Improving best practise for patients receiving hospital discharge letters: a realist review protocol

Community mobilisation approaches to preventing adolescent multiple risk behaviour: a realist review

BACKGROUND

Adolescent multiple risk behaviour (MRB) is a global health issue. Most interventions have focused on the proximal causes of adolescent MRB such as peer or family influence, with systematic reviews reporting mixed evidence of effectiveness. There is increasing recognition that community mobilisation approaches could be beneficial for adolescent health. There are gaps in the current literature, theory and implementation that would benefit from a realist approach. We use a theory-driven evidence synthesis to assess how and why community mobilisation interventions work/do not work to prevent adolescent MRB and in what contexts.

METHODS

This realist review used a six-stage iterative process, guided by the RAMESES framework. We systematically searched PubMed, MEDLINE, PsycINFO, Web of Science, CINAHL and Sociological Abstracts, from their inception to 2021. Studies were screened for relevance to the programme theory, assessed for rigour and included based on a priori criteria. Two independent reviewers selected, screened and extracted data from included studies. A realist logic of analysis was used to develop context-mechanism-outcome configurations that contributed to our programme theory.

FINDINGS

We reviewed 35 documents describing 22 separate community mobilisation intervention studies. Most studies (n = 17) had a quality assessment score of three or four (out of four). We analysed the studies in relation to three middle range theories. To uphold our theory that these interventions work by creating a social environment where adolescents are less likely to engage in MRB, interventions should: (1) embed a framework of guiding principles throughout the community, (2) establish community readiness with population data and (3) ensure a diverse coalition with the support of intervention champions. Mechanisms such as empowerment through coalition ownership over the delivery of the intervention, cohesion across the community and motivation to work collaboratively to improve adolescent health are triggered to achieve social environment shifts. However, certain contexts (e.g. limited funding) restrict intervention success as these mechanisms are not fired.

CONCLUSIONS

For community mobilisation interventions to reduce adolescent MRB, the coalitions within them must seek to alter the social environment in which these behaviours occur. Mechanisms including empowerment, cohesion and motivation lead to this shift, but only under certain contexts.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020205342.

Understanding How Newly Implemented Rehabilitation Best Practices Are Sustained: A Realist Review

OBJECTIVE

We conducted a realist review to understand how (mechanism) and in what circumstances (context) evidence-based practices are sustained in rehabilitation (outcome).

DATA SOURCES

MEDLINE, Embase, reference lists, and targeted websites.

STUDY SELECTION

Two independent reviewers calibrated study selection; then 1 reviewer screened all titles and abstracts, while the second reviewer screened a random 20%. We repeated this process for full texts. We included 115 documents representing 61 implementation projects (8.9% of identified documents). Included documents described implementation projects in which physical therapists, occupational therapists, and/or speech-language pathologists were the target users of an evidence-based practice.

DATA EXTRACTION

Two reviewers repeated the independent process described in study selection to extract basic study and sustainability characteristics as well as context, mechanism, outcome, and strategy text.

DATA SYNTHESIS

Using basic numerical analyses, we found that only 54% of evidence-based practices in rehabilitation are sustained. Furthermore, while authors who reported sustainability planning sustained the practice 94% of the time, sustainability planning in rehabilitation is rare (only reported 26% of the time). Extracted text was synthesized using the realist technique of inductive and deductive retroduction in which context, mechanism, outcome, and strategy text are combined into narrative explanations of how sustainability works. To inform these explanations, we applied normalization process theory and the theory of planned behavior. Collectively, the 52 identified narratives provide evidence for 3 patterns: (1) implementation and sustainability phases are interconnected, (2) continued use of the evidence-based practice can be interpreted as the ultimate sustainability outcome, and (3) intermediate sustainability outcomes (ie, fit/alignment, financial support, benefits, expertise) can become contextual features influencing other sustainability outcomes.

CONCLUSIONS

Implementation teams can use the narrative explanations generated in this review to optimize sustainability planning. This can sustain practice changes and improve quality of care and patient outcomes. Future research should seek to iteratively refine the proposed narrative explanations.

Understanding how and under what circumstances decision coaching works for people making healthcare decisions: a realist review

Background

Decision coaching is non-directive support delivered by a trained healthcare provider to help people prepare to actively participate in making healthcare decisions. This study aimed to understand how and under what circumstances decision coaching works for people making healthcare decisions.

