Realist Review Methodology Research Articles

Shared decision-making interventions in the choice of antipsychotic prescription in people living with psychosis (SHAPE): Protocol for a realist review.

Shared decision-making (SDM) has yet to be successfully adopted into routine use in psychiatric settings amongst people living with severe mental illnesses. Suboptimal rates of SDM are particularly prominent amongst patients with psychotic illnesses during antipsychotic treatment choices. Many interventions have been assessed for their efficacy in improving SDM within this context, although results have been variable and inconsistent. To generate an in-depth understanding of how, why, for whom, and to what extent interventions facilitating the application of SDM during antipsychotic treatment choices work and the impact of contextual factors on intervention effectiveness. This review will use realist review methodology to provide a causal understanding of how and why interventions work when implementing SDM during antipsychotic treatment choices. The cohort of interest will be those experiencing psychosis where ongoing treatment with an antipsychotic is clinically indicated. The review will take place over five stages; (1) Locating existing theories, (2) Searching for evidence, (3) Selecting articles, (4) Extracting and organising data and (5) Synthesizing evidence and drawing conclusions. An understanding of how and why interventions work will be achieved by developing realist programme theories on intervention effectiveness through iterative literature reviews and engaging with various stakeholder groups, including patient, clinician and carer representatives. This is the first realist review aiming to identify generative mechanisms explaining how and why successful interventions aimed at improving SDM within the parameters outlined work and in which contexts desired outcomes are most likely to be achieved. Review findings will include suggestions for clinicians, policy and decision-makers about the most promising interventions to pursue and their ideal attributes.

A Realist Review Protocol into the Contexts and Mechanisms That Enable the Inclusion of Environmental Sustainability Outcomes in the Design of Lean Healthcare Improvement Interventions.

Healthcare makes a significant contribution to the social, economic and environmental benefits of communities. It is correspondingly a significant employer and consumer of both energy and consumables, often at high costs. Lean, a quality improvement methodology focuses on the elimination of non-value add (NVA) activities (steps that do not add value from the perspective of the customer) to improve the flow of people, information or goods. Increasingly, Lean thinking is evolving from its initial focus on eliminating NVA to a more holistic approach that encompasses sustainability. However, little work has been undertaken intentionally, including environmental sustainability outcomes in Lean healthcare interventions. Realist review methodology facilitates an understanding of the extent to which an intervention works, for whom, in what context, why and how, and has proven useful in research relating to Lean interventions in healthcare settings. This protocol provides details for a realist review that will enable an understanding of the specific contexts in which certain mechanisms are activated that enable the inclusion of environmental sustainability outcomes in the design of Lean healthcare improvement interventions.

A protocol for a critical realist systematic synthesis of interventions to promote pupils' wellbeing by improving the school climate in low- and middle-income countries.

The review described in this protocol will be the first critical realist review of the literature reporting on the impact of interventions to promote pupils' wellbeing by improving the school climate in Low- and Middle-Income Countries. The review is being carried out to inform the programme theory for a critical realist evaluation of a whole school mindfulness intervention in Ethiopia and Rwanda to improve pupils' mental wellbeing. Our initial programme theory hypothesises that pupils' (and teachers') responses to the mindfulness intervention as well as changing the behaviour and attitudes of individual pupils and teachers, will change the 'school climate' in ways that have a positive impact on mental wellbeing. This literature review will facilitate the identification of mechanisms for change working at the level of the whole school climate, something which is only infrequently discussed in evaluations of mindfulness interventions. A critical realist review methodology will be used to provide a causal interdisciplinary understanding of how school climate can promote the wellbeing of pupils. This will be done through a systematic literature review and extrapolating context, agency, intervention, mechanisms, and outcome configurations and synthesising these to provide a conceptual understanding of the impact of interventions to improve school climate. The review findings will inform a critical realist evaluation of a mindfulness intervention in schools that we will be carrying out. The findings from the review will enable us to focus more precisely and transparently on what policymakers and other stakeholders need to know about how school climate changes due to introducing mindfulness to the curriculum and how this impacts pupils' wellbeing [and for which pupils]. We will publish the findings from the review in academic and professional publications, policy briefs, workshops, conferences, and social media. PROSPERO registration number: CRD42023417735.

