How to achieve delivery of a cardiovascular health intervention in community mental health settings: a process evaluation of Flinders Program using RE-AIM framework

Abstract

Background, research problem & context: Globally, it is well recorded that adults with severe mental illness (SMI) die 10-20 years earlier than the general population, with cardiovascular disease being recorded as the key contributor to this health inequity. To address this health gap, the Flinders Chronic Condition Self-Management Program (will be referred to as Flinders Programme from here onward) was delivered within an NHMRC-funded randomised controlled trial (RCT) during 2018-2020 among 130 South Australian community-living adults diagnosed with SMI and CVD risk factors. Intervention design: The Flinders Programme is a person-centred care planning approach designed by Flinders University Behavioural Health Unit’s researchers. For this study, the programme aimed to improve the heart health and quality of life of the study participants. Intervention evaluation methods: This study sat alongside the RCT research and employed a longitudinal qualitative methodology underpinned by Roy Bhaskar’s Critical Realism philosophy and ontology. The aim was to understand why, how, and under which contexts the Flinders Program worked (or not). Alongside an outcome evaluation, this study also investigated how the Flinders Programme was delivered. Reach (R), Effectiveness/Efficacy (E), Adoption (A), Implementation/Delivery (I), Maintenance (M) or RE-AIM framework was used to conduct this qualitative process evaluation. Data were collected from 19 trial team members at multiple time points using multiple methods. In total, ten in-depth interviews, two focus group discussions, ten meeting minutes, and five reflective journals were analysed. Data analysis involved a Critical Realist Analysis (CRA) approach. Results & impact: The key findings were organised within the RE-AIM framework: Reach (low recruitment, strategies taken to increase recruitment), Effectiveness (non-specific effects, ‘invisible’ changes such as enhanced awareness, motivation, hope), Adoption (model of care, work atmosphere, the physical structure of the setting), Implementation (preparation, pilot survey, revising study design, actual trial and adaptations, fidelity), Maintenance (self-management capacity, resources, care continuity). Learning for the international audience: This study described the steps taken in delivering the Flinders Programme within a few South Australian metropolitan community mental health settings between the period November 2017 – September 2020. The trial team faced difficulties in fulfilling the recruitment target for the trial. There were a few critical reasons identified- the South Australian community mental health system went through a significant restructuring during the same time, resulting in enormous workload increases in an already resource-scarce sector. Health system-level politics had a direct negative effect on the trial. Besides, improving the cardiovascular health of SMI was not deemed a priority in a system that was struggling to deal with acute mentally ill patients within a crisis-driven system. There was a clear indication that most sites did not have enough clear communication from the trial team before recruitment and throughout the trial period. The next steps: In the future, more preparation, including education sessions among clinicians, are required before delivering such physical health interventions within mental health settings.