Methods

We followed the realist review methodology for this study. This study was built on a Cochrane systematic review of the effectiveness of decision coaching interventions for people facing healthcare decisions. It involved six iterative steps: (1) develop the initial program theory; (2) search for evidence; (3) select, appraise, and prioritize studies; (4) extract and organize data; (5) synthesize evidence; and (6) consult stakeholders and draw conclusions.

Results

We developed an initial program theory based on decision coaching theories and stakeholder feedback. Of the 2594 citations screened, we prioritized 27 papers for synthesis based on their relevance rating. To refine the program theory, we identified 12 context-mechanism-outcome (CMO) configurations. Essential mechanisms for decision coaching to be initiated include decision coaches’, patients’, and clinicians’ commitments to patients’ involvement in decision making and decision coaches’ knowledge and skills (four CMOs). CMOs during decision coaching are related to the patient (i.e., willing to confide, perceiving their decisional needs are recognized, acquiring knowledge, feeling supported), and the patient-decision coach interaction (i.e., exchanging information, sharing a common understanding of patient’s values) (five CMOs). After decision coaching, the patient’s progress in making or implementing a values-based preferred decision can be facilitated by the decision coach’s advocacy for the patient, and the patient’s deliberation upon options (two CMOs). Leadership support enables decision coaches to have access to essential resources to fulfill their role (one CMOs).

Discussion

In the refined program theory, decision coaching works when there is strong leadership support and commitment from decision coaches, clinicians, and patients. Decision coaches need to be capable in coaching, encourage patients’ participation, build a trusting relationship with patients, and act as a liaison between patients and clinicians to facilitate patients’ progress in making or implementing an informed values-based preferred option. More empirical studies, especially qualitative and process evaluation studies, are needed to further refine the program theory.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-02007-0.

Multi-professional perceptions of clinical research delivery and the Clinical Research Nurse role: a realist review

Introduction & Background

The delivery of clinical research and the Clinical Research Nurse (CRN) role is fundamental to the wider health agenda, yet both remain misunderstood outwith research teams.

Methods

A realist review was conducted to identify factors that influence how clinical research is perceived by healthcare professionals operating outside NHS clinical research teams. Keyword searches were undertaken across four healthcare databases including grey literature, with iterative snowball searching. Data were extracted from 42/387 sources. Coding generated 3664 extracts of text across 160 themes. Theories generated were presented as ‘If-Then’ statements.

Results

Thirteen theory statements described factors that may influence how clinical research is perceived by healthcare professionals operating outside clinical research teams across three contextual levels: • Micro: Individual characteristics/behaviours/CRN perceptions • Meso: Interpersonal relationships at the interface between CRN roles and healthcare delivery • Macro: Systemwide/infrastructural/cultural issues impacting clinical research delivery.

Conclusion

Factors at micro, meso and macro level contexts may influence how clinical research is perceived by healthcare professionals operating outside clinical research teams. This has the potential to affect the success of clinical research delivery. Meso level theories regarding the perceptions of healthcare professionals outwith research teams may provide insight. Empirical testing of one such theory is underway.

Realist evaluation of Autism ServiCe Delivery (RE-ASCeD): which diagnostic pathways work best, for whom and in what context? Findings from a rapid realist review

OBJECTIVES

Waiting times in the UK for an autism diagnostic assessment have increased rapidly in the last 5 years. This review explored research (including 'grey' literature) to uncover the current evidence base about autism diagnostic pathways and what works best, for whom and in what circumstances, to deliver high quality and timely diagnosis.

DESIGN

We performed a Rapid Realist Review consistent with recognised standards for realist syntheses. We collected 129 grey literature and policy/guidelines and 220 articles from seven databases (January 2011-December 2019). We developed programme theories of how, why and in what contexts an intervention worked, based on cross comparison and synthesis of evidence. The focus was on identifying factors that contributed to a clearly defined intervention (the diagnostic pathway), associated with specific outcomes (high quality and timely), within specific parameters (Autism diagnostic services in Paediatric and Child & Adolescent Mental Health services in the UK). Our Expert Stakeholder Group, including representatives from local parent forums, national advocacy groups and clinicians, was integral to the process.