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

The review described in this protocol will be the first critical realist review of the literature reporting on the impact of school-based mindfulness interventions on the mental wellbeing of pupils. Mindfulness interventions are increasingly being introduced into schools to promote children's (and teachers') wellbeing. Findings from impact evaluations, including systematic reviews and metanalysis, suggest that school-based mindfulness interventions promote pupils' wellbeing. However, there is a need for further evidence on the underlying causal mechanisms and contexts that explain program outcomes, to provide insight into how mindfulness programs can be successfully implemented in other contexts. A critical realist review methodology will be used to provide a causal interdisciplinary understanding of how school-based mindfulness interventions promote the mental wellbeing of pupils. This will be done through a systematic literature review and extrapolating context, agency, intervention, mechanisms, and outcome configurations. This will enable an understanding of how, in certain contexts, pupils can use the resources offered by a mindfulness intervention knowingly or unknowingly to trigger mechanisms that promote their mental wellbeing and what mechanisms in the context support, restrict or prevent change. We will then use retrodiction and retroduction to develop the most plausible interdisciplinary middle-range theory to explain the findings. The review findings will inform a critical realist evaluation of a mindfulness intervention in schools. The findings from the review will also enable us to inform policymakers and other stakeholders about what conditions need to be in place for mindfulness interventions to promote pupils' mental wellbeing. We will publish the findings from the review in academic and professional publications, policy briefs, workshops, conferences, and social media.PROSPERO registration number: CRD42023410484.

Interventions to address unprofessional behaviours between staff in acute care: what works for whom and why? A realist review

BackgroundUnprofessional behaviour (UB) between staff encompasses various behaviours, including incivility, microaggressions, harassment, and bullying. UB is pervasive in acute healthcare settings and disproportionately impacts minoritised staff. UB has detrimental effects on staff wellbeing, patient safety and organisational resources. While interventions have been implemented to mitigate UB, there is limited understanding of how and why they may work and for whom.MethodsThis study utilised a realist review methodology with stakeholder input to improve understanding of these complex context-dependent interventions. Initial programme theories were formulated drawing upon scoping searches and reports known to the study team. Purposive systematic searches were conducted to gather grey and published global literature from databases. Documents were selected if relevant to UB in acute care settings while considering rigour and relevance. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories.ResultsOf 2977 deduplicated records, 148 full text reports were included with 42 reports describing interventions to address UB in acute healthcare settings. Interventions drew on 13 types of behaviour change strategies and were categorised into five types of intervention (1) single session (i.e. one off); (2) multiple session; (3) single or multiple sessions combined with other actions (e.g. training sessions plus a code of conduct); (4) professional accountability and reporting programmes and; (5) structured culture change interventions. We formulated 55 context-mechanism-outcome configurations to explain how, why, and when these interventions work. We identified twelve key dynamics to consider in intervention design, including importance of addressing systemic contributors, rebuilding trust in managers, and promoting a psychologically safe culture; fifteen implementation principles were identified to address these dynamics.ConclusionsInterventions to address UB are still at an early stage of development, and their effectiveness to reduce UB and improve patient safety is unclear. Future interventions should incorporate knowledge from behavioural and implementation science to affect behaviour change; draw on multiple concurrent strategies to address systemic contributors to UB; and consider the undue burden of UB on minoritised groups.Study registrationThis study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490.

1.K. Workshop: Health Promoting Sports Clubs: tackling intervention implementation and evaluation challenges

