Programming Theory Research Articles

Community mobilisation approaches to preventing adolescent multiple risk behaviour: a realist review

BackgroundAdolescent multiple risk behaviour (MRB) is a global health issue. Most interventions have focused on the proximal causes of adolescent MRB such as peer or family influence, with systematic reviews reporting mixed evidence of effectiveness. There is increasing recognition that community mobilisation approaches could be beneficial for adolescent health. There are gaps in the current literature, theory and implementation that would benefit from a realist approach. We use a theory-driven evidence synthesis to assess how and why community mobilisation interventions work/do not work to prevent adolescent MRB and in what contexts.MethodsThis realist review used a six-stage iterative process, guided by the RAMESES framework. We systematically searched PubMed, MEDLINE, PsycINFO, Web of Science, CINAHL and Sociological s, from their inception to 2021. Studies were screened for relevance to the programme theory, assessed for rigour and included based on a priori criteria. Two independent reviewers selected, screened and extracted data from included studies. A realist logic of analysis was used to develop context-mechanism-outcome configurations that contributed to our programme theory.FindingsWe reviewed 35 documents describing 22 separate community mobilisation intervention studies. Most studies (n = 17) had a quality assessment score of three or four (out of four). We analysed the studies in relation to three middle range theories. To uphold our theory that these interventions work by creating a social environment where adolescents are less likely to engage in MRB, interventions should: (1) embed a framework of guiding principles throughout the community, (2) establish community readiness with population data and (3) ensure a diverse coalition with the support of intervention champions. Mechanisms such as empowerment through coalition ownership over the delivery of the intervention, cohesion across the community and motivation to work collaboratively to improve adolescent health are triggered to achieve social environment shifts. However, certain contexts (e.g. limited funding) restrict intervention success as these mechanisms are not fired.ConclusionsFor community mobilisation interventions to reduce adolescent MRB, the coalitions within them must seek to alter the social environment in which these behaviours occur. Mechanisms including empowerment, cohesion and motivation lead to this shift, but only under certain contexts.Systematic review registrationPROSPERO CRD42020205342

Participatory Process Evaluation of Flexible and Integrative Treatment (FIT) Models in German Psychiatry – A Mixed Method Study

Flexible and integrative treatment (FIT) services in Germany make it possible to shift mental health inpatient care to day- and outpatient care. This paper presents the results of the mixed methods, participatory process evaluation (= PE) of the PsychCare clinical trial, which compares the outcomes of nine FIT departments to those of eight standard mental health care services. This PE integrates diverse data using a program theory and data transformation approach. It shows various implementation types of FIT services and how their processes and structures are distinct from those of control conditions, also experienced by service users. It contributes to mixed methods research by showing that the PE methodological frame is a valuable tool to effectively involve service users and other stakeholders.

Estimation of the Region of Attraction of Polynomial Swing Equation Using Sum of Squares Theory

Estimation of the region of attraction of the power system using sum of squares (SOS) programming theory is investigated in this paper. Firstly, the Taylor expansion formula is applied to explore the inherent polynomial structure of the swing equation. The single machine projection equation for a multi-machine system is proposed based on the amplitude characteristic of the rotor angle response in decoupled space. Secondly, the theory of SOS programming originating from the polynomial system is derived, and the theory about estimation of the region of attraction for the differential algebraic system is summarized. Thirdly, the method for estimating the region of attraction for the polynomial swing equation based on a V-S two-stage iterative procedure is proposed. Finally, a single machine infinite bus power system, an IEEE 3-machine power system, and an IEEE 4-machine power system are employed to validate the effectiveness and accuracy of the proposed method and analysis.

A ride time-oriented scheduling algorithm for dial-a-ride problems

This paper offers a new algorithm to efficiently optimize scheduling decisions for dial-a-ride problems (DARPs), including problem variants considering electric and autonomous vehicles (e-ADARPs). The scheduling heuristic, based on linear programming theory, aims at finding minimal user ride time schedules in worst-case quadratic time. The algorithm can either return feasible routes or it can return incorrect infeasibility declarations, on which feasibility can be recovered through a specifically-designed heuristic. The algorithm is furthermore supplemented by a battery management algorithm that can be used to determine charging decisions for electric and autonomous vehicle fleets. Timing solutions from the proposed scheduling algorithm are obtained on millions of routes extracted from DARP and e-ADARP benchmark instances. They are compared to those obtained from a linear program, as well as to popular scheduling procedures from the DARP literature. The proposed procedure mostly yields optimal solutions, with nearly-optimal solutions occurring in only 27 out of 21.5 million cases on DARP instances. Additionally, it demonstrates an average speed improvement of around 60% compared to a linear program and performs comparably to benchmark scheduling approaches from the DARP literature, while outperforming them in solution quality.