RESULTS

Based on 45 relevant articles, we identified 7 programme theories that were integral to the process of diagnostic service delivery. Four were related to the clinical pathway: initial recognition of possible autism; referral and triaging; diagnostic model; and providing feedback to parents. Three programme theories were pertinent to all stages of the referral and diagnostic process: working in partnership with families; interagency working; and training, service evaluation and development.

CONCLUSIONS

This theory informed review of childhood autism diagnostic pathways identified important aspects that may contribute to efficient, high quality and family-friendly service delivery. The programme theories will be further tested through a national survey of current practice and in-depth longitudinal case studies of exemplar services.

TRIAL REGISTRATION NUMBER

NCT04422483.

A realist review protocol of the role and contribution of the advanced nurse practitioner (ANP) in gastroenterology nursing

Background: The role and contribution of advanced nurse practitioners (ANP) has been well researched and found to be of great value for improving quality patient care and enhancing patient outcomes through education and health promotion. However, the role and the contribution of the ANP to gastroenterology nursing have not been evaluated either nationally or internationally. A review to determine the role and contribution of the ANP in gastroenterology nursing will inform on the contribution of the role and whether the role makes a difference to patient outcomes and cost effectiveness of patient care. Objective: This review aims to investigate the nursing role and contribution of the advanced nurse practitioner in gastroenterology. Furthermore, improved understanding of the underlying causal mechanisms explaining how the ANP role in gastroenterology nursing works, will provide a deeper understanding of how, why, for whom and in what contexts the role and contribution of the ANP to gastroenterology nursing are most successful. Methods: A realist review will consolidate evidence on how, when why and where the ANP role in gastroenterology works or fails through identifying programme theories underlying to the role’s introduction. The following steps will be operationalised; locating existing theories, searching the literature, documenting literature selection, engaging in data extraction and synthesis and refining programme theory. As an iterative approach, review cycles will uncover explanatory and contingent theories through context-mechanism-outcome configurations (CMOCc). Due to the variation in context and mechanisms, different outcomes will be likely across different clinical settings although similar patterns may be identified. Conclusions: Due to the theory-oriented approach of realist reviews, the pragmatic consequences of the review, will lend itself to deeper understanding of how the role and contribution of the ANP in gastroenterology nursing works in practice.

A Rapid Realist Review of Quality Care Process Metrics Implementation in Nursing and Midwifery Practice

Quality measurement initiatives promote quality improvement in healthcare but can be challenging to implement effectively. This paper presents a Rapid Realist Review (RRR) of published literature on Quality Care-Process Metrics (QCP-M) implementation in nursing and midwifery practice. An RRR informed by RAMESES II standards was conducted as an efficient means to synthesize evidence using an expert panel. The review involved research question development, quality appraisal, data extraction, and evidence synthesis. Six program theories summarised below identify the key characteristics that promote positive outcomes in QCP-M implementation. Program Theory 1: Focuses on the evidence base and accessibility of the QCP-M and their ease of use by nurses and midwives working in busy and complex care environments. Program Theory 2: Examines the influence of external factors on QCP-M implementation. Program Theory 3: Relates to existing cultures and systems within clinical sites. Program Theory 4: Relates to nurses’ and midwives’ knowledge and beliefs. Program Theory 5: Builds on the staff theme of Programme Theory four, extending the culture of organizational learning, and highlights the meaningful engagement of nurses and midwives in the implementation process as a key characteristic of success. Program Theory 6: Relates to patient needs. The results provide nursing and midwifery policymakers and professionals with evidence-based program theory that can be translated into action-orientated strategies to help guide successful QCP-M implementation.

Community mobilisation approaches to preventing and reducing adolescent multiple risk behaviour: a realist review protocol

BACKGROUND

Adolescent multiple risk behaviour (MRB) continues to be a global health issue. Most interventions have focused on the proximal causes of adolescent MRB such as peer or family influence, rather than targeting the wider environmental or structural context. There is increasing recognition that community mobilisation approaches could be beneficial for adolescent health. Despite this, there are gaps in the current literature, theory and implementation that would benefit from a realist approach due to the suitability of this methodology to analysing complex interventions. The objective of this study is to understand 'how, why, for whom and in what circumstances and time periods' do community mobilisation interventions work to prevent and/or reduce adolescent multiple risk behaviour.

