Contexts and mechanisms that promote access to healthcare for populations experiencing homelessness: a realist review

ObjectiveThe objective of this study was to identify and understand the health system contexts and mechanisms that allow for homeless populations to access appropriate healthcare when needed.DesignA realist review.Data sourcesOvid MEDLINE, embase.com, CINAHL, ASSIA and grey literature until April 2019.Eligibility criteria for selecting studiesThe purpose of the review was to identify health system patterns which enable access to healthcare for people who experience homelessness. Peer-reviewed articles were identified through a systematic search, grey literature search, citation tracking and expert recommendations. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded to identify data relating to contexts, mechanisms and/or outcomes.AnalysisInductive and deductive coding was used to generate context–mechanism–outcome configurations, which were refined and then used to build several iterations of the overarching programme theory.ResultsSystematic searching identified 330 review articles, of which 24 were included. An additional 11 grey literature and primary sources were identified through citation tracking and expert recommendation. Additional purposive searching of grey literature yielded 50 records, of which 12 were included, for a total of 47 included sources. The analysis found that healthcare access for populations experiencing homelessness is improved when services are coordinated and delivered in a way that is organised around the person with a high degree of flexibility and a culture that rejects stigma, generating trusting relationships between patients and staff/practitioners. Health systems should provide long-term, dependable funding for services to ensure sustainability and staff retention.ConclusionsWith homelessness on the rise internationally, healthcare systems should focus on high-level factors such as funding stability, building inclusive cultures and setting goals which encourage and support staff to provide flexible, timely and connected services to improve access.

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Contexts and mechanisms that promote access to healthcare for populations experiencing homelessness: a realist review

10.21203/rs.3.rs-79236/v1 ◽

2020 ◽

Cited By ~ 1

Author(s):

Rikke Siersbaek ◽

John Ford ◽

Sara Burke ◽

Clíona Ní Cheallaigh ◽

Steve Thomas

Keyword(s):

Health System ◽

Health Systems ◽

Healthcare Access ◽

Grey Literature ◽

Realist Review ◽

Access To Healthcare ◽

Staff Retention ◽

Programme Theory ◽

Eligibility Criteria

Abstract Objective: The objective of this study was to identify and understand the health system contexts and mechanisms that allow for homeless populations to access appropriate healthcare when needed.Design: A realist review.Data sources: Ovid MEDLINE, embase.com, CINAHL, ASSIA and grey literature until April 2019. Eligibility criteria for selecting studies: The purpose of the review was to identify health system patterns which enable access to healthcare for people who experience homelessness. Peer reviewed articles were first identified through a systematic search, grey literature searching, citation tracking and expert recommendations. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded to identify data relating to contexts, mechanisms and/or outcomes.Analysis: Inductive coding was used to generate Context-Mechanism-Outcome configurations which were refined and then used to build several iterations of the overarching programme theory.Results: Searching identified 330 review articles, of which 24 were included. Additional searching of grey literature yielded 50 records of which 12 were included. An additional 11 grey literature and primary sources were identified through citation tracking and expert recommendation for a total of 47 included sources. The analysis found that healthcare access for populations experiencing homelessness is improved when services are coordinated and delivered in a way that is organised around the person with a high degree of flexibility and a culture that rejects stigma generating trusting relationships between patients and staff/providers. Health systems should provide long-term, dependable funding for services to ensure sustainability and staff retention. Conclusions: With homelessness on the rise internationally, this study will inform health systems policy-making and implementation. It contributes to our understanding how healthcare systems can be more accessible for populations experiencing homelessness by providing long-term stable funding, promoting inclusive cultures and limiting stigma. Health systems should be flexible, timely and connected.

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Upskilling health and care workers with augmented and virtual reality: protocol for a realist review to develop an evidence-informed programme theory

BMJ Open ◽

10.1136/bmjopen-2021-050033 ◽

2021 ◽

Vol 11 (7) ◽

pp. e050033

Author(s):

Norina Gasteiger ◽

Sabine N van der Veer ◽

Paul Wilson ◽

Dawn Dowding

Keyword(s):

