Monique Lhussier

What's in a mechanism? Development of a key concept in realist evaluation

BackgroundThe idea that underlying, generative mechanisms give rise to causal regularities has become a guiding principle across many social and natural science disciplines. A specific form of this enquiry, realist evaluation is gaining momentum in the evaluation of complex social interventions. It focuses on ‘what works, how, in which conditions and for whom’ using context, mechanism and outcome configurations as opposed to asking whether an intervention ‘works’. Realist evaluation can be difficult to codify and requires considerable researcher reflection and creativity. As such there is often confusion when operationalising the method in practice. This article aims to clarify and further develop the concept of mechanism in realist evaluation and in doing so aid the learning of those operationalising the methodology.DiscussionUsing a social science illustration, we argue that disaggregating the concept of mechanism into its constituent parts helps to understand the difference between the resources offered by the intervention and the ways in which this changes the reasoning of participants. This in turn helps to distinguish between a context and mechanism. The notion of mechanisms ‘firing’ in social science research is explored, with discussions surrounding how this may stifle researchers’ realist thinking. We underline the importance of conceptualising mechanisms as operating on a continuum, rather than as an ‘on/off’ switch.SummaryThe discussions in this article will hopefully progress and operationalise realist methods. This development is likely to occur due to the infancy of the methodology and its recent increased profile and use in social science research. The arguments we present have been tested and are explained throughout the article using a social science illustration, evidencing their usability and value.

Paradoxes, locations and the need for social coherence: a qualitative study of living with a learning difficulty

Policy rhetoric over recent decades has promoted social inclusion of the more vulnerable sectors of society, such as people with learning difficulties. This study aimed to describe the experiences of people who live with learning difficulties in order to inform local service development. Thirty‐five people with a learning difficulty and/or a family member were interviewed. A model of social coherence was developed that moves beyond the self‐limiting debates about social inclusion and exclusion. It is underpinned by a sense of location for the person with a disability in relation to services and carers, family and community, dependency and risk, temporality and space, events, control and society. Key recommendations are for services to know the individual and his/her family; to be responsive to individual needs; to enhance the capacity of families and communities to support people with difficulty in learning; and to help these people to feel more valued.

Health-related lifestyle advice: critical insights

This article situates itself within contemporary public health workforce development issues and provides critical insights into the newly developed roles of health trainers and the wider practice of health-related lifestyle advice. It highlights a number of contradictions and paradoxes in relation to health-related lifestyle advice, in terms of the organisation of the public body in intervention targets, in terms of choice and risk, of the power relation it involves and in terms of the dichotomy between professionalisation and personalisation of public health messages. The analysis highlights the competing discourses of expertise on the one side, and empowerment, autonomy and independence on the other. It is likely that, rather than enforcing only one kind of narrative, health trainer roles would realise a greater liberating potential by facilitating the navigation between different sets of realities at different times and different geographical, cultural and conceptual places.

Understanding integrated care pathways in palliative care using realist evaluation: a mixed methods study protocol

Introduction Policy- and evidence-based guidelines have highlighted the need for improved palliative and end-of-life care. However, there is still evidence of individuals dying undignified deaths with little pain control, therefore inflicting unnecessary suffering. New commissioning powers have enabled a 2-year pilot of an innovative integrated care pathway (ICP) designed to improve arrangements for individuals with life-limiting illnesses requiring palliative care. A novel feature of the ICP is its focus on palliative care over the last 6 months of life, aiming to intervene early to prepare for and ensure a good death. What is not known is if this pathway works, how it works and who it works for. Methods and analysis A realist evaluation and a complex analytical framework will investigate and discover context, mechanism and outcome conjectures and configurations of the ICP and thus facilitate exploration of how it works and who it works for. A mixed methods approach will be used with small sample sizes to capture the breadth of the ICP. Phase 1 will identify if the pathway works through analysis of NHS Morbidity Information Query and Export Syntax data, locality Death Audit data and the Quality of Dying and Death Questionnaire. Phase 2 employs soft systems methodology with data from focus groups with health professionals to identify how the pathway works. Phase 3 uses the Miller Behavioural Style Scale and interviews with palliative care patients and bereaved relatives to analyse communication in palliative care. Ethics and dissemination Ethical approval has been granted from the NHS local ethics committee (REC reference number: 11/NE/0318). Research & Development approval has been gained from four different trusts, and relevant voluntary organisations and the local council have been informed about the research. This protocol illustrates the complexity inherent in evaluating a palliative care ICP. Identification of whether the pathway works, how it works and who it works for will be beneficial to all practices and other care providers involved as it will give objective data on the impact of the ICP. Results will be disseminated throughout the study for continuous quality improvement of the ICP. Outcomes from each data collection phase will be disseminated separately if analysis warrants it; all data collection will be utilised in the realist evaluation. The research provides a potential for the dissemination of the pathway to other localities through the transferable knowledge it will generate, from its focus on the contexts that are crucial for successful implementation, the mechanisms that facilitate implementation and the outcomes achieved.