METHODS

This is a protocol for a realist review. The review will use a six-stage iterative process, guided by the RAMESES framework. We will systematically search PubMed, MEDLINE, PsycINFO, Web of Science, CINAHL and Sociological Abstracts, from their inception to 2021. Studies will be screened for relevance to the programme theory and included based on a priori eligibility criteria including (1) reporting a community mobilisation intervention (2) targeting two health risk behaviors (3) for adolescent populations. Two independent reviewers will select, screen and extract data related to the program theory from all relevant sources. A realist logic of analysis will be used to identify all context-mechanism-outcome configurations that contribute to our programme theory. The findings will be synthesised to produce a refined programme theory model.

DISCUSSION

The goal of this realist review is to identify and refine a programme theory for community mobilisation approaches to the prevention and/or reduction of adolescent multiple risk behaviour. Our aim is that the findings surrounding the programme theory refinement can be used to develop and implement adolescent multiple risk behaviour interventions and maintain collaboration between local policy makers, researchers and community members.

SYSTEMATIC REVIEW REGISTRATION

This realist review is registered on the PROSPERO database (registration number: CRD42020205342).

The informed consent process in health research with under-served populations: a realist review protocol

BACKGROUND

The informed consent process aims to provide potential participants with information about health research that enables them to make an informed decision as to whether they choose to participate, or not. However, it remains unclear as to whether the process is effective for those who are under-served in health research. It is a pivotal issue within health research that the diversity of people who participate is broadened. The National Institute for Health Research (NIHR) pledges to support equality, diversity and inclusion, actively creating opportunities for all citizens whom are eligible, to take part in health research.

METHODS

In order to understand how the informed consent process for under-served populations in health research works, under what circumstances and in what respects, a realist review approach will be undertaken. Searches will be carried out using electronic databases (EMBASE, MEDLINE, Web of Science and PsycINFO), along with selected websites and grey literature. Development of initial rough programme theory(ies) will lead to a more refined programme theory that will provide an explanation of context, mechanism and outcomes. Stakeholder involvement by NIHR (Public) Research Champions, health professionals and clinical academics will provide expert opinion about concepts and programme theory.

DISCUSSION

Findings of this realist review will highlight how the informed consent process in health research affects the experience and decision-making process of potential participants from under-served populations. They will be written up in accordance with RAMESES guidelines and disseminated to patients and the public, health researchers, health professionals and policymakers through peer-reviewed publication, presentations and discussions. The review will contribute to our understanding of the mechanisms that cause both positive and negative outcomes in the informed consent process for those whom are often under-represented in health research to inform policy, study design and delivery.

Realist Evaluation of Autism ServiCe Delivery (RE-ASCeD): which diagnostic pathways work best, for whom and in what context? Protocol for a rapid realist review

INTRODUCTION

The National Health Service (NHS) Long-Term Plan (2019) acknowledges that children and young people with suspected autism wait too long for diagnostic assessment and sets out to reduce waiting times. However, diagnostic pathways vary with limited evidence on what model works best, for whom and in what circumstances. The National Autism Plan for Children (2003) recommended that assessment should be completed within 13 weeks but referral to diagnosis can take as long as 799 days.This Rapid Realist Review (RRR) is the first work package in a national programme of research: a Realist Evaluation of Autism ServiCe Delivery (RE-ASCeD). We explore how particular approaches may deliver high-quality and timely autism diagnostic services for children with possible autism; high quality is defined as compliant with National Institute for Heath and Care Excellence (2011) guidelines, and timely as a pathway lasting no more than one calendar year, based on previous work.

METHODS AND ANALYSIS

RRR is a well-established approach to synthesising evidence within a compressed timeframe to identify models of service delivery leading to desired outcomes. RRR works backwards from intended outcomes, identified by NICE guidelines and the NHS England Long-Term Plan. The focus is a clearly defined intervention (the diagnostic pathway), associated with specific outcomes (high quality and timely), within a particular set of parameters (Autism and Child & Adolescent Mental Health services in the UK). Our Expert Stakeholder Group consists of policymakers, content experts and knowledge users with a wide range of experience to supplement, tailor and expedite the process. The RRR is consistent with Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) and includes identifying the research question, searching for information, quality appraisal, data extraction, synthesising the evidence, validation of findings with experts and dissemination.

ETHICS AND DISSEMINATION

Ethical approval not required. Findings will inform the wider RE-ASCeD evaluation and be reported to NHS England.

