Realist review protocol for understanding the real-world barriers and enablers to practitioners implementing self-management support to people living with and beyond cancer

Adult day programs and their effects on individuals with dementia and their caregivers (ADAPT-DemCare): a realist synthesis to develop program theories on the how and why

BACKGROUND

Adult day programs aim to facilitate aging in place by supporting the health and well-being of persons with dementia and providing respite to their caregivers. However, studies on the effects of day programs are inconclusive, and we especially lack insights into the context conditions and mechanisms of day programs that may produce different outcomes for different groups of persons with dementia and their caregivers. Our objective was to conduct a realist review, synthesizing research on day programs to develop program theories explaining how and why day programs do or do not produce positive or negative outcomes for different groups of persons with dementia, and caregivers.

METHODS

We identified 14 literature reviews (including 329 references published between 1975 and 2021) on adult day programs. From this initial pool of studies, we will include those that focused on day program attendees with dementia or meaningful cognitive impairment, and/or their caregivers, and that report how day program contexts (C) and mechanisms (M) bring about outcomes (O) for attendees and caregivers. We will extract CMO statements (i.e., narratives that explain how and why day programs do or do not bring about certain outcomes for whom and under what circumstances). Using additional focused searches, citation mapping, citation tracking, and discussions with our researcher and expert team members, we will identify additional references. CMO statements will be synthesized, transformed into hypotheses, and linked and visualized to form program theories. Using focus groups and the James Lind Alliance Priority Setting Partnership method, we will discuss and prioritize our CMO statements and refine our program theories with 32 experts (older adults, caregivers, Alzheimer societies, caregiver organizations, day program staff and managers, and health system and policy decision makers).

DISCUSSION

By identifying essential elements and processes of day programs and related knowledge gaps, this study will generate much-needed knowledge to leverage the full potential of day programs so they can provide appropriate care, preventing premature institutionalization, and unnecessary acute and primary care use. This will ultimately improve the quality of life of persons with dementia and their caregivers, alleviate caregiver burden, and reduce social costs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42024504030.

improving Pain mAnagement for childreN and young people attendeD by Ambulance (PANDA): protocol for a realist review

Background

Each year in England, 450,000 children and young people (CYP) under 18 years of age are transported by ambulance to emergency departments. Approximately 20% of these suffer acute pain caused by illness or injury. Pain is a highly complex sensory and emotional experience. The intersection between acute pain, unwell CYP and the unpredictable pre-hospital environment is convoluted. Studies have shown that prehospital pain management in CYP is poor, with 61% of those suffering acute pain not achieving effective pain relief (abolition or reduction of pain score by 2 or more out of 10) when attended by ambulance. Consequences of poor acute pain management include altered pain perception, post-traumatic stress disorder and the development of chronic pain. This realist review will aim to understand how ambulance clinicians can provide improved prehospital acute pain management for CYP.

Methods

A realist review will be conducted in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance. A five-stage approach will be adopted; 1) Developing an Initial Programme Theory (IPT): develop an IPT with key stakeholder input and evidence from informal searching; 2) Searching and screening: conduct a thorough search of relevant research databases and other literature sources and perform screening in duplicate; 3) Relevance and rigour assessment: assess documents for relevance and rigour in duplicate; 4) Extracting and organising data: code relevant data into conceptual "buckets" using qualitative data analysis software; and 5) Synthesis and Programme Theory (PT) refinement: utilise a realist logic of analysis to generate context-mechanism-outcome configurations (CMOCs) within and across conceptual "buckets", test and refine the IPT into a realist PT.

Conclusion

The realist PT will enhance our understanding of what works best to improve acute prehospital pain management in CYP, which will then be tested and refined within a realist evaluation.

Registration

PROSPERO Registration: CRD42024505978.

A systematic review of the mechanisms influencing engagement in diabetes prevention programmes for people with pre-diabetes

AIMS

To identify barriers and enablers that influence engagement in and acceptability of diabetes prevention programmes for people with pre-diabetes. The results will provide insights for developing strategies and recommendations to improve design and delivery of diabetes prevention programmes with enhanced engagement and acceptability for people with pre-diabetes.