The supervision of professional doctorates: Experiences of the processes and ways forward

The doctoral research terrain is changing, as new-styles, for example professional doctorates, are being developed (Park, C., 2005. New variant PhDL the changing nature of the doctorate in the UK. Journal of Higher Education Policy and Management 27(2), 189-207). There is a scarcity of literature aimed at supervisors (Gatfield, T., 2005, An investigation into PhD supervisory management styles: development of a dynamic conceptual model and its managerial implications. Journal of Higher Education Policy and Management 27(3), 311-325) and this is particularly so in relation to professional doctorates. In this position paper we argue that the supervisory approach required for a professional doctorate student is different than that required for a PhD. Professional doctorate students, like PhD students, are required to make an explicit contribution to knowledge. Their emphasis, however, needs to be in producing knowledge that is theoretically sound, original, and of relevance to their practice area. This is of increasing importance within healthcare with the growing emphasis on patient driven translational research. As such, the students and their supervisors face unique challenges of balancing academic requirements with praxis. We suggest this requires specific tools to make explicit the dialogical relationship between a particular project and the cultural, social, educational and political aspects of its environment. We expose the potential of soft systems methodology as a means to highlight the emergent aspects of a doctoral practice development project, their respective and evolving supervisory interactions. This focus of this paper is therefore not about guiding supervision in a managerial sense, but rather at offering methodological suggestions that could underpin applied research at doctoral level.

Reducing inequalities in care for patients with non-malignant diseases: Insights from a realist evaluation of an integrated palliative care pathway

Background: The need for palliative care is growing internationally with an increasing prevalence of non-malignant diseases. The integrated care pathway was implemented in primary care by multidisciplinary teams from 2009 in a locality in the North East of England. Fourteen general practitioner practices provided data for the study. Aim: To find whether, how, and under what circumstances palliative care registrations are made for patients with non-malignant diseases in primary care. Design: General practitioner practice data were analysed statistically and qualitative data were collected from health care professionals and members of relevant organisations. Findings: A mixed-effects logistic model indicated a significant difference beyond the 0.1% level (p < 0.001) in registrations between the malignant and non-malignant groups in 2011, with an odds ratio of 0.09 (=exp(−2.4266)), indicating that patients in the non-malignant group are around 11 times (1/0.09) less likely to be registered than patients in the malignant group. However, patients with non-malignant diseases were significantly more likely to be registered in 2012 than in 2011 with an odds ratio of 1.46, significant beyond the 1% level. Qualitative analyses indicate that health care professionals find registering patients with non-malignant diseases stressful, yet feel that their confidence in treating this population is increasing. Conclusion: The integrated care pathway began to enable the reduction in inequalities in care by identifying, registering and managing an increasing number of palliative patients with non-malignant diseases. Consensual and inclusive definitions of palliative care were developed in order to legitimise the registration of such patients.

Care planning for long-term conditions – a concept mapping

This article focuses on approaches within clinical practice that seek to actively involve patients with long‐term conditions (LTCs) and how professionals may understand and implement them. Personalized care planning is one such approach, but its current lack of conceptual clarity might have impeded its widespread implementation to date. A variety of overlapping concepts coexist in the literature, which have the potential to impair both clinical and research agendas. The aim of this article is therefore to explore the meaning of the concept of care planning in relation to other overlapping concepts and how this translates into clinical practice implementation.