Virtual Reality ◽

Grey Literature ◽

Healthcare Providers ◽

Realist Review ◽

Relevant Information ◽

Care Providers ◽

Programme Theory ◽

Clinical Educators ◽

Continued Learning ◽

Search Quality

IntroductionAugmented reality (AR) and virtual reality (VR) are increasingly used to upskill health and care providers, including in surgical, nursing and acute care settings. Many studies have used AR/VR to deliver training, providing mixed evidence on their effectiveness and limited evidence regarding contextual factors that influence effectiveness and implementation. This review will develop, test and refine an evidence-informed programme theory on what facilitates or constrains the implementation of AR or VR programmes in health and care settings and understand how, for whom and to what extent they ‘work’.Methods and analysisThis realist review adheres to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) standards and will be conducted in three steps: theory elicitation, theory testing and theory refinement. First, a search will identify practitioner, academic and learning and technology adoption theories from databases (MEDLINE, Scopus, CINAHL, Embase, Education Resources Information Center, PsycINFO and Web of Science), practitioner journals, snowballing and grey literature. Information regarding contexts, mechanisms and outcomes will be extracted. A narrative synthesis will determine overlapping configurations and form an initial theory. Second, the theory will be tested using empirical evidence located from the above databases and identified from the first search. Quality will be assessed using the Mixed Methods Appraisal Tool (MMAT), and relevant information will be extracted into a coding sheet. Third, the extracted information will be compared with the initial programme theory, with differences helping to make refinements. Findings will be presented as a narrative summary, and the MMAT will determine our confidence in each configuration.Ethics and disseminationEthics approval is not required. This review will develop an evidence-informed programme theory. The results will inform and support AR/VR interventions from clinical educators, healthcare providers and software developers. Upskilling through AR/VR learning interventions may improve quality of care and promote evidence-based practice and continued learning. Findings will be disseminated through conference presentations and peer-reviewed journal articles.

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Conversations about FGM in primary care: a realist review on how, why and under what circumstances FGM is discussed in general practice consultations

BMJ Open ◽

10.1136/bmjopen-2020-039809 ◽

2021 ◽

Vol 11 (3) ◽

pp. e039809

Author(s):

Sharon Dixon ◽

Claire Duddy ◽

Gabrielle Harrison ◽

Chrysanthi Papoutsi ◽

Sue Ziebland ◽

...

Keyword(s):

Primary Care ◽

Grey Literature ◽

Relevant Literature ◽

Theory Development ◽

Realist Review ◽

Primary Outcome Measure ◽

Mandatory Reporting ◽

Programme Theory ◽

Genital Mutilation ◽

The Impact

ObjectivesLittle is known about the management of female genital mutilation (FGM) in primary care. There have been significant recent statutory changes relevant to general practitioners (GPs) in England, including a mandatory reporting duty. We undertook a realist synthesis to explore what influences how and when GPs discuss FGM with their patients.SettingPrimary care in England.Data sourcesRealist literature synthesis searching 10 databases with terms: GPs, primary care, obstetrics, gynaecology, midwifery and FGM (UK and worldwide). Citation chasing was used, and relevant grey literature was included, including searching FGM advocacy organisation websites for relevant data. Other potentially relevant literature fields were searched for evidence to inform programme theory development. We included all study designs and papers that presented evidence about factors potentially relevant to considering how, why and in what circumstances GPs feel able to discuss FGM with their patients.Primary outcome measureThis realist review developed programme theory, tested against existing evidence, on what influences GPs actions and reactions to FGM in primary care consultations and where, when and why these influences are activated.Results124 documents were included in the synthesis. Our analysis found that GPs need knowledge and training to help them support their patients with FGM, including who may be affected, what needs they may have and how to talk sensitively about FGM. Access to specialist services and guidance may help them with this role. Reporting requirements may complicate these conversations.ConclusionsThere is a pressing need to develop (and evaluate) training to help GPs meet FGM-affected communities’ health needs and to promote the accessibility of primary care. Education and resources should be developed in partnership with community members. The impact of the mandatory reporting requirement and the Enhanced Dataset on healthcare interactions in primary care warrants evaluation.PROSPERO registration numberCRD42018091996.

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Motivation as a mechanism underpinning exercise-based falls prevention programmes for older adults with cognitive impairment: a realist review

BMJ Open ◽

10.1136/bmjopen-2018-024982 ◽

2019 ◽

Vol 9 (6) ◽

pp. e024982 ◽

Cited By ~ 4

Author(s):

Vicky Booth ◽

Rowan Harwood ◽

Jennie E Hancox ◽

Victoria Hood-Moore ◽

Tahir Masud ◽

...