TRIAL REGISTRATION NUMBER

NCT04422483. This protocol relates to Pre-results.

Achieving beneficial outcomes for children with life-limiting and life-threatening conditions receiving palliative care and their families: A realist review

BACKGROUND

Palliative care for children and young people is a growing global health concern with significant resource implications. Improved understanding of how palliative care provides benefits is necessary as the number of children with life-limiting and life-threatening conditions rises.

AIM

The aim is to investigate beneficial outcomes in palliative care from the perspective of children and families and the contexts and hidden mechanisms through which these outcomes can be achieved.

DESIGN

This is a systematic realist review following the RAMESES standards. A protocol has been published in PROSPERO (registration no: CRD42018090646).

DATA SOURCES

An iterative literature search was conducted over 2 years (2015-2017). Empirical research and systematic reviews about the experiences of children and families in relation to palliative care were included.

RESULTS

Sixty papers were included. Narrative synthesis and realist analysis led to the proposal of context-mechanism-outcome configurations in four conceptual areas: (1) family adaptation, (2) the child's situation, (3) relationships with healthcare professionals and (4) access to palliative care services. The presence of two interdependent contexts, the 'expert' child and family and established relationships with healthcare professionals, triggers mechanisms, including advocacy and affirmation in decision-making, which lead to important outcomes including an ability to place the emphasis of care on lessening suffering. Important child and family outcomes underpin the delivery of palliative care.

CONCLUSION

Palliative care is a complex, multifactorial intervention. This review provides in-depth understanding into important contexts in which child and family outcomes can be achieved so that they benefit from palliative care and should inform future service development and practice.

The Discharge Communication Study: research protocol for a mixed methods study to investigate and triangulate discharge communication experiences of patients, GPs, and hospital professionals, alongside a corresponding discharge letter sample

BACKGROUND

Discharge letters are crucial during care transitions from hospital to home. Research indicates a need for improvement to increase quality of care and decrease adverse outcomes. These letters are often sent from the hospital discharging physician to the referring clinician, typically the patient's General Practitioner (GP) in the UK, and patients may or may not be copied into them. Relatively little is known about the barriers and enablers to sending patients discharge letters. Hence, the aim of this study was to investigate from GP, hospital professional (HP) and patient perspectives how to improve processes of patients receiving letters and increase quality of discharge letters. The study has a particular focus on the impacts of receiving or not receiving letters on patient experiences and quality of care.

METHODS

The setting was a region in the West Midlands of England, UK. The research aimed to recruit a minimum of 30 GPs, 30 patients and 30 HPs in order to capture 90 experiences of discharge communication. Participating GPs initially screened and selected a range of recent discharge letters which they assessed to be successful and unsuccessful exemplars. These letters identified potential participants who were invited to take part: the HP letter writer, GP recipient and patient. Participant viewpoints are collected through interviews, focus groups and surveys and will be "matched" to the discharge letter sample, so forming multiple-perspective "quartet" cases. These "quartets" allow direct comparisons between different discharge experiences within the same communicative event. The methods for analysis draw on techniques from the fields of Applied Linguistics and Health Sciences, including: corpus linguistics; inferential statistics; content analysis.

DISCUSSION

This mixed-methods study is novel in attempting to triangulate views of patients, GPs and HPs in relation to specific discharge letters. Patient and practitioner involvement will inform design decisions and interpretation of findings. Recommendations for improving discharge letters and the process of patients receiving letters will be made, with the intention of informing guidelines on discharge communication. Ethics approval was granted in July 2017 by the UK Health Research Authority. Findings will be disseminated in peer-reviewed journals, reports and newsletters, and presentations.