Abstract Settings have been defined as ‘the place or social context where people engage in daily activities in which environmental, organizational and personal factors interact to affect health and well-being’. Settings-based approaches have successfully been applied in different traditional settings, like schools, cities, and workplaces. During the last two decades, the health promoting sports clubs theoretical and empirical foundation has emerged to support sports clubs’ investment in health promotion beyond the provision of sport itself, leading to physical, social and mental benefits. Two recent literature reviews have showed limited evidence on validated health promotion measurement instrument and interventions, identifying only three interventions worldwide that have been rigorously evaluated. The present workshop will synthetises the mechanisms used in different health promoting sports clubs’ interventions, reflect on methods for intervention evaluation and offer guidelines for sports federation and clubs. The first presentation will set the scene by describing youth sports club's participation in Finland from 2016 to 2022, specifically providing insights on the determinants of sport drop out. The second presentation will offer a deep understanding of context and mechanisms leading to effectiveness, used in interventions to promote men's health in organised sport, using a rapid realist review methodology. The third presentation will complete the second by mapping provision and evaluation practice of interventions delivered by professional sports clubs in the UK, through a practice-based targeted review. The fourth presentation will showcase the type of evaluation needed to investigate health promoting sports club's intervention, drawing from a pragmatic feasibility trial conducted in Ireland. The fifth presentation will offer practical guidelines for national sports federation on how to implement health promoting sports clubs, through a toolkit which has been edited in collaboration with the World Health Organisation. Based on the different presentations, discussion will be engaged with Jan Seghers, who has conducted major work on implementing health promoting sports clubs in Flanders, as well as the speakers and the audience. We also plan to discuss the active mechanisms identified in the interventions and how to address challenges in conducting empirical research on health promoting sports clubs. Lastly, we will open the floor for reflections on intervention research conducted in other settings. Key messages • The workshop will synthetises evidence on health promoting sports club's intervention implementation and evaluation. • The workshop will provide guidelines and recommendations for conducting and evaluating health promoting sports clubs’ interventions.

Circumstances that promote social connectedness in older adults participating in intergenerational programmes with adolescents: a realist review

ObjectivesLimited social connectedness in older adults is a risk factor for poor physical and mental health. Older adults who are socially isolated, lonely and disconnected have a higher risk of...

Complex interventions for aggressive challenging behaviour in adults with intellectual disability: A rapid realist review informed by multiple populations.

Approximately 10% of people with intellectual disability display aggressive challenging behaviour, usually due to unmet needs. There are a variety of interventions available, yet a scarcity of understanding about what mechanisms contribute to successful interventions. We explored how complex interventions for aggressive challenging behaviour work in practice and what works for whom by developing programme theories through contexts-mechanism-outcome configurations. This review followed modified rapid realist review methodology and RAMESES-II standards. Eligible papers reported on a range of population groups (intellectual disability, mental health, dementia, young people and adults) and settings (community and inpatient) to broaden the scope and available data for review. Five databases and grey literature were searched and a total of 59 studies were included. We developed three overarching domains comprising of 11 contexts-mechanism-outcome configurations; 1. Working with the person displaying aggressive challenging behaviour, 2. Relationships and team focused approaches and 3. Sustaining and embedding facilitating factors at team and systems levels. Mechanisms underlying the successful application of interventions included improving understanding, addressing unmet need, developing positive skills, enhancing carer compassion, and boosting staff self-efficacy and motivation. The review emphasises how interventions for aggressive challenging behaviour should be personalised and tailored to suit individual needs. Effective communication and trusting relationships between service users, carers, professionals, and within staff teams is essential to facilitate effective intervention delivery. Carer inclusion and service level buy-in supports the attainment of desired outcomes. Implications for policy, clinical practice and future directions are discussed. CRD42020203055.

Developing Design Principles for Sustainability-Oriented Blended Learning in Higher Education

Climate change forces higher educational institutions (HEI) to reconsider their traditional ways of teaching and organising education. This implies that they should reduce their impact on the environment and provide sustainability-oriented education. Blended learning (fusion of on-campus and online learning) may provide an appealing solution to achieve both objectives. It may reduce HEI’s climate impact by reducing student travel to and from campus and support the development of students’ sustainability competencies. In this paper, pedagogical design principles and recommendations are developed to design such a sustainability-oriented blended learning configuration. A realist review methodology is used to distil and develop pedagogical principles for blended learning. These principles were mirrored against pedagogical approaches that have been identified as suitable for developing sustainability competencies. This mirroring revealed some overlap but also some notable differences. Common principles include self-regulation, community building, discussion, knowledge management, and collaboration, but some principles identified in sustainability-oriented education are noticeably absent, including self-awareness, orientation towards sustainable change, and interdisciplinary collaboration. The insights guide designing sustainability-oriented blended learning and vice versa can also provide ideas for people working in off-line place-based contexts on sustainability-oriented education, to consider blended options.