Keyword(s):

Older Adults ◽

Cognitive Impairment ◽

Exercise Intervention ◽

Data Extraction ◽

Realist Review ◽

Falls Prevention ◽

Cochrane Library ◽

Programme Theory ◽

Eligibility Criteria ◽

Prevention Programmes

ObjectivesThis review aimed to identify mechanisms underlying participation in falls prevention interventions, in older adults with cognitive impairment. In particular we studied the role of motivation.DesignA realist review of the literature.Data sourcesEMBASE, MEDLINE, CINAHL, the Cochrane Library, PsycINFO and PEDRO.Eligibility criteriaPublications reporting exercise-based interventions for people with cognitive impairment, including dementia, living in the community.Data extraction and synthesisA ‘rough programme theory’ (a preliminary model of how an intervention works) was developed, tested against findings from the published literature and refined. Data were collected according to elements of the programme theory and not isolated to outcomes. Motivation emerged as a key element, and was prioritised for further study.ResultsAn individual will access mechanisms to support participation when they think that exercise will be beneficial to them. Supportive mechanisms include having a ‘gate-keeper’, such as a carer or therapist, who shares responsibility for the perception of exercise as beneficial. Lack of access to support decreases adherence and participation in exercise. Motivational mechanisms were particularly relevant for older adults with mild-to-moderate dementia, where the exercise intervention was multicomponent, in a preferred setting, at the correct intensity and level of progression, correctly supported and considered, and flexibly delivered.ConclusionMotivation is a key element enabling participation in exercise-based interventions for people with cognitive impairment. Many of the mechanisms identified in this review have parallels in motivational theory. Clinically relevant recommendations were derived and will be used to further develop and test a motivationally considered exercise-based falls intervention for people with mild dementia.PROSPERO registration numberCRD42015030169.

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

BMJ Open ◽

10.1136/bmjopen-2018-027588 ◽

2019 ◽

Vol 9 (6) ◽

pp. e027588 ◽

Cited By ~ 5

Author(s):

Katharine Weetman ◽

Geoff Wong ◽

Emma Scott ◽

Eilidh MacKenzie ◽

Stephanie Schnurr ◽

...

Keyword(s):

Hospital Discharge ◽

Best Practice ◽

Data Extraction ◽

Realist Review ◽

Patient Choice ◽

Programme Theory ◽

Eligibility Criteria ◽

New Information ◽

Starting Point ◽

Outpatient Settings

ObjectiveTo understand how different outcomes are achieved from adult patients receiving hospital discharge letters from inpatient and outpatient settings.DesignRealist 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 criteriaDocuments reporting evidence that met criteria for relevance to the PT. Documents relating solely to mental health or children aged <18 years were excluded.AnalysisData 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.Results3113 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.ConclusionsThis 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.

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Search for unpublished data by systematic reviewers: an audit

BMJ Open ◽

10.1136/bmjopen-2017-017737 ◽

2017 ◽

Vol 7 (10) ◽

pp. e017737 ◽

Cited By ~ 10

Author(s):

Hedyeh Ziai ◽

Rujun Zhang ◽

An-Wen Chan ◽

Nav Persaud

Keyword(s):

Publication Bias ◽

Systematic Reviews ◽

Data Extraction ◽

Grey Literature ◽

Cochrane Library ◽

Eligibility Criteria ◽

Ovid Medline ◽

Cochrane Reviews ◽

Unpublished Studies ◽

Cochrane Database

ObjectivesWe audited a selection of systematic reviews published in 2013 and reported on the proportion of reviews that researched for unpublished data, included unpublished data in analysis and assessed for publication bias.DesignAudit of systematic reviews.Data sourcesWe searched PubMed and Ovid MEDLINE In-Process & Other Non-Indexed Citations between 1 January 2013 and 31 December 2013 for the following journals:Journal of the American Medical Association,The British Medical Journal,Lancet,Annals of Internal Medicineand theCochrane Database of Systematic Reviews. We also searched the Cochrane Library and included 100 randomly selected Cochrane reviews.Eligibility criteriaSystematic reviews published in 2013 in the selected journals were included. Methodological reviews were excluded.Data extraction and synthesisTwo reviewers independently reviewed each included systematic review. The following data were extracted: whether the review searched for grey literature or unpublished data, the sources searched, whether unpublished data were included in analysis, whether publication bias was assessed and whether there was evidence of publication bias.Main findings203 reviews were included for analysis. 36% (73/203) of studies did not describe any attempt to obtain unpublished studies or to search grey literature. 89% (116/130) of studies that sought unpublished data found them. 33% (68/203) of studies included an assessment of publication bias, and 40% (27/68) of these found evidence of publication bias.ConclusionA significant fraction of systematic reviews included in our study did not search for unpublished data. Publication bias may be present in almost half the published systematic reviews that assessed for it. Exclusion of unpublished data may lead to biased estimates of efficacy or safety in systematic reviews.