The role of provincial health administration in supporting district health management teams in the Democratic Republic of Congo: eliciting an initial programme theory of a realist evaluation

BackgroundIn 2006, the Ministry of Health in the Democratic Republic of Congo designed a strategy to strengthen the health system by developing health districts. This strategy included a reform of the provincial health administration to provide effective technical support to district health management teams in terms of leadership and management. The provincial health teams were set up in 2014, but few studies have been done on how, for whom, and under what circumstances their support to the districts works. We report on the development of an initial programme theory that is the first step of a realist evaluation seeking to address this knowledge gap.MethodsTo inform the initial programme theory, we collected data through a scoping review of primary studies on leadership or management capacity building of district health managers in sub-Saharan Africa, a review of policy documents and interviews with the programme designers. We then conducted a two-step data analysis: first, identification of intervention features, context, actors, mechanisms and outcomes through thematic content analysis, and second, formulation of intervention–context–actor–mechanism–outcome (ICAMO) configurations using a retroductive approach.ResultsWe identified six ICAMO configurations explaining how effective technical support (i.e. personalised, problem-solving centred and reflection-stimulating) may improve the competencies of the members of district health management teams by activating a series of mechanisms (including positive perceived relevance of the support, positive perceived credibility of provincial health administration staff, trust in provincial health administration staff, psychological safety, reflexivity, self-efficacy and perceived autonomy) under specific contextual conditions (including enabling learning environment, integration of vertical programmes, competent public health administration staff, optimal decision space, supportive work conditions, availability of resources and absence of negative political influences).ConclusionsWe identified initial ICAMO configurations that explain how provincial health administration technical support for district health management teams is expected to work, for whom and under what conditions. These ICAMO configurations will be tested in subsequent empirical studies.

How and why do financial incentives contribute to helping people stop smoking? A realist review

BackgroundTobacco smoking remains a key cause of preventable illness and death globally. In response, many countries provide extensive services to help people to stop smoking by offering a variety of effective behavioural and pharmacological therapies. However, many people who wish to stop smoking do not have access to or use stop smoking supports, and new modes of support, including the use of financial incentives, are needed to address this issue. A realist review of published international literature was undertaken to understand how, why, for whom, and in which circumstances financial incentives contribute to success in stopping smoking for general population groups and among pregnant women.MethodsSystematic searches were undertaken from inception to February 2022 of five academic databases: MEDLINE (ovid), Embase.com, CIHAHL, Scopus and PsycINFO. Study selection was inclusive of all study designs. Twenty-two studies were included. Using Pawson and Tilley’s iterative realist review approach, data collected were screened, selected, coded, analysed, and synthesised into a set of explanatory theoretical findings.ResultsData were synthesised into six Context-Mechanism-Outcome Configurations and one overarching programme theory after iterative rounds of analysis, team discussion, and expert panel feedback. Our programme theory shows that financial incentives are particularly useful to help people stop smoking if they have a financial need, are pregnant or recently post-partum, have a high threshold for behaviour change, and/or respond well to external rewards. The incentives work through a number of mechanisms including the role their direct monetary value can play in a person’s life and through a process of reinforcement where they can help build confidence and self-esteem.ConclusionThis is the first realist review to synthesise how, why, and for whom financial incentives work among those attempting to stop smoking, adding to the existing evidence demonstrating their efficacy. The findings will support the implementation of current knowledge into effective programmes which can enhance the impact of stop smoking care.PROSPERO registration numberCRD42022298941.

Integrated Community Care Delivered by Public Health-Care and Social-Care Systems: Results from a Realist Synthesis.