METHODS

This review used a critical realist approach to examine context and mechanisms of diabetes prevention programmes. Medline, Embase, PsycInfo, Cinahl, Web of Science, Scopus and Pre-Medline were searched for English language studies published between 2000 and 2023. A quality assessment was conducted using Joanna Briggs Institute critical appraisal tools.

RESULTS

A total of 90 papers met inclusion criteria. The included studies used a variety of quantitative and qualitative methodologies. Data extracted focused on barriers and enablers to engagement in and acceptability of diabetes prevention programmes, with seven key mechanisms identified. These included financial, environmental, personal, healthcare, social and cultural, demographic and programme mechanisms. Findings highlighted diverse factors that influenced engagement in preventive programmes and the importance of considering these factors when planning, developing and implementing future diabetes prevention programmes.

CONCLUSIONS

Mechanisms identified in this review can inform design and development of diabetes prevention programmes for people with pre-diabetes and provide guidance for healthcare professionals and policymakers. This will facilitate increased participation and engagement in preventive programmes, potentially reducing progression and/or incidence of pre-diabetes to type 2 diabetes and improving health outcomes.

Transition of young people from children's into adults' services: what works for whom and in what circumstances - protocol for a realist synthesis

INTRODUCTION

The process of transitioning young people from children's or adolescents' health services into adults' services is a crucial time in the lives and health of young people and has been reported to be disjointed rather than a process of preparation in which they are involved. Such transitions not only fail to meet the needs of young people and families at this time of significant change, but they may also result in a deterioration in health, or disengagement with services, which can have deleterious long-term consequences. Despite the wealth of literature on this topic, there has yet to be a focus on what works for whom, in what circumstances, how and why, in relation to all young people transitioning from children's into adults' services, which this realist synthesis aims to address.

METHODS AND ANALYSIS

This realist synthesis will be undertaken in six stages: (1) the scope of the review will be defined; (2) initial programme theories (IPTs) developed; (3) evidence searched; (4) selection and appraisal; (5) data extraction and synthesis; and (6) finally, refine/confirm programme theory. A theory-driven, iterative approach using the 'On Your Own Feet Ahead' theoretical framework, will be combined with an evidence search including a review of national transition policy documents, supplemented by citation tracking, snowballing and stakeholder feedback to develop IPTs. Searches of EMBASE, EMCARE, Medline, CINAHL, Cochrane Library, Web of Science, Scopus, APA PsycINFO and AMED will be conducted from 2014 to present, supplemented with grey literature, free-text searching (title, abstract and keywords) and citation tracking. Data selection will be based on relevance and rigour and extracted and synthesised iteratively with the aim of identifying and exploring causal links between contexts, mechanisms and outcomes. Results will be reported according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards Quality and Publication Standards.

ETHICS AND DISSEMINATION

This realist synthesis forms part of the National Transition Evaluation Study, which has received ethical and regulatory approval (IRAS ID: 313576). Results will be disseminated through peer-review publication, conference presentations and working with healthcare organisations, stakeholder groups and charities.

TRIAL REGISTRATION NUMBER

NCT05867745.

PROSPERO REGISTRATION NUMBER

CRD42023388985.

BREATHLEssness in INDIA (BREATHE-INDIA)-Study protocol for the co-design of a community breathlessness intervention in India using realist methods and intervention mapping

BACKGROUND

Breathlessness that persists despite treatment of causal disease(s) is disabling, associated with high therapy-related costs and poor socioeconomic outcomes. Low resource countries bear a disproportionate burden of respiratory problems, often characterised by disabling breathlessness. Low-cost self-management breathlessness-targeted interventions are effective and deliverable in community settings but have been developed in high-income countries. We aim to understand how breathlessness self-management works in 'real life' populations and cultural contexts, to develop programme theory and co-design a prototype intervention to improve persistent breathlessness management in India.