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Caregiver-mediated interventions to support self-regulation among infants and young children (0–5 years): a protocol for a realist review

BMJ Open ◽

10.1136/bmjopen-2020-046078 ◽

2021 ◽

Vol 11 (6) ◽

pp. e046078

Author(s):

Amy Finlay-Jones ◽

Jetro Emanel Ang ◽

Elaine Bennett ◽

Jenny Downs ◽

Sally Kendall ◽

...

Keyword(s):

School Readiness ◽

Working Group ◽

Protective Factor ◽

Evidence Synthesis ◽

Grey Literature ◽

Self Regulation ◽

Realist Review ◽

Programme Theory ◽

Review Team ◽

The Impact

IntroductionSelf-regulation is a modifiable protective factor for lifespan mental and physical health outcomes. Early caregiver-mediated interventions to promote infant and child regulatory outcomes prevent long-term developmental, emotional and behavioural difficulties and improve outcomes such as school readiness, educational achievement and economic success. To harness the population health promise of these programmes, there is a need for more nuanced understanding of the impact of these interventions. The aim of this realist review is to understand how, why, under which circumstances and for whom, early caregiver-mediated interventions improve infant and child self-regulation. The research questions guiding this review were based on consultation with families and community organisations that provide early childhood and family services.Methods and analysisRealist reviews take a theory-driven and iterative approach to evidence synthesis, structured around continuous refinement of a programme theory. Programme theories specify context-mechanism-outcome configurations to explain what works, for whom, under which circumstances and how. Our initial programme theory is based on prior work in this field and will be refined through the review process. A working group, comprising service users, community organisation representatives, representatives from specific populations, clinicians and review team members will guide the evidence synthesis and interpretation, as well as the development and dissemination of recommendations based on the findings of the review. The review will involve searching: (i) electronic databases, (ii) connected papers, articles and citations and (iii) grey literature. Decisions to include evidence will be guided by judgements about their contribution to the programme theory and will be made by the research team, with input from the working group. Evidence synthesis will be reported using the Realist and MEta-narrative Evidence Synthesis: Evolving Standards guidelines.Ethics and disseminationEthical approval is not required as this is a review. Findings will be disseminated to our working group and through peer-reviewed publications and conference presentations.Review registration numberThe protocol is registered with Open Science Framework https://osf.io/5ce2z/registrations.

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Remediating doctors’ performance to restore patient safety: a realist review protocol

BMJ Open ◽

10.1136/bmjopen-2018-025943 ◽

2018 ◽

Vol 8 (10) ◽

pp. e025943 ◽

Cited By ~ 2

Author(s):

Tristan Price ◽

Nicola Brennan ◽

Jennifer Cleland ◽

Linda Prescott-Clements ◽

Amanda Wanner ◽

...

Keyword(s):

Patient Safety ◽

Evidence Synthesis ◽

Grey Literature ◽

Realist Review ◽

Evidence Base ◽

Stakeholder Group ◽

Programme Theory ◽

Dissemination Strategy ◽

Knowledge To Action ◽

Patient Representatives

IntroductionUnderperformance by doctors poses a risk to patient safety. Remediation is an intervention designed to remedy underperformance and return a doctor to safe practice. Remediation is widely used across healthcare systems globally, and has clear implications for both patient safety and doctor retention. Yet, there is a poor evidence base to inform remediation programmes. In particular, there is a lack of understanding as to why and how a remedial intervention may work to change a doctor’s practice. The aim of this research is to identify why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to support patient safety.Methods and analysisRealist review is an approach to evidence synthesis that seeks to develop programme theories about how an intervention works to produce its effects. The initial search strategy will involve: database and grey literature searching, citation searching and contacting authors. The evidence search will be extended as the review progresses and becomes more focused on the development of specific aspects of the programme theory. The development of the programme theory will involve input from a stakeholder group consisting of professional experts in the remediation process and patient representatives. Evidence synthesis will use a realist logic of analysis to interrogate data in order to develop and refine the initial programme theory into a more definitive realist programme theory of how remediation works. The study will follow and be reported according to Realist And Meta-narrative Evidence Syntheses—Evolving Standards (RAMESES).Ethics and disseminationEthical approval is not required. Our dissemination strategy will include input from our stakeholder group. Customised outputs will be developed using the knowledge-to-action cycle framework, and will be targeted to: policy-makers; education providers and regulators, the National Health Service, doctors and academics.PROSPERO registration numberCRD42018088779.