Integrated community care (ICC) is defined as an interweaving of health-care and social-care interventions deployed in spatial and relational proximity using an interdisciplinary and cross-sectoral approach. Consideration of territory scale and time scale are at the center of ICC practices. Its deployment in public health and social care networks (HSCN) can be complex due to their broad mandate, the complexity of their management, and accountability. Therefore, we aimed to describe ICC delivered by public HSCN to determine how, why, for whom, and in what circumstances ICC works and produces outcomes. A realist synthesis was conducted consisting of five steps consistent with realist synthesis standards (RAMESES projects) to produce configurations of Context - Mechanism - Outcomes (CMOc) and development of a middle-range explanatory theory of why and how the identified outcomes may have occurred. In total, 26 studies were selected and used, as evidence, to support-either partially or fully-the production of CMOc based on the initial program theory. Nine unique CMO configurations were identified based on the data analyses and team discussion. ICC middle-range theory is informed by the CMO configurations identified. This realist synthesis allowed us to identify the central mechanisms of ICC delivered by public HSCN and to produce a middle range theory. ICC is based on a specific philosophy and deployed by a professional agency oriented toward a community agency within a local system of interdisciplinary and cross-sectoral action. Our middle-range theory will provide a solid analytical framework as a foundation for ICC implementation and future research.

Sustainability of an outcome measure in outpatient stroke rehabilitation: A realist evaluation.

Only half of newly implemented evidence-based practices are sustained. Though poor sustainment can lead to negative consequences for clinical teams, organizationsand patients, the causal explanations of sustainment are largely unknown. We aimed to ascertain how (mechanisms) and in what circumstances (context) a newly implemented outcome measure in rehabilitation was sustained or not (outcome). Informed by an integrated knowledge translation approach, we conducted a realist evaluation using a mixed method, embedded single case study design with data collection up to 18 months following the implementation of the Mayo-Portland Adaptability Inventory - version 4 (MPAI-4), a rehabilitation outcome measure. Quantitative data (survey and patient charts) was analysed using descriptive statistics, then integrated with qualitative data (interviews with 10 key informants) and analysed using inductive and deductive retroduction. We integrated the data to develop a case description and ultimately, to refine the programme theory to better understand the sustainability of the MPAI-4. We linked context, mechanismsand outcomes, and also emphasized sustainability strategies in 18 explanations of how sustainability works. These explanations provide evidence for four overarching patterns: (1) implementation and sustainability phases are interconnected, (2) outcomes build on each other recursively, with patient benefits as the keystone outcome, (3) sustainment is achieved to varying levels across different sustainability outcomes [e.g., high level (e.g., rate of MPAI-4 scoring: 77.7%) to low level (e.g., rate of MPAI-4 application to clinical decision-making: 3.7%)] and (4) the work of sustaining the MPAI-4 is shared amongst different stakeholders. Implementation teams can draw from this programme theory to improve the sustainment of outcomes measures while researchers could continue to refine the theory. Continued investigation of sustainability, including diverse and continuous sustainability outcomes, is needed to understand how to maintain improvements in quality of care and patient outcomes.

Integrated care system leadership: a rapid realist review

PurposeGiven the complex nature of integrated care systems (ICSs), the geographical spread and the large number of organisations involved in partnership delivery, the importance of leadership cannot be overstated. This paper aims to present novel findings from a rapid realist review of ICS leadership in England. The overall review question was: how does leadership in ICSs work, for whom and in what circumstances?Design/methodology/approachDevelopment of initial programme theories and associated context–mechanism–outcome configurations (CMOCs) were supported by the theory-gleaning activities of a review of ICS strategies and guidance documents, a scoping review of the literature and interviews with key informants. A refined programme theory was then developed by testing these CMOCs against empirical data published in academic literature. Following screening and testing, six CMOCs were extracted from 18 documents. The study design, conduct and reporting were informed by the Realist And Metanarrative Evidence Syntheses: Evolving Standards (RAMESES) training materials (Wong et al., 2013).FindingsThe review informed four programme theories explaining that leadership in ICSs works when ICS leaders hold themselves and others to account for improving population health, a sense of purpose is fostered through a clear vision, partners across the system are engaged in problem ownership and relationships are built at all levels of the system.Research limitations/implicationsDespite being a rigorous and comprehensive investigation, stakeholder input was limited to one ICS, potentially restricting insights from varied geographical contexts. In addition, the recent establishment of ICSs meant limited literature availability, with few empirical studies conducted. Although this emphasises the importance and originality of the research, this scarcity posed challenges in extracting and applying certain programme theory elements, particularly context.Originality/valueThis review will be of relevance to academics and health-care leaders within ICSs in England, offering critical insights into ICS leadership, integrating diverse evidence to develop new evidence-based recommendations, filling a gap in the current literature and informing leadership practice and health-care systems.

