, feasibility, appropriateness, economic evidence, and equity. The process of question formulation allows reviewers to situate the topic in relation to how it informs and explains effectiveness, using the criterion of meaningfulness, appropriateness, feasibility, and implementation. Questions related to complex questions and interventions can be structured by drawing on an increasingly wide range of question frameworks. Logic models and theoretical frameworks are useful tools for conceptually mapping the literature to illustrate the complexity of the phenomenon of interest. Furthermore, protocol development may require iterative question formulation and searching. Consequently, the final protocol may function as a guide rather than a prescriptive route map, particularly in qualitative reviews that ask more exploratory and open-ended questions.

Cochrane Qualitative and Implementation Methods Group guidance series-paper 5: methods for integrating qualitative and implementation evidence within intervention effectiveness reviews

The Cochrane Qualitative and Implementation Methods Group develops and publishes guidance on the synthesis of qualitative and mixed-method evidence from process evaluations. Despite a proliferation of methods for the synthesis of qualitative research, less attention has focused on how to integrate these syntheses within intervention effectiveness reviews. In this article, we report updated guidance from the group on approaches, methods, and tools, which can be used to integrate the findings from quantitative studies evaluating intervention effectiveness with those from qualitative studies and process evaluations. We draw on conceptual analyses of mixed methods systematic review designs and the range of methods and tools that have been used in published reviews that have successfully integrated different types of evidence. We outline five key methods and tools as devices for integration which vary in terms of the levels at which integration takes place; the specialist skills and expertise required within the review team; and their appropriateness in the context of limited evidence. In situations where the requirement is the integration of qualitative and process evidence within intervention effectiveness reviews, we recommend the use of a sequential approach. Here, evidence from each tradition is synthesized separately using methods consistent with each tradition before integration takes place using a common framework. Reviews which integrate qualitative and process evaluation evidence alongside quantitative evidence on intervention effectiveness in a systematic way are rare. This guidance aims to support review teams to achieve integration and we encourage further development through reflection and formal testing.

Co-located welfare advice in general practice: A realist qualitative study

General practitioners (GPs) engage with patients about a variety of social issues distinct from direct clinical work ("non-health" issues), such as health-related benefits and debt. Co-located welfare advice services could provide support to practices but have usually been considered in terms of patient rather than practice outcomes. We aimed to develop an initial programme theory for how the provision of co-located advice supports specific practice outcomes, and to identify salient barriers and enabling factors. Twenty-four semi-structured interviews with general practice staff, advice staff and service funders in two UK urban localities were conducted between January and July 2016. Data were thematically analysed and a modified Realist Evaluation approach informed the topic guide, thematic analysis and interpretation. Two outcomes are described linked to participant accounts of the impact of such non-health work on practices: reduction of GP consultations linked to non-health issues and reduced practice time spent on non-health issues. We found that individual responses and actions influencing service awareness were key facilitators to each of the practice outcomes, including proactive engagement, communication, regular reminders and feedback between advice staff, practice managers and funders. Facilitating implementation factors were: not limiting access to GP referral, and offering booked appointments and advice on a broader range of issues responsive to local need. Key barriers included pre-existing sociocultural and organisational rules and norms largely outside of the control of service implementers, which maintained perceptions of the GP as the "go-to-location". We conclude that co-location of welfare advice services alone is unlikely to enable positive outcomes for practices and suggest several factors amenable to intervention that could enhance the potential for co-location to meet desired objectives.

A novel income security intervention to address poverty in a primary care setting: a retrospective chart review

OBJECTIVE

To examine the development and implementation of a novel income security intervention in primary care.

DESIGN

A retrospective, descriptive chart review of all patients referred to the Income Security Heath Promotion service during the first year of the service (December 2013-December 2014).

SETTING

A multisite interdisciplinary primary care organisation in inner city Toronto, Canada, serving over 40 000 patients.

PARTICIPANTS

The study population included 181 patients (53% female, mean age 48 years) who were referred to the Income Security Health Promotion service and engaged in care.

INTERVENTION

The Income Security Health Promotion service consists of a trained health promoter who provides a mixture of expert advice and case management to patients to improve income security. An advisory group, made up of physicians, social workers, a community engagement specialist and a clinical manager, supports the service.

OUTCOME MEASURES

Sociodemographic information, health status, referral information and encounter details were collected from patient charts.