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Barriers to access of healthcare services by the immigrant population in Scandinavia: a scoping review protocol

BMJ Open ◽

10.1136/bmjopen-2019-032596 ◽

2020 ◽

Vol 10 (1) ◽

pp. e032596

Author(s):

Lily Appoh ◽

Franca Felix ◽

Preben Ulrich Pedersen

Keyword(s):

Scoping Review ◽

Research Question ◽

Grey Literature ◽

Healthcare Services ◽

Access To Healthcare ◽

Ovid Medline ◽

Health Authorities ◽

Barriers To Access ◽

Review Protocol ◽

Legal Immigrants

IntroductionAccess to healthcare services for legal immigrants in Scandinavia is part of the policy agenda of the various governments as they strive to provide equal healthcare services to its citizens. Legal immigrants have the same rights as natives; however, studies have shown that there are inequalities in access to healthcare services between legal immigrants and natives. The extent of access depends on several factors, including organisational, social, financial and cultural factors. The lack of these factors acts as a barrier to access of healthcare services. The aim of this review is to map and report the evidence available on the barriers to access of healthcare services by legal immigrants in Scandinavia.Methods and analysisWe will adopt the six-stage framework developed by Arksey and O’Malley: (1) identifying the research question(s); (2) searching for relevant studies; (3) selecting studies; (4) charting the data; (5) collating, summarising and reporting the results; (6) conducting consultation exercises refined by Levacet aland the Joanna Briggs Institute. The search strategy for this scoping review will involve electronic databases including Ovid Medline, PsycINFO, Ovid EMBASE, PubMed and Google Scholar, in addition to grey literature from websites of relevant organisations. Data will be extracted and charted by two independent reviewers. A narrative summary of the findings will be presented.Ethics and disseminationThis is a review of the literature and all data will be obtained from publicly available materials; therefore, ethics approval is not required. The findings from this study will be disseminated as publications in peer-reviewed journals, at relevant national and international conferences, and as presentations to the health authorities in several municipalities in the Trøndelag region of Norway.

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21 Realist Review of General Practitioners’ Role in Advancing Practice in Care Homes (Grape Study)

Age and Ageing ◽

10.1093/ageing/afab028.21 ◽

2021 ◽

Vol 50 (Supplement_1) ◽

pp. i1-i6

Author(s):

N H Chadborn ◽

A L Gordon ◽

R Devi ◽

C Williams ◽

C Goodman ◽

...

Keyword(s):

Resource Constraints ◽

Care Home ◽

Grey Literature ◽

Realist Review ◽

Healthcare Services ◽

Care Quality ◽

Leadership Role ◽

Care Homes ◽

Healthcare Team ◽

Programme Theory

Abstract Introduction Many care home residents have high levels of complex needs and their medical care is the responsibility of the general practitioner (GP) in UK. GPs have multiple roles, including gatekeeper for access to other healthcare services and often play a leadership role in the healthcare team. Our aim is to develop realist programme theories for how GPs interact with care homes to facilitate improvements in care of residents. Method Using realist review we aimed to describe “what works” for GPs to be involved in improvements in care of residents. Firstly we carried out a scoping review of UK literature and interviewed GP leaders in order to build programme theory. Secondly iterative literature searches were performed in Medline, Embase, CINAHL, PsycInfo, ASSIA, Scopus and many grey literature databases. This international literature is being used to test and refine programme theories and to explore the range of contexts. Results A scoping search identified a small number (n = 5) of recent UK articles (2010–19) that described GP input into quality improvement. To gain insight into context, observational studies (n = 4 in UK and Ireland) were identified which described concerns about workload and resource constraints. To develop initial programme theories, we conducted interviews with 6 GP leaders, where themes of risk and specialism were identified. We are developing the following mechanisms within programme theory: where GP profession have an ownership of the agenda, this encourages GP involvement. In other initiatives, the mechanism may be a trusting relationship between GP and another practitioner, eg pharmacist. Conclusion Many reported projects which aim to improve care quality in care homes do not describe how the initiative relates to GP practice. We have identified mechanisms which, when present, may cause GPs to contribute leadership and medical expertise, and thus lead to successful outcomes for residents.

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