Exploring and optimising maternal and infant nutrition in North West Pakistan

OBJECTIVES the aim of this study was to explore and contextualise meanings, beliefs and practices surrounding maternal and infant nutrition in North West Pakistan and to use the findings to inform the development of a nutritional improvement programme adapted to local needs. DESIGN the Context-Mechanism-Outcome framework was used to gather contextual data, formulate questions and conduct focus groups to inform the design of a culturally appropriate nutritional health programme with the overall goal of improving practices related to maternal and infant nutrition. Two focus groups were conducted with the team of local lady health workers (n=16), one prior to implementing a nutritional improvement programme and one 6 months after implementation. SETTINGS the study was conducted in communities surrounding and served by the Emergency Satellite Hospital (ESH) in Nahaqi in Khyber Pakhtunkhawa (KP) (formally known as the Northwest Frontier Province), Pakistan. FINDINGS poverty and specific cultural practices impeded the achievement of optimum maternal and infant nutrition. A nutrition support programme was implemented; it involved cookery demonstration kitchens and free food supplements, coupled with nutrition and health-care information-giving for pregnant and lactating women. Focus group discussions revealed that women had positive perceptions of the impact of the nutritional health improvement programme, feeling that knowledge and practices were enhanced. However, structural and cultural factors continued to have a powerful influence on their practices. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE this study highlights that despite structural, cultural and practical barriers, a culturally sensitive health improvement programme has the potential to enhance maternal and infant nutritional practices. However, we should not underestimate the powerful influence of poverty and culturally embedded norms upon womens decisions and practices.

Leadership for health improvement – implementation and evaluation

PURPOSE The purpose of this paper is to present a co-authored reflection on the health improvement leadership development programme and the key evaluation messages derived from piloting in an English National Health Service region. It highlights the specific attributes of this approach to health improvement leadership development and clarifies health improvement development issues. DESIGN/METHODOLOGY/APPROACH Appreciative inquiry and soft systems methodology are combined in an evaluation approach designed to capture individual as well as organisation learning and how it impacts on leadership in specific contexts. FINDINGS The evaluation exposes the health improvement leadership needs of a multi-organisation cohort, offers some explanations for successful achievement of learning needs while also exposing of the challenges and paradoxes faced in this endeavour. ORIGINALITY/VALUE There are limited reported templates of how to develop leadership for health improvement. This paper details a whole systems approach, acknowledging the impact of context on leadership and an approach to evaluating such complex initiatives.

Cost-effectiveness of health-related lifestyle advice delivered by peer or lay advisors: synthesis of evidence from a systematic review

BackgroundDevelopment of new peer or lay health-related lifestyle advisor (HRLA) roles is one response to the need to enhance public engagement in, and improve cost-effectiveness of, health improvement interventions. This article synthesises evidence on the cost-effectiveness of HRLA interventions aimed at adults in developed countries, derived from the first systematic review of the effectiveness, cost-effectiveness, equity and acceptability of different types of HRLA role.MethodsThe best available evidence on the cost-effectiveness of HRLA interventions was obtained using systematic searches of 20 electronic databases and key journals, as well as searches of the grey literature and the internet. Interventions were classified according to the primary health behaviour targeted and intervention costs were estimated where necessary. Lifetime health gains were estimated (in quality-adjusted life years, where possible), based on evidence of effectiveness of HRLAs in combination with published estimates of the lifetime health gains resulting from lifestyle changes, and assumptions over relapse. Incremental cost-effectiveness ratios are reported.ResultsEvidence of the cost-effectiveness of HRLAs was identified from 24 trials included in the systematic review. The interventions were grouped into eight areas. We found little evidence of effectiveness of HRLAs for promotion of exercise/improved diets. Where HRLAs were effective cost-effectiveness varied considerably: Incremental Cost effectiveness Ratios were estimated at £6,000 for smoking cessation; £14,000 for a telephone based type 2 diabetes management; and £250,000 or greater for promotion of mammography attendance and for HIV prevention amongst drug users. We lacked sufficient evidence to estimate ICERs for breastfeeding promotion and mental health promotion, or to assess the impact of HRLAs on health inequalities.ConclusionsOverall, there is limited evidence suggesting that HRLAs are cost-effective in terms of changing health-related knowledge, behaviours or health outcomes. The evidence that does exist indicates that HRLAs are only cost-effective when they target behaviours likely to have a large impact on overall health-related quality of life. Further development of HRLA interventions needs to target specific population health needs where potential exists for significant improvement, and include rigorous evaluation to ensure that HRLAs provide sufficient value for money.