Unpacking the design, implementation and uptake of community-integrated health care services: a critical realist synthesis

Abstract

IntroductionCommunity-integrated care initiatives are increasingly being used for social and health service delivery and show promising outcomes. Nevertheless, it is unclear what structures and underlining causal agents (generative mechanisms) are responsible for explaining how and why they work or not.Methods and analysisCritical realist synthesis, a theory-driven approach to reviewing and synthesising literature based on the critical realist philosophy of science, underpinned the study. Two lenses guided our evidence synthesis, the community health system and the patient-focused perspective of integrated care. The realist synthesis was conducted through the following steps: (1) concept mining and framework formulation, (2) searching for and scrutinising the evidence, (3) extracting and synthesising the evidence (4) developing the narratives from causal explanatory theories, and (5) disseminate, implement and evaluate.ResultsThree programme theories, each aligning with three groups of stakeholders, were unearthed. At the systems level, three bundles of mechanisms were identified, that is, (1) commitment and motivation, (2) willingness to address integrated health concerns and (3) shared vision and goals. At the provider level, five bundles of mechanisms critical to the successful implementation of integrated care initiatives were abstracted, that is, (1) shared vision and buy-in, (2) shared learning and empowerment, (3) perceived usefulness, (4) trust and perceived support and (5) perceived role recognition and appreciation. At the user level, five bundles of mechanisms were identified, that is, (1) motivation, (2) perceived interpersonal trust, (3) user-empowerment, (4) perceived accessibility to required services and (5) self-efficacy and self-determination.ConclusionWe systematically captured mechanism-based explanatory models to inform practice communities on how and why community-integrated models work and under what health systems conditions.PROSPERO registration numberCRD42020210442.

Formulating Initial Programme Theories of the Healthy Homes and Neighbourhoods Integrated Care Initiative

“…We found that at the consumer level, critical mechanisms include awareness of family dynamics, knowledge acquisition, self-efficacy and encouragement embedded in trust. A recent realist review to identify causal mechanisms on how and why community-based integrated care initiatives work found five bundles of mechanisms at the consumer level (1) motivation, (2) perceived interpersonal trust, (3) user-empowerment, (4) perceived accessibility to required services, and (5) self-efficacy and self-determination [ 37 ]. These mechanisms align with those found in this review at the same level but for family dynamics.…”

Applying and reporting relevance, richness and rigour in realist evidence appraisals: Advancing key concepts in realist reviews

“…Quality guidelines and checklists have been created to help researchers F I G U R E 1 Proposed iterative process for searching articles in the synthesis. Adapted from Copper et al 13 and Mukumbang et al 14 [Colour figure can be viewed at wileyonlinelibrary.com] make these judgements for traditional reviews. However, Pawson 22 also claims these traditional assessments of quality should be balanced, as '"nuggets" of wisdom can be found in methodologically weak studies, and realist review encourages the use of non-academic sources'.…”

“…Proposed iterative process for searching articles in the synthesis. Adapted from Copper et al 13 and Mukumbang et al 14 [Colour figure can be viewed at wileyonlinelibrary.com]…”

A protocol for a systematic critical realist synthesis of school mindfulness interventions designed to promote pupils’ mental wellbeing

“…Instead, they argue that there are demi-regularities, and it is how they occur that needs to be explained; that is why an intervention works in some contexts and not others and for some people and not others (52). Critical realism is theory-driven and seeks to explain/theorise why things occur in the way they do, what the (generally hidden) mechanisms are that generate events, recognise that social systems are open, eliminated and layered and that events are often the outcome of the complex interaction of mechanisms (75,(77)(78)(79)(80). The effectiveness of an intervention is not based only on its inherent qualities but on the action of agents in taking up the opportunities afforded by the intervention to trigger mechanisms that result in the outcomes (60,71).…”

“…Hypothetical links will then be made between the CAIMO themes, creating potential pathways that account for the impacts of school-based mindfulness interventions on pupils and why, for whom and under what circumstances these impacts occur. Figure 3: Critical Realist Evaluation Process However, to take account of complexity, it is necessary to develop a non-linear pathway of change showing how the complex interaction of mechanisms (context mechanisms that predate the intervention and those triggered by the intervention) leads to the observed outcomes (Figure 4) (75,79,80,93). To do this, we will use feedback loop diagrams to model change, showing both mechanisms triggered by the intervention that cause change, those already in the context that supported change (+ve mechanism) and those already in the context and mechanisms triggered by the intervention that restricted or prevented change (ve mechanisms).…”