RESULTS

Encounters focused on helping patients with increasing their income (77.4%), reducing their expenses (58.6%) and improving their financial literacy (26.5%). The health promoter provided an array of services to patients, including assistance with taxes, connecting to community services, budgeting and accessing free services. The service could be improved with more specific goal setting, better links to other members of the healthcare team and implementing routine follow-up with each patient after discharge.

CONCLUSIONS

Income Security Health Promotion is a novel service within primary care to assist vulnerable patients with a key social determinant of health. This study is a preliminary look at understanding the functioning of the service. Future research will examine the impact of the Income Security Health Promotion service on income security, financial literacy, engagement with health services and health outcomes.

Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis

BACKGROUND

Prolonged mechanical ventilation is associated with a longer intensive care unit (ICU) length of stay and higher mortality. Consequently, methods to improve ventilator weaning processes have been sought. Two recent Cochrane systematic reviews in ICU adult and paediatric populations concluded that protocols can be effective in reducing the duration of mechanical ventilation, but there was significant heterogeneity in study findings. Growing awareness of the benefits of understanding the contextual factors impacting on effectiveness has encouraged the integration of qualitative evidence syntheses with effectiveness reviews, which has delivered important insights into the reasons underpinning (differential) effectiveness of healthcare interventions.

OBJECTIVES

1. To locate, appraise and synthesize qualitative evidence concerning the barriers and facilitators of the use of protocols for weaning critically-ill adults and children from mechanical ventilation;2. To integrate this synthesis with two Cochrane effectiveness reviews of protocolized weaning to help explain observed heterogeneity by identifying contextual factors that impact on the use of protocols for weaning critically-ill adults and children from mechanical ventilation;3. To use the integrated body of evidence to suggest the circumstances in which weaning protocols are most likely to be used.

SEARCH METHODS

We used a range of search terms identified with the help of the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) mnemonic. Where available, we used appropriate methodological filters for specific databases. We searched the following databases: Ovid MEDLINE, Embase, OVID, PsycINFO, CINAHL Plus, EBSCOHost, Web of Science Core Collection, ASSIA, IBSS, Sociological Abstracts, ProQuest and LILACS on the 26th February 2015. In addition, we searched: the grey literature; the websites of professional associations for relevant publications; and the reference lists of all publications reviewed. We also contacted authors of the trials included in the effectiveness reviews as well as of studies (potentially) included in the qualitative synthesis, conducted citation searches of the publications reporting these studies, and contacted content experts.We reran the search on 3rd July 2016 and found three studies, which are awaiting classification.

SELECTION CRITERIA

We included qualitative studies that described: the circumstances in which protocols are designed, implemented or used, or both, and the views and experiences of healthcare professionals either involved in the design, implementation or use of weaning protocols or involved in the weaning of critically-ill adults and children from mechanical ventilation not using protocols. We included studies that: reflected on any aspect of the use of protocols, explored contextual factors relevant to the development, implementation or use of weaning protocols, and reported contextual phenomena and outcomes identified as relevant to the effectiveness of protocolized weaning from mechanical ventilation.

DATA COLLECTION AND ANALYSIS

At each stage, two review authors undertook designated tasks, with the results shared amongst the wider team for discussion and final development. We independently reviewed all retrieved titles, abstracts and full papers for inclusion, and independently extracted selected data from included studies. We used the findings of the included studies to develop a new set of analytic themes focused on the barriers and facilitators to the use of protocols, and further refined them to produce a set of summary statements. We used the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to arrive at a final assessment of the overall confidence of the evidence used in the synthesis. We included all studies but undertook two sensitivity analyses to determine how the removal of certain bodies of evidence impacted on the content and confidence of the synthesis. We deployed a logic model to integrate the findings of the qualitative evidence synthesis with those of the Cochrane effectiveness reviews.

MAIN RESULTS

We included 11 studies in our synthesis, involving 267 participants (one study did not report the number of participants). Five more studies are awaiting classification and will be dealt with when we update the review.The quality of the evidence was mixed; of the 35 summary statements, we assessed 17 as 'low', 13 as 'moderate' and five as 'high' confidence. Our synthesis produced nine analytical themes, which report potential barriers and facilitators to the use of protocols. The themes are: the need for continual staff training and development; clinical experience as this promotes felt and perceived competence and confidence to wean; the vulnerability of weaning to disparate interprofessional working; an understanding of protocols as militating against a necessary proactivity in clinical practice; perceived nursing scope of practice and professional risk; ICU structure and processes of care; the ability of protocols to act as a prompt for shared care and consistency in weaning practice; maximizing the use of protocols through visibility and ease of implementation; and the ability of protocols to act as a framework for communication with parents.

