What works for whom in pharmacist-led smoking cessation support: realist review

Abstract

BackgroundNew models of primary care are needed to address funding and staffing pressures. We addressed the research question “what works for whom in what circumstances in relation to the role of community pharmacies in providing lifestyle interventions to support smoking cessation?”MethodsThis is a realist review conducted according to RAMESES standards. We began with a sample of 103 papers included in a quantitative review of community pharmacy intervention trials identified through systematic searching of seven databases. We supplemented this with additional papers: studies that had been excluded from the quantitative review but which provided rigorous and relevant additional data for realist theorising; citation chaining (pursuing reference lists and Google Scholar forward tracking of key papers); the ‘search similar citations’ function on PubMed. After mapping what research questions had been addressed by these studies and how, we undertook a realist analysis to identify and refine candidate theories about context-mechanism-outcome configurations.ResultsOur final sample consisted of 66 papers describing 74 studies (12 systematic reviews, 6 narrative reviews, 18 RCTs, 1 process detail of a RCT, 1 cost-effectiveness study, 12 evaluations of training, 10 surveys, 8 qualitative studies, 2 case studies, 2 business models, 1 development of complex intervention). Most studies had been undertaken in the field of pharmacy practice (pharmacists studying what pharmacists do) and demonstrated the success of pharmacist training in improving confidence, knowledge and (in many but not all studies) patient outcomes. Whilst a few empirical studies had applied psychological theories to account for behaviour change in pharmacists or people attempting to quit, we found no studies that had either developed or tested specific theoretical models to explore how pharmacists’ behaviour may be affected by organisational context. Because of the nature of the empirical data, only a provisional realist analysis was possible, consisting of five mechanisms (pharmacist identity, pharmacist capability, pharmacist motivation and clinician confidence and public trust). We offer hypotheses about how these mechanisms might play out differently in different contexts to account for the success, failure or partial success of pharmacy-based smoking cessation efforts.ConclusionSmoking cessation support from community pharmacists and their staff has been extensively studied, but few policy-relevant conclusions are possible. We recommend that further research should avoid duplicating existing literature on individual behaviour change; seek to study the organisational and system context and how this may shape, enable and constrain pharmacists’ extended role; and develop and test theory.

What works and why in the identification and referral of adults with comorbid obesity in primary care: A realist review

“…The main limitation of this review—in keeping with most realist reviews—is that the primary data often lacked sufficient detail about the interventions, or their context, and were largely atheoretical, making it difficult to produce robust CMO configurations . Indeed, the 12 mechanisms proposed in this review and the range of contextual factors identified should be considered as preliminary and in need of further empirical testing.…”

“…Finally, as well as theoretical literature, this review could have extended its search to include a wider range of empirical literature from different clinical settings (eg, smoking, alcohol, domestic violence), which might have contributed to theory development.…”

“…The main limitation of this review-in keeping with most realist reviews 76 -is that the primary data often lacked sufficient detail about the interventions, or their context, and were largely atheoretical, making it difficult to produce robust CMO configurations. 77 Finally, we have not only confirmed that the middle-range theory of candidacy has good explanatory potential in this area but have developed the model to more explicitly consider the contextual factors (at micro, meso, and macro levels) which influence candidacy.…”

<p>Improving Exercise-Based Interventions for People Living with Both COPD and Frailty: A Realist Review</p>

“…We reviewed full-text articles to determine if they contained enough detail or theoretical discussion to contribute to our aims. 43 For transparency, we noted whether the relevance of contributions were high (well aligned to the review questions, with rich descriptions contributing to theory); moderate (some relevance to review question and some theoretical insights) or low (meets broad inclusion criteria and provides at least one insight).…”

Dental therapists in general dental practice. A literature review and case‐study analysis to determine what works, why, how and in what circumstances

“…Realist evaluation is an established method in healthcare practice research, particularly for investigating the real-life implementation of interventions, guidelines or protocols. [26][27][28][29][30] The purpose of realist evaluation is to find out why interventions work differently across different contexts, 28,31 moving beyond a descriptive account to uncover deeper causal factors. 32 The aim of this evaluation was to explore: "does it work, for whom, when and why?"…”