A realist review of community engagement with health research

Introduction: Community engagement is increasingly recognized as a critical aspect of global health. Recent years have seen an expansion of community engagement activities linked to health research, but debates and inconsistencies remain about the aims of different types of engagement, mechanisms underpinning their implementation and impact, and influential contextual factors. Greater commitment to and consistency around community engagement by health research programs, implementers and funders requires a more coherent evidence base. This realist review is designed to improve our understanding of how and why community engagement contributes to intended and unintended outcomes (including research and ethical outcomes) in different contexts. Given the breadth and diversity of the literature on community engagement in health research, the review will initially focus on malaria research in low- and middle-income countries (LMICs) and draw on wider global health literature where needed. Methods and analysis: Community engagement in practice is often a complex set of interventions. We will conduct a realist review - a theory driven approach to evidence synthesis - to provide explanations for how and why community engagement with health research produces the pattern of outcomes observed across different contexts of application. We will consolidate evidence from a range of documents, including qualitative, quantitative and mixed method studies. The review will follow several stages: devising an initial programme theory, searching evidence, selecting appropriate documents, extracting data, synthesizing and refining the programme theory, and reiteration of these steps as needed. Ethics and dissemination: A formal ethics review is not required for this literature review.  Findings will be disseminated in a peer reviewed journal, through national and international conferences, and through a set of short briefings tailored for audiences with an interest in community engagement. Outputs and presentations will be informed by and feed into our network of community engagement experts. PROSPERO registration number: CRD42019125687.

The influence of narrative medicine on medical students' readiness for holistic care practice: a realist synthesis protocol

INTRODUCTION

Holistic healthcare considers the whole person-their body, mind, spirit and emotions-and has been associated with narrative medicine practice. Narrative medicine is medicine performed with narrative skill and has been offered as a model for humanism and effective medical practice. Narrative medicine interventions have been associated with physicians' increased empathy and more meaningful interactions with patients about managing their illness and preventative medicine. However, while there is some evidence that certain groups are more open to narrative practices (eg, traditional vs Western medical students), the extent to which narrative medicine interventions during undergraduate medical education impacts on students' readiness for holistic care, as well as the underlying reasons why, is unknown.

METHODS AND ANALYSIS

Realist review is a theory-driven approach to evaluate complex interventions. It focuses on understanding how interventions and programmes work (or not) in their contextual setting. This realist synthesis aimed to formulate a theory around the influence of narrative medicine medical students' readiness for holistic care practice. We will follow Pawson's five steps: locate existing theories, search strategy, study selection, data extraction, data analysis and synthesis. We will use the following electronic databases: Web of Science, Medline, Scopus and Embase. Articles between January 2008 and September 2018 will be included. Results will be written according to the RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) standard for reporting realist syntheses.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Chang Gung Memorial Hospital for the wider study. The findings of this review will provide useful information for academics and policymakers, who will be able to apply the findings in their context when deciding whether and how to introduce narrative medicine programmes into medical students' curricula. We will publish our findings in peer-reviewed journals and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42018115447.

Improving best practice for patients receiving hospital discharge letters: a realist review

OBJECTIVE

To understand how different outcomes are achieved from adult patients receiving hospital discharge letters from inpatient and outpatient settings.

DESIGN

Realist review conducted in six main steps: (1) development of initial theory, (2) searching, (3) screening and selection, (4) data extraction and analysis, (5) data synthesis and (6) programme theory (PT) refinement.

ELIGIBILITY CRITERIA

Documents reporting evidence that met criteria for relevance to the PT. Documents relating solely to mental health or children aged <18 years were excluded.

ANALYSIS

Data were extracted and analysed using a realist logic of analysis. Texts were coded for concepts relating to context, mechanism, outcome configurations (CMOCs) for the intervention of patients receiving discharge letters. All outcomes were considered. Based on evidence and our judgement, CMOCs were labelled 'positive' or 'negative' in order to clearly distinguish between contexts where the intervention does and does not work.

RESULTS

3113 documents were screened and 103 were included. Stakeholders contributed to refining the PT in step 6. The final PT included 48 CMOCs for how outcomes are affected by patients receiving discharge letters. 'Patient choice' emerged as a key influencer to the success (or not) of the intervention. Important contexts were identified for both 'positive' CMOCs (eg, no new information in letter) and 'negative' CMOCs (eg, letter sent without verifying patient contact details). Two key findings were that patient understanding is possibly greater than clinicians perceive, and that patients tend to express strong preference for receiving letters. Clinician concerns emerged as a barrier to wider sharing of discharge letters with patients, which may need to be addressed through organisational policies and direction.

CONCLUSIONS

This review forms a starting point for explaining outcomes associated with whether or not patients receive discharge letters. It suggests several ways in which current processes might be modified to support improved practice and patient experience.