Facilitators and barriers to the implementation of prehabilitation for frail patients into routine health care: a realist review

BackgroundDespite evidence supporting the effectiveness of prehabilitation as a new preoperative care pathway to optimise perioperative outcomes, its implementation into routine health care is widely pending. Frail patients might particularly benefit from prehabilitation interventions, but facilitating and hindering factors need to be considered in the implementation process. Thus, our aim was to derive a programme theory on what prehabilitation programmes work for frail patients in what circumstances and why.MethodsFollowing Pawson’s realist review approach, preliminary programme theories on facilitators and barriers were established. General and topic-specific databases were searched systematically for facilitators and barriers to the implementation of prehabilitation for frail patients. Articles were included if they dealt with multimodal prehabilitation programmes prior to surgery in a frail population and if they contained information on facilitators and barriers during the implementation process in the full text. Based on these articles, refined programme theories were generated.ResultsFrom 2,609 unique titles, 34 were retained for the realist synthesis. Facilitating factors included the individualisation of prehabilitation programmes to meet the patients’ needs and abilities, multimodality, adaption to the local setting and health care system, endorsement by an ambassador and sharing of responsibilities among a multidisciplinary team. Central barriers for frail patients were transportation, lack of social support, and inadequate, overwhelming information provision.ConclusionsImplementing prehabilitation as a new care pathway for frail patients requires organisational readiness and adaptability to the local setting. On an individual level, a clear understanding of responsibilities and of the intervention’s goal among patients and providers are necessary. Added attention must be paid to the individualisation to fit the needs and restrictions of frail patients. This makes prehabilitation a resource-intense, but promising intervention for frail surgery patients.Trial registrationPROSPERO (CRD42022335282).

How do urban green spaces influence heat-related mortality in elderly? A realist synthesis

BackgroundAn important consequence of climate change for urban health is heat-related mortality. Vulnerable groups, especially elderly, will be the most affected. A solution put forward in many reports and policy documents is the introduction or expansion of urban green spaces. While they have a proven effect in decreasing the ambient temperature and reducing heat related mortality, the causal pathways are far from clear. Moreover, results vary for different contexts, population types and characteristics of green spaces as they are ‘complex systems thrusted into complex systems’. To our knowledge, there is no systematic synthesis of the literature that examines the mechanisms by which and the circumstances under which green spaces work to decrease heat-related mortality for elderly.MethodsWe performed a realist synthesis– a theory-driven review method– to develop a complexity- and context-sensitive program theory. As a first step, a causal loop diagram was constructed which describes the possible pathways through which urban green spaces influence heat-related mortality in elderly. In a second step, one of the pathways - how they may lead to a reduction of heat-related mortality by increasing social capital - was further explored for underlying mechanisms, the context in which they work and the differentiated patterns of outcomes they generate. Literature was searched for evidence supporting or contradicting the initial programme theory, resulting in a refined theory.ResultsResults show how urban green space can impact on heat-related mortality in elderly by its influence on their exposure to outdoor and indoor heat, by improving their resilience as well as by affecting their access to treatment. Urban green spaces and their interactions with social capital affect the access to health information, social support, and the capacity for effective lobbying. Several mechanisms help to explain these observed demi-regularities, among others perceived behavioural control, perceived usefulness, receptiveness, ontological security, and self-interest. If and how they are triggered depends on the characteristics of the urban green space, the population, and other contextual factors.ConclusionLooking into the impact of urban green spaces on heat-related mortality in elderly, researchers and policy makers should take interest in the role of social capital.