AUTHORS' CONCLUSIONS

There is a clear need for weaning protocols to take account of the social and cultural environment in which they are to be implemented. Irrespective of its inherent strengths, a protocol will not be used if it does not accommodate these complexities. In terms of protocol development, comprehensive interprofessional input will help to ensure broad-based understanding and a sense of 'ownership'. In terms of implementation, all relevant ICU staff will benefit from general weaning as well as protocol-specific training; not only will this help secure a relevant clinical knowledge base and operational understanding, but will also demonstrate to others that this knowledge and understanding is in place. In order to maximize relevance and acceptability, protocols should be designed with the patient profile and requirements of the target ICU in mind. Predictably, an under-resourced ICU will impact adversely on protocol implementation, as staff will prioritize management of acutely deteriorating and critically-ill patients.

Exposing the impact of Citizens Advice Bureau services on health: a realist evaluation protocol

INTRODUCTION

Welfare advice services can be used to address health inequalities, for example, through Citizens Advice Bureau (CAB). Recent reviews highlight evidence for the impact of advice services in improving people's financial position and improving mental health and well-being, daily living and social relationships. There is also some evidence for the impact of advice services in increasing accessibility of health services, and reducing general practitioner appointments and prescriptions. However, direct evidence for the impact of advice services on lifestyle behaviour and physical health is currently much less well established. There is a need for greater empirical testing of theories around the specific mechanisms through which advice services and associated financial or non-financial benefits may generate health improvements.

METHODS AND ANALYSIS

A realist evaluation will be conducted, operationalised in 5 phases: building the explanatory framework; refining the explanatory framework; testing the explanatory framework through empirical data (mixed methods); development of a bespoke data recording template to capture longer term impact; and verification of findings with a range of CAB services. This research will therefore aim to build, refine and test an explanatory framework about how CAB services can be optimally implemented to achieve health improvement.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee at Northumbria University, UK. Project-related ethical issues are described and quality control aspects of the study are considered. A stakeholder mapping exercise will inform the dissemination of results in order to ensure all relevant institutions and organisations are targeted.

Work or welfare after cancer? Explorations of identity and stigma

With increasing numbers of people living with cancer, a greater focus is required on the social consequences of the disease. This article explores the connections between cancer and employment and the constraints imposed by ill health and wider structural conditions. Narrative data from 23 people of working age with cancer in north-east England collected longitudinally over 16 months highlight the impact of financial strain caused by temporary or permanent interruption to employment, and the positive benefits of an upstream welfare rights intervention in enabling participants to claim benefit entitlements and boost incomes. Returning to work, for those who were able, helped repair the disruption caused by the illness. For those unable to work, reliance on welfare benefits, while necessary, conferred a stigmatised identity that compounded the disruption wrought by cancer. While stigma occurs at the individual level, the structural dimensions of stigma need to be acknowledged in order to analyse the forces that cause, maintain and perpetuate the stigma associated with claiming welfare while ill. We conclude that current UK policies and welfare reforms to reduce sickness-related welfare claims will lead to greater hardship during periods of ill health and increase inequalities.

What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis

Background

Demand management describes any method used to monitor, direct or regulate patient referrals. Several strategies have been developed to manage the referral of patients to secondary care, with interventions targeting primary care, specialist services, or infrastructure.

Objective

This research aimed to conduct an inclusive systematic review and logic model synthesis in order to better understand factors impacting on the effectiveness of interventions targeting referral between primary and secondary medical health care.

Design

The approach combined systematic review with logic modelling synthesis techniques to develop an evidence-based framework of factors influencing the pathway between interventions and system-wide changes.

Setting

Primary health care.

Main outcome measures

Referral from primary to secondary care.

Review methods

Systematic searches were undertaken to identify recent, relevant studies. Quality of individual studies was appraised, with consideration of overall strength of evidence. A narrative synthesis and logic model summary of the data was completed.