METHODS AND ANALYSIS

Using a Realist approach, Intervention Mapping and the Medical Research Council Complex Intervention Framework we will undertake two phases of work supported by our Expert Group (of respiratory, primary, palliative care physicians) and key stakeholder groups (opinion leader clinicians, community health workers and people with lived experiences of breathlessness). 1) Realist review and evaluation to identify and refine evidence and theory for breathlessness self-management, producing intervention and implementation programme theory. We will identify literature through our Expert Group, scoping searches and systematic searches (Medline, Ebscohost, CINAHL, Scopus, Psychinfo). We will map intervention components to 'what works, for whom, and where.' 2) Intervention development using Intervention Mapping to map intervention and implementation programme theory to intervention components, develop materials to support intervention delivery, and co-design a prototype educational intervention ready for early acceptability and delivery-feasibility testing and evaluation planning in India. Use of stakeholder groups is to allow people with experience of breathlessness and/or its management to contribute their views on content developed by our team based upon review of secondary data sources. Experts and Stakeholders are therefore not research subjects but are included as extended members of the study team and will not follow informed consent procedures. Experts and stakeholders will be acknowledge in outputs arising from our project if they wish to be. Our review conduct will be consistent with RAMESES quality standards.

DISCUSSION

At the conclusion of our study, we will have co-designed a breathlessness intervention for use in the community setting in India ready for further evaluation of: effectiveness, socioeconomic outcomes, acceptability and transferability to other low resource settings.

Peer support interventions in maternal and child healthcare delivery in sub-Saharan Africa: protocol for a realist review

BACKGROUND

Peer support has been proposed as a promising policy intervention for addressing adverse maternal and child healthcare (MCH) outcomes in sub-Saharan Africa (SSA). Existing reviews on peer support largely draw on evidence from high-income countries or focus on single services like breastfeeding, nutrition or postnatal care. In contrast, this review aims to provide a comprehensive overview of the empirical literature on peer support interventions across various MCH services in sub-Saharan Africa. Specifically, we aim to understand how, why, for whom, and in what circumstances different forms of MCH peer support interventions contribute to improving healthcare outcomes in sub-Saharan Africa.

METHODS

This review follows five iterative steps for undertaking realist reviews (1) defining the review scope; (2) developing initial programme theories; (3) searching for evidence; (4) selecting and appraising evidence; and (5) extracting, analysing and synthesising evidence. Four databases-Cochrane Library, PubMed, CINAHL, and EMBASE-were repeatedly searched between March and June 2021. From a large volume of records retrieved from the database and citation search, 61 papers have been selected for review. We will conduct a second search of the same database covering June 2021 to the present before the final extraction and synthesis. The final list of selected papers will be imported into NVivo 12 software and organised, extracted, analysed and synthesised iteratively to examine and illustrate the causal links between contexts, mechanisms and outcomes of MCH peer support interventions in SSA. We have drawn on the existing literature on peer support in healthcare generally to develop initial programme theories. We will then use the empirical literature on MCH peer support interventions in SSA, inputs from a stakeholders' workshop in Ghana and a conference presentation to refine the initial programme theory.

DISCUSSION

The review will develop an explicit theory of peer support intervention in healthcare delivery and provide insights for developing evidence-informed policy on the intervention. Drawing lessons from the different national contexts and diverse areas of MCH in SSA, the review will provide an analytically generalizable programme theory that can guide intervention design and implementation. While focusing on MCH peer support interventions in SSA, the review contributes to evolving conversations on the use of theory for health policy planning and complex intervention design and implementation globally.

TRIAL REGISTRATION

PROSPERO registration ID: CRD42023427751 .