Understanding how therapeutic exercise prescription changes outcomes important to patients with persistent non-specific low back pain: a realist review protocol

IntroductionPersistent low back pain (LBP) is the leading cause of disability worldwide, and therapeutic exercise is recommended as a first-line treatment in international guidelines. The effects of exercise on clinical outcomes of pain and physical function are small to moderate, despite broader impacts on cardiovascular systems, biological health, mood, and emotional well-being. Therapeutic exercise prescription is defined as exercise that is prescribed by a clinician for a health-related treatment. It is unknown how therapeutic exercise prescription creates effects on outcomes of importance. Realist reviews explore how underlying mechanisms (M) may be active in the context (C) of certain situations, settings, or populations to create an intended or unintended outcome (O). Our objective is to explore and understand the mechanisms by which therapeutic exercise prescription changes outcomes for people with persistent LBP.MethodsWe will develop initial programme theories based on preliminary data from a previous systematic review and consensus workshop. These theories will be modified with input from a steering group (experts), a stakeholder group (people with lived experience of exercise for persistent LBP and clinicians), and a scoping search of the published literature. An information specialist will design and undertake an iterative search strategy. These will be used to create CMO configurations, which will be refined and tested using the literature. The realist review will be reported following RAMESES guidance.DiscussionRealist reviews are uncommon in LBP research to date, yet those offer an opportunity to contrast with traditional methods of randomised controlled trials and systematic reviews and provide additional information regarding the contexts and mechanisms that may trigger certain outcomes. This can aid our understanding of the contextual features that may influence exercise prescription, such as for whom they are most effective, in what setting, how they are implemented and why. This realist synthesis will enhance our understanding of therapeutic exercise prescription to improve adherence and engagement and ultimately will provide clinically relevant recommendations regarding exercise prescription for those with persistent LBP.Systematic review registrationThe review has been registered with PROSPERO (CRD42017072023).

An exploration of analytical tools to conduct a realist synthesis and demonstrate programme theory development: An example from a realist review

Introduction A realist literature review involves iterative processes, with searches, appraisal and synthesis occurring simultaneously. Whilst this lends itself to theory development, the synthesis process often lacks transparency. This has led to unanticipated challenges for novice realist researchers, particularly PhD candidates. Methods The aim of this paper is to contribute to the realist methodological knowledge base by outlining the analytical tools of coding, consolidating and conceptual mapping used within a realist review. Specifically, how these techniques aid the synthesis process and demonstrate the development of valid and evidence informed programme theories. Results A worked example is provided to illustrate how; (i) coding techniques using realist logic can evidence a rigorous synthesis process; (ii) the use of consolidating techniques facilitates data management and aids theory development; and (iii) conceptual mapping demonstrates programme theory development. Conclusions Recommendations for novice realist researchers include defining and documenting the analytical tools for conducting a rigorous realist synthesis to provide transparency about how valid programme theories were developed. Plus, theory development checks can be built into the structure of the review process.

The application of operation research in the design of on-site construction organization

This article explores the integration of Operations Research (OR) principles in the design and management of on-site construction organizations. The first section introduces Operations Research as a multidisciplinary field that employs mathematical modelling, statistical analysis, and optimization techniques to enhance decision-making processes across various sectors. Key aspects such as mathematical modelling, optimization, decision analysis, simulation, queueing theory, linear programming, and game theory are highlighted. The second section focuses on the design of on-site construction organizations, emphasizing the structure and organization of resources, personnel, and processes essential for efficient project execution. Various key elements, including project management, site personnel, project support teams, engineering and design teams, health and safety personnel, procurement and supply chain, communication and coordination, equipment and maintenance, and environmental compliance, are discussed. The third section delves into the application of Operations Research techniques in the design and management of on-site construction organizations. It outlines how OR principles can be employed for resource allocation and optimization, project scheduling and planning, inventory management, equipment utilization, project costing and budgeting, risk management, supply chain management, human resource management, facility layout and design, and the development of decision support systems. The conclusion highlights that the strategic application of Operations Research methodologies contributes to enhanced efficiency, optimized resources, and improved decision-making throughout the construction project lifecycle. The integration of OR principles not only enhance the overall effectiveness of on-site construction organizations but also leads to cost savings, timely project completion, and improved project outcomes. As construction projects continue to grow in scale and complexity, the systematic and analytical approach provided by Operations Research becomes increasingly valuable in addressing the intricate challenges faced by construction stakeholders.

Integrated palliative care in oncology: a protocol for a realist synthesis

IntroductionEmerging evidence suggests improved quality of life, reduced symptom burden and lower health services costs when integrated palliative care and cancer care are implemented. Integrated palliative care aims to achieve...

