Realist review of community coalitions and outreach interventions to increase access to primary care for vulnerable populations: a realist review

BACKGROUND

There are meaningful gaps in equitable access to Primary Health Care (PHC), especially for vulnerable populations after widespread reforms in Western countries. The Innovative Models Promoting Access-to-Care Transformation (IMPACT) research program is a Canadian-Australian collaboration that aims to improve access to PHC for vulnerable populations. Relationships were developed with stakeholders in six regions across Canada and Australia where access-related needs could be identified. The most promising interventions would be implemented and tested to address the needs identified. This realist review was conducted to understand how community coalition and outreach (e.g., mobile or pop-up) services improve access for underserved vulnerable residents.

OBJECTIVE

To inform the development and delivery of an innovative intervention to increase access to PHC for vulnerable populations.

METHODS

A realist review was conducted in collaboration with the Local Innovative Partnership (LIP) research team and the IMPACT research members who conducted the review. We performed an initial comprehensive systematic search using MEDLINE, EMBASE, PsycINFO, and the Cochrane Library up to October 19, 2015, and updated it on August 8, 2020. Studies were included if they focused on interventions to improve access to PHC using community coalition, outreach services or mobile delivery methods. We included Randomized Controlled Trials (RCTs), and systematic reviews. Studies were screened by two independent reviewers and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used for data extraction and framework analysis to obtain themes. The LIP research team was also allowed to suggest additional papers not included at screening.

RESULTS

We included 43 records, comprising 31 RCTs, 11 systematic reviews, and 1 case control study that was added by the LIP research team. We identified three main themes of PHC interventions to promote access for vulnerable residents, including: 1) tailoring of materials and services decreases barriers to primary health care, 2) services offered where vulnerable populations gather increases the "reach" of the interventions, 3) partnerships and collaborations lead to positive health outcomes. In addition, implementation designs and reporting elements should be considered.

CONCLUSION

Realist reviews can help guide the development of locally adapted primary health care interventions.

Changing patterns of case ascertainment and trends in meningococcal disease in England and Wales

We have reviewed data on meningococcal disease routinely collected in England and Wales from 1989 to 1995 to illustrate and explain changing patterns and guide future surveillance. Statutory notifications of meningococcal meningitis and septicaemia, laboratory confirmed infections, and death registrations coded as meningococcal disease were analysed in terms of their numbers, the age of cases, season of the report, and (if available) site of isolation, serogroup, and serotype. Case fatality rates were estimated for clinically diagnosed and culture confirmed cases. The number of cases notified each year, in particular those notified as septicaemia, rose significantly over the period (p < 0.0001) but there was no net change in the number of culture confirmed cases. Case fatality rates estimated from routine data fell, most markedly for cases notified as septicaemia, but the true case fatality rate of culture confirmed cases did not change between 1993 and 1995. These data suggest that reporting practice changed between 1989 and 1995 and that the ascertainment of clinically diagnosed disease improved, particularly for meningococcal septicaemia. Late in 1995, reports from all data sources increased and the age distribution of both notified and laboratory confirmed cases changed. These changes were accompanied by an increase in the proportion of infections due to Neisseria meningitidis of serogroup C and a significant increase in serotype C2a infections (p < 0.0001). Continuing efforts to reconcile data from several sources will be needed to ensure that routine data can be interpreted accurately to provide evidence for the development of future vaccination policy and to monitor vaccination programmes. In addition, the role of non-culture diagnosis will be crucial in enhancing surveillance based on clinical diagnoses.