Community engagement in maternal and perinatal death surveillance and response (MPDSR): Realist review protocol

Background: While there has been a decline in maternal and perinatal mortality, deaths remain high in sub-Saharan Africa and Asia. With the sustainable development goals (SDGs) targets to reduce maternal and perinatal mortality, more needs to be done to accelerate progress and improve survival. Maternal and perinatal death surveillance and response (MPDSR) is a strategy to identify the clinical and social circumstances that contribute to maternal and perinatal deaths. Through MPDSR, an active surveillance and response cycle is established by bringing together different stakeholders to review and address these social and clinical factors. Community engagement in MPDSR provides a strong basis for collective action to address social factors and quality of care issues that contribute to maternal and perinatal deaths. Studies have shown that community members can support identification and reporting of maternal and/or perinatal deaths. Skilled care at birth has been increasing globally, but there are still gaps in quality of care. Through MPDSR, community members can collaborate with health workers to improve quality of care. But we do not know how community engagement in MPDSR works in practice; for whom it works and what aspects work (or do not work) and why. This realist review answers the question: which strategies of community engagement in MPDSR produce which outcomes in which contexts? Methods : For this realist review, we will identify published and grey literature by searching relevant databases for articles. We will include papers published from 2004 in all languages and from all countries. We have set up an advisory group drawn from academia, international organizations, and practitioners of both MPDSR and community engagement to guide the process. Conclusion: This protocol and the subsequent realist review will use theoretical approaches from the community engagement literature to generate theory on community engagement in MPDSR. Prospero registration number:  CRD42022345216.

A realist process evaluation of an intervention to promote competencies in interprofessional collaboration among interdisciplinary integrated care teams for older people: Study protocol

Background: International policy is increasingly committed to placing interdisciplinary team-working at the centre of health and social care integration across the lifespan. The National Clinical Programme for Older People in Ireland has a critical role in the design and implementation of the National Older Person's Service Model, which aims to shift the delivery of care away from acute hospitals towards community-based care. Interdisciplinary Community Specialist Teams for older persons (CST-OPs) play an important role in this service model. To support the development of competencies for interprofessional collaboration and an interdisciplinary team-based approach to care integration, a culture shift will be required within care delivery. Design:This study builds upon a collaborative partnership project which co-designed a framework describing core competencies for interprofessional collaboration in CST-OPs. A realist-informed process evaluation of the framework will be undertaken as the competencies described in the framework are being fostered in newly developed CST-OPs under the national scale-up of the service model. Realist evaluation approaches reveal what worked, why it worked (or did not), for whom and under what circumstances. Three iterative and integrated work packages are proposed which combine multiple methods of data collection, analysis and synthesis. Prospective data collection will be undertaken within four CST-OPs, including qualitative exploration of the care experiences of older people and family carers. Discussion: The realist explanatory theory will provide an understanding of how interprofessional collaboration can be fostered and sustained in various contexts of care integration for older people. It will underpin curriculum development for team-based education and training of health and social care professionals, a key priority area in the national Irish health strategy. It will provide healthcare leaders with knowledge of the resources and supports required to harness the benefits of interprofessional collaboration and to realise the goals of integrated care for older people.

Implementation of Home-Based Telerehabilitation of Patients With Stroke in the United States: Protocol for a Realist Review

BACKGROUND

Stroke is a common cause of mortality and morbidity. Insufficient and untimely rehabilitation has been associated with inadequate recovery. Telerehabilitation provides an opportunity for timely and accessible services for individuals with stroke, especially in remote areas. Telerehabilitation is defined as a health care team's use of a communication mode (eg, videoconferencing) to remotely provide rehabilitation services. Telerehabilitation is as effective as facility-based rehabilitation; however, it is infrequently used due to implementation barriers.

OBJECTIVE

The aim of the study is to explore the interaction between the implementation strategies, context, and outcomes of telerehabilitation of patients with stroke.

METHODS

This review will follow four steps: (1) defining the review scope, (2) literature search and quality appraisal, (3) data extraction and evidence synthesis, and (4) narrative development. PubMed via MEDLINE, the PEDro database, and CINAHL will be queried till June 2023 and supplemented with citation tracking and a gray literature search. The relevance and rigor of papers will be appraised using the TAPUPAS (Transparency, Accuracy, Purposivity, Utility, Propriety, Accessibility, and Specificity) and Weight of Evidence frameworks. The reviewers will extract and synthesize data iteratively and develop explanatory links between contexts, mechanisms, and outcomes. The results will be reported according to the Realist Synthesis publication standards set by Wong and colleagues in 2013.