Pedagogical effectiveness and improvement of the process of fostering a culture of safe behavior in primary school children

Introduction. The authors propose to comprehend the reasons for the relevance of the problem of forming a safety culture in pedagogical theory and practice and the need to build educational programs, directions that take into account the reality of modern childhood, the specific conditions of a person's growing up during this period, implementing all available options for the formation and accumulation of life experience by the child, in which the culture of safe behavior occupies one of the leading places. The purpose of the work is to identify the validity of the inclusion of the subjects of the system of additional education for children in the process of forming a culture of safe behavior of younger schoolchildren and to formulate the idea of the dissertation research. Materials and methods. In November-December 2023, a pilot study was conducted to establish the level of formation of basic concepts related to safe behavior in children who have reached primary school age. The methods of survey, content analysis, and conversation were used. The theoretical basis of the study is the concept of uncertainty as a condition of growing up in a changing world (A.G. Asmolov), the activity approach, the principle of complementarity in relation to pedagogical systems (N. Bohr), culturological and subject-object approaches to the study of childhood. The results are presented by the authors in full, and they testify to the well-known effectiveness of the work of preschool educational organizations and schools in the field of forming children's ideas about human safety in the environment. In preschool age, parents are active participants in this process for most children. In the course of the conversations, it was found that children form an indicative basis for activities based on a list of specific situations that may develop in everyday life, but its reproduction is difficult if it is not supported by the child's experience. The absence of situations of experience, teaching safe behavior only in the format of game activities in constructed situations with the use of any visuals, including information and communication technologies (rollers, videos, etc.), or in the format of classes using the explanatory and illustrative method do not allow us to draw conclusions about the formation of safe behavior skills in preschool children. Discussion and conclusion. The authors present a discussion of debatable issues related to the bias in favor of the theory of programs for the education of a culture of safe behavior, with insufficient operationality of the concepts of «danger» and «risk» for the purposes of education. Based on the results of the pilot study and theoretical analysis of some existing approaches, the inclusion in this process of subjects of additional education that carry out activities in the field of physical culture and sports, as a natural environment for the life of children, with pedagogical conditions for modeling situations of controlled danger in order to form real skills and experience of risk in children, is substantiated. This is the idea behind the intended dissertation research.

Contexts, behavioural mechanisms and outcomes to optimise therapeutic exercise prescription for persistent low back pain: a realist review

ObjectiveTherapeutic exercises are a core treatment for low back pain (LBP), but it is uncertain how rehabilitative exercise facilitates change in outcomes. Realist reviews explore how the context (C) of...

Understanding Australian general practice patients’ decisions to deprescribe antidepressants in the WiserAD trial: a realist informed approach

ObjectivesTo evaluate how an approach to antidepressant deprescribing works, for whom, and in what contexts by (1) examining the experiences and perceptions of the approach for antidepressant users, (2) identifying...

Developing middle-range theories within a realist evaluation of how health committees support community capacity for health

Health committees link formalised health services and the community. However, ‘how, why, and for whom’ health committees work warrants further exploration. This article presents the development of a middle-range theory for how health committees work for building community capacity for health. Resulting programme theories from a realist evaluation in Uganda were synthesised for demi-regularities and supplemented by four key informant interviews – substantive theories were used to help explain the findings from the case studies to develop the final middle-range theories. Eighteen existing programme theories and 47 supporting context-mechanism-outcome configurations were synthesised into four middle-range theories for how health committees work for community capacity building for health at the individual, organisational, community and societal levels. The middle-range theories developed in this study provide important insight for those implementing health committees. Given the little guidance available for developing and refining middle-range theories, this study provides transparent methodological processes, which may assist future research.

A graphical method for causal program attribution in theory-based evaluation

We describe a simple yet rigorous graphical method for eliminating bias in theory-based program evaluation. The method is an application to social and international development program evaluation of the graphical causal models used to test medical treatments. We implement a graphical causal model for the World Bank’s well-known Bangladesh Integrated Nutrition Project. We show how to construct the graphical causal model to represent program theory in context in explicitly causal terms. We then show how to visually inspect the graphical causal model to distinguish causal from non-causal associations between variables in evaluation data. Finally, we show how to select a set of adjustment variables to neutralize non-causal associations, eliminating bias in all forms of causal inference—qualitative and quantitative, linear and non-linear.