A realist review of best practices and contextual factors enhancing treatment of opioid dependence in Indigenous contexts

ObjectivesThe objective of this study was to examine international literature to identify best practices for treatment of opioid dependence in Indigenous contexts.MethodsWe utilized a systematic search to identify relevant literature. The literature was analysed using a realist review methodology supported by a two-step knowledge contextualization process, including a Knowledge Holders Gathering to initiate the literature search and analysis, and five consensus-building meetings to focus and synthesize relevant findings. A realist review methodology incorporates an analysis of the complex contextual factors in treatment by identifying program mechanisms, namely how and why different programs are effective in different contexts.ResultsA total of 27 sources were identified that met inclusion criteria. Contextual factors contributing to opioid dependence described in the literature often included discussions of a complex interaction of social determinants of health in the sampled community. Twenty-four articles provided evidence of the importance of compassion in treatment. Compassion was evidenced primarily at the individual level, in interpersonal relationships based on nonjudgmental care and respect for the client, as well as in more holistic treatment programs beyond biophysical supports such as medically assisted treatment. Compassion was also shown to be important at the structural level in harm reduction policies. Twenty-five articles provided evidence of the importance of client self-determination in treatment programs. Client self-determination was evidenced primarily at the structural level, in community-based programs and collaborative partnerships based in trust and meaningful engagement but was also shown to be important at the individual level in client-directed care. Identified outcomes moved beyond a reduction in opioid use to include holistic health and wellness goals, such as improved life skills, self-esteem, feelings of safety, and healing at the individual level. Community-level outcomes were also identified, including more families kept intact, reduction in drug-related medical evacuations, criminal charges and child protection cases, and an increase in school attendance, cleanliness, and community spirit.ConclusionsThe findings from this realist review indicate compassion and self-determination as key program mechanisms that can support outcomes beyond reduced incidence of substance use to include mitigating systemic health inequities and addressing social determinants of health in Indigenous communities, ultimately healing the whole human being.

Navigation for youth mental health and addictions: protocol for a realist review and synthesis of approaches and practices (The NavMAP standards project)

IntroductionMental health and/or addiction (MHA) concerns affect approximately 1.2 million children and youth in Canada, yet less than 20% receive appropriate treatment for these concerns. Youth who do not receive...

Understanding how and under what circumstances decision coaching works for people making healthcare decisions: a realist review

BackgroundDecision coaching is non-directive support delivered by a trained healthcare provider to help people prepare to actively participate in making healthcare decisions. This study aimed to understand how and under what circumstances decision coaching works for people making healthcare decisions.MethodsWe followed the realist review methodology for this study. This study was built on a Cochrane systematic review of the effectiveness of decision coaching interventions for people facing healthcare decisions. It involved six iterative steps: (1) develop the initial program theory; (2) search for evidence; (3) select, appraise, and prioritize studies; (4) extract and organize data; (5) synthesize evidence; and (6) consult stakeholders and draw conclusions.ResultsWe developed an initial program theory based on decision coaching theories and stakeholder feedback. Of the 2594 citations screened, we prioritized 27 papers for synthesis based on their relevance rating. To refine the program theory, we identified 12 context-mechanism-outcome (CMO) configurations. Essential mechanisms for decision coaching to be initiated include decision coaches’, patients’, and clinicians’ commitments to patients’ involvement in decision making and decision coaches’ knowledge and skills (four CMOs). CMOs during decision coaching are related to the patient (i.e., willing to confide, perceiving their decisional needs are recognized, acquiring knowledge, feeling supported), and the patient-decision coach interaction (i.e., exchanging information, sharing a common understanding of patient’s values) (five CMOs). After decision coaching, the patient’s progress in making or implementing a values-based preferred decision can be facilitated by the decision coach’s advocacy for the patient, and the patient’s deliberation upon options (two CMOs). Leadership support enables decision coaches to have access to essential resources to fulfill their role (one CMOs).DiscussionIn the refined program theory, decision coaching works when there is strong leadership support and commitment from decision coaches, clinicians, and patients. Decision coaches need to be capable in coaching, encourage patients’ participation, build a trusting relationship with patients, and act as a liaison between patients and clinicians to facilitate patients’ progress in making or implementing an informed values-based preferred option. More empirical studies, especially qualitative and process evaluation studies, are needed to further refine the program theory.

Understanding How and Under What Circumstances Social Media Supports Health Care Providers' Knowledge Use in Clinical Practice: A Realist Review.