RESULTS

The literature search and screening will be completed in July 2023. Data extraction and analysis will be completed in August 2023, and findings will be synthesized and reported in October 2023.

CONCLUSIONS

This will be the first realist synthesis, uncovering the causal mechanisms to explain how, why, and to what extent implementation strategies impact telerehabilitation adoption and implementation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47009.

Understanding how primary care practitioners can be supported to recognise, screen and initially diagnose oropharyngeal dysphagia: protocol for a behavioural science realist review

INTRODUCTION

Oropharyngeal dysphagia (OD) affects around 15% of older people; however, it is often unrecognised and underdiagnosed until patients are hospitalised. Screening is an important process which aims to facilitate proactive assessment, diagnosis and management of health conditions. Healthcare systems do not routinely screen for OD in older people, and healthcare professionals (HCPs) are largely unaware of the need to screen. This realist review aims to identify relevant literature and develop programme theories to understand what works, for whom, under what circumstances and how, to facilitate primary care HCPs to recognise, screen and initially diagnose OD.

METHODS AND ANALYSIS

We will follow five steps for undertaking a realist review: (1) clarify the scope, (2) literature search, (3) appraise and extract data, (4) evidence synthesis and (5) evaluation. Initial programme theories (IPTs) will be constructed after the preliminary literature search, informed by the Theoretical Domains Framework and with input from a stakeholder group. We will search Medline, Google Scholar, PubMed, EMBASE, CINAHL, AMED, Scopus and PsycINFO databases. We will obtain additional evidence through grey literature, snowball sampling, lateral searching and consulting the stakeholder group. Literature will be screened, evaluated and synthesised in Covidence. Evidence will be assessed for quality by evaluating its relevance and rigour. Data will be extracted and synthesised according to their relation to IPTs. We will follow the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication standards to report study results.

ETHICS AND DISSEMINATION

Formal ethical approval is not required for this review. We will disseminate this research through publication in a peer-reviewed journal, written pieces targeted to diverse groups of HCPs on selected online platforms and public engagement events.

PROSPERO REGISTRATION NUMBER

CRD42022320327.

Factors influencing decisions about whether to participate in health research by people of diverse ethnic and cultural backgrounds: a realist review

OBJECTIVE

To develop and refine a programme theory that explains factors that influence decisions to take part in health research by people of diverse ethnic and cultural backgrounds.

DESIGN

Realist review following a sequence of five steps: (a) scoping search and identification of programme theory; (b) evidence searching; (c) critical appraisal and data extraction; (d) organisation of evidence and (e) refinement of programme theory.

ELIGIBILITY CRITERIA

Documents (including peer-reviewed articles, grey literature, websites, reports and conference papers) either full text, or a section of relevance to the overarching research question were included.

DATA SOURCES

EMBASE, Medline, Web of Science, Psych Info, Google and Google Scholar were searched iteratively between May and August 2020. Search strategy was refined for each database providing a broad enough review for building of programme theory.

ANALYSIS

Data from eligible documents was extracted to build understanding of the factors that influence decision-making. Data were mapped to create a data matrix according to context (C), mechanism (M), outcome (O), configurations (C) (CMOCs) for the process of informed consent, to aid interpretation and produce final programme theory.

RESULTS

566 documents were screened and 71 included. Final programme theory was underpinned by CMOCs on processes influencing decisions to take part in research. Key findings indicate the type of infrastructure required, for example, resources, services and policies, to support inclusion in health research, with a greater need to increase the social presence of researchers within communities, improve cultural competency of individuals and organisations, reduce the complexity of participant information, and provide additional resources to support adaptive processes and shared decision making.

CONCLUSION

The review indicates the need for a more inclusive research infrastructure that facilitates diverse participation in health research through incorporating adaptive processes that support shared decision making within the informed consent process and in the conduct of research projects.