A realist review of community engagement with health research

Introduction: Community engagement is increasingly recognized as a critical aspect of global health. Recent years have seen an expansion of community engagement activities linked to health research, but debates and inconsistencies remain about the aims of different types of engagement, mechanisms underpinning their implementation and impact, and influential contextual factors. Greater commitment to and consistency around community engagement by health research programs, implementers and funders requires a more coherent evidence base. This realist review is designed to improve our understanding of how and why community engagement contributes to intended and unintended outcomes (including research and ethical outcomes) in different contexts. Given the breadth and diversity of the literature on community engagement in health research, the review will initially focus on malaria research in low- and middle-income countries (LMICs) and draw on wider global health literature where needed. Methods and analysis: Community engagement in practice is often a complex set of interventions. We will conduct a realist review - a theory driven approach to evidence synthesis - to provide explanations for how and why community engagement with health research produces the pattern of outcomes observed across different contexts of application. We will consolidate evidence from a range of documents, including qualitative, quantitative and mixed method studies. The review will follow several stages: devising an initial programme theory, searching evidence, selecting appropriate documents, extracting data, synthesizing and refining the programme theory, and reiteration of these steps as needed. Ethics and dissemination: A formal ethics review is not required for this literature review.  Findings will be disseminated in a peer reviewed journal, through national and international conferences, and through a set of short briefings tailored for audiences with an interest in community engagement. Outputs and presentations will be informed by and feed into our network of community engagement experts. PROSPERO registration number: CRD42019125687.

Adapting health interventions for local fit when scaling-up: a realist review protocol

INTRODUCTION

Scaling-up is essential to ensure universal access of effective health interventions. Scaling-up is a complex process, which occurs across diverse systems and contexts with no one-size-fits-all approach. To date, little attention has been paid to the process of scaling-up in how to make adaptations for local fit. The aim of this research is to develop theory on what actions can be used to make adaptations to health interventions for local fit when scaling-up across diverse contexts that will have practical application for implementers involved in scaling-up.

METHODS AND ANALYSIS

Given the complexity of this subject, a realist review methodology was selected. Specifically, realist review emphasises an iterative, non-linear process, whereby the review is refined as it progresses. The identification of how the context may activate mechanisms to achieve outcomes is used to generate theories on what works for whom in what circumstances. This protocol will describe the first completed stage of development of an initial programme theory framework, which identified potential actions, contexts, mechanisms and outcomes that could be used to make adaptations when scaling-up. It will then outline the methods for future stages of the review which will focus on identifying case examples of scale-up and adaptation in practice. This realist review consists of six stages: (i) clarifying scope and development of a theoretical framework, (ii) developing a search strategy, (iii) selection and appraisal, (iv) data extraction, (v) data synthesis and analysis and (vi) further theory refinement with stakeholders.

ETHICS AND DISSEMINATION

This review will develop theory on how adaptations can be made when scaling-up. Findings will be disseminated in a peer-reviewed journal and through stakeholder engagement as part of the research process. Ethical approval has been received through Health Policy and Management/Centre for Global Health Research Ethics Committee of Trinity College Dublin.

Understanding the impact of delegated home visiting services accessed via general practice by community-dwelling patients: a realist review protocol

INTRODUCTION

In western countries, early visiting services (EVS) have been proposed as a recent intervention to reduce both general practitioner workload and hospital admissions among housebound individuals experiencing a healthcare need within the community. EVS involves the delegation of the patient home visits to other staff groups such as paramedics or nursing staff. However, the principles of organising this care are unknown and it remains unclear how different contexts, such as patient conditions and the processes of organising EVS influence care outcomes. A review has been designed to understand how EVS are enacted and, specifically, who benefits, why, how and when in order to provide further insight into the design and delivery of EVS.

METHODS AND ANALYSIS

The purpose of this review is to produce findings that provide explanations of how and why EVS contexts influence their associated outcomes. Evidence on EVS will be consolidated through realist review-a theory-driven approach to evidence synthesis. A realist approach is needed as EVS is a complex intervention. What EVS achieve is likely to vary for different individuals and contexts. We expect to synthesise a range of relevant data such as qualitative, quantitative and mixed-method research in the following stages: devising an initial programme theory, searching evidence, selecting appropriate documents, extracting data, synthesising and refining the programme theory.

ETHICS AND DISSEMINATION

A formal ethics review is not required as this study is secondary research. Findings will be disseminated in a peer-reviewed journal, at national and international conferences and to relevant professional associations.

PROSPERO REGISTRATION NUMBER

CRD42018096518.