Results

From a database of 8327 unique papers, 290 were included in the review. The intervention studies were grouped into four categories of education interventions (n = 50); process change interventions (n = 49); system change interventions (n = 38); and patient-focused interventions (n = 3). Effectiveness was assessed variously in these papers; however, there was a gap regarding the mechanisms whereby these interventions lead to demand management impacts. The findings suggest that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions. Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient. System changes including the community provision of specialist services by general practitioners, outreach provision by specialists and the return of inappropriate referrals appeared to have evidence of effect. The pathway whereby interventions might lead to service-wide impact was complex, with multiple factors potentially acting as barriers or facilitators to the change process. Factors related, first, to the doctor (including knowledge, attitudes and beliefs, and previous experiences of a service), second, to the patient (including condition and social factors) and, third, to the influence of the doctor–patient relationship. We also identified a number of potentially influential factors at a local level, such as perceived waiting times and the availability of a specialist. These elements are key factors in the pathway between an intervention and intended demand management outcomes influencing both applicability and effectiveness.

Conclusions

The findings highlight the complexity of the referral process and multiple elements that will impact on intervention outcomes and applicability to a local area. Any interventions seeking to change referral practice need to address factors relating to the individual practitioner, the patient and also the situation in which the referral is taking place. These conclusions apply especially to referral management in a UK context where this whole range of factors/issues lies well within the remit of the NHS. This work highlights that intermediate outcomes are important in the referral pathway. It is recommended that researchers include measure of these intermediate outcomes in their evaluation of intervention effectiveness in order to determine where blocks to or facilitators of system-wide impact may be occurring.

Study registration

The study is registered as PROSPERO CRD42013004037.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Financial capability, health and disability

Background

It has been suggested that improving people’s ability to deal with their finances, their financial capability, will directly improve their wellbeing and indirectly their health. To this end, financial capability initiatives have been funded by statutory and charitable health bodies, sometimes as part of a practice termed ‘social prescribing’.

Discussion

This paper examines financial capability from the perspective of the Capability Approach to welfare and justice. It argues that the Approach shows current conceptions of financial capability to be flawed in that they focus on it as a personal quality in isolation from the socioeconomic environment. Using the Capability Approach as applied to disability the paper argues that financial capability is best viewed as a ‘conversion factor’ rather than a capability, that is, something necessary to convert resources, particularly money, into something of value to an individual, such as an adequate pension. Often, those judged as lacking financial capability are poor and this fact is at the heart of their inability to, say, plan a pension; by contrast, those who are not poor may find it relatively easy to do so and thus be deemed financially capable. Hence there are two distinct types of financial capability: i) in poverty and ii) not in poverty. To be able to plan a pension or make ends meet in poverty requires distinct and perhaps rare skills in an individual. However, some environmental or social changes may help individuals to improve their financial capability without calling on them to develop extraordinary abilities. Given the potential of such work to improve people’s health, making such changes can reasonably be described as Public Health work. The article concludes with a defence of this use of the Capability Approach against possible criticism.

Summary

The Capability Approach enables analysis of financial capability that is theoretically important to and has practical implications for Public Health.

Using logic model methods in systematic review synthesis: describing complex pathways in referral management interventions

BACKGROUND

There is increasing interest in innovative methods to carry out systematic reviews of complex interventions. Theory-based approaches, such as logic models, have been suggested as a means of providing additional insights beyond that obtained via conventional review methods.

METHODS

This paper reports the use of an innovative method which combines systematic review processes with logic model techniques to synthesise a broad range of literature. The potential value of the model produced was explored with stakeholders.

RESULTS

The review identified 295 papers that met the inclusion criteria. The papers consisted of 141 intervention studies and 154 non-intervention quantitative and qualitative articles. A logic model was systematically built from these studies. The model outlines interventions, short term outcomes, moderating and mediating factors and long term demand management outcomes and impacts. Interventions were grouped into typologies of practitioner education, process change, system change, and patient intervention. Short-term outcomes identified that may result from these interventions were changed physician or patient knowledge, beliefs or attitudes and also interventions related to changed doctor-patient interaction. A range of factors which may influence whether these outcomes lead to long term change were detailed. Demand management outcomes and intended impacts included content of referral, rate of referral, and doctor or patient satisfaction.

CONCLUSIONS

The logic model details evidence and assumptions underpinning the complex pathway from interventions to demand management impact. The method offers a useful addition to systematic review methodologies.

TRIAL REGISTRATION NUMBER

PROSPERO registration number: CRD42013004037.