Background: Although theoretical frameworks exist to guide social media interventions, few of them make it explicit how social media is supposed to work to improve the knowledge use by health care providers. This study aimed to synthesize literature to understand how and under what circumstances social media supports knowledge use by health care providers in clinical practice. Methods: We followed the realist review methodology described by Pawson et al. It involved six iterative steps: (1) develop an initial program theory; (2) search for evidence; (3) select and appraise studies; (4) extract data; (5) synthesize data; and (6) draw conclusions. Results: Of the 7,175 citations retrieved, 32 documents were prioritized for synthesis. We identified two causal explanations of how social media could support health care providers' knowledge use, each underpinned by distinct context-mechanism-outcome (CMO) configurations. We defined these causal explanations as: (1) the rationality-driven approach that primarily uses open social media platforms (n = 8 CMOs) such as Twitter, and (2) the relationality-driven approach that primarily uses closed social media platforms (n = 6 CMOs) such as an online community of practice. Key mechanisms of the rationality-driven approach included social media content developers capabilities and capacities, in addition to recipients' access to, perceptions of, engagement with, and intentions to use the messages, and ability to function autonomously within their full scope of practice. However, the relationality-driven approach encompassed platform receptivity, a sense of common goals, belonging, trust and ownership, accessibility to expertise, and the fulfillment of needs as key mechanisms. Conclusion: Social media has the potential to support knowledge use by health care providers. Future research is necessary to refine the two causal explanations and investigate their potential synergistic effects on practice change.

Changing Primary School Children's Engagement in Active School Travel Using Safe Routes to School Interventions: A Rapid Realist Review.

Safe Routes to School (SR2S) interventions have been implemented in many economically developed countries to improve children’s engagement in Active School Travel (AST). Evaluations have highlighted inconsistencies in SR2S intervention outcomes, raising questions as to how, why, and under what contextual conditions these interventions work. This review used a Rapid Realist Review (RRR) methodology to build, test, and refine an overarching program theory that unpicks the contextual factors and underlying mechanisms influencing children’s engagement in AST. From the 45 included documents, 16 refined Context–Mechanism–Outcome Configurations (CMOCs) were developed and clustered into three partial program theories (i.e., implementor/implementation, child, and parent), with the associated mechanisms of: (1) School Reliance; (2) School Priority; (3) Fun; (4) Pride; (5) Perceived Safety; (6) Distrust; (7) Convenience; (8) Perceived Capabilities; and (9) Reassurance. The overarching program theory delineates the pathways between intervention implementation, children’s motivation, parental decision-making, and children’s engagement in AST. The findings suggest SR2S interventions can motivate children to engage in AST, but whether this motivation is translated into engagement is determined by parental decision-making. This review is novel for highlighting that many of the factors influencing parental decision-making are contextually driven and appear to be unaddressed by the current suite of SR2S intervention strategies. The review additionally highlights the complexity of parental perceptions of safety, with the traffic and the road environment shaping only part of this multidimensional mechanism. Practitioners and policymakers need to tailor SR2S interventions to local contexts to better influence parental decision-making for children’s engagement in AST.

A realist review of voluntary actions by the food and beverage industry and implications for public health and policy in low- and middle-income countries.

The increasing availability of unhealthy processed food products is linked to rising rates of non-communicable diseases and obesity in low- and middle-income countries. Voluntary actions (VAs) are often adopted in lieu of regulating the composition, production, marketing and sale of unhealthy commodities, but their effectiveness is unclear. This realist review examines VAs adopted by the food and beverage industry in low- and middle-income countries. We developed a conceptual framework and followed a three-stage search to identify literature and VAs and, adhering to the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines, we produced a synthesized analysis of VAs. VAs, often initiated in response to governments' efforts to introduce regulations, were difficult to evaluate due to vague language and a lack of enforcement mechanisms. The review found no evidence indicating that VAs are effective in safeguarding public health. Yet their implementation has resulted in weaker responses and policy substitution, and so we suggest that VAs have the potential to negatively influence public health and policy. The United Nations should rescind their endorsement of industry involvement and mandatory measures should be favoured over VAs.

Mechanisms and contextual influences on the implementation of advance care planning for older people in long-term care facilities: A realist review

BackgroundOlder people in long-term care facilities face clinical uncertainty and unpredictable decline. Advance care planning enables older people to identify preferences and wishes for future treatment and care before any loss of capacity. However, it is unclear how, why and under what circumstances the implementation of advance care planning for older people can be normalised into routine practice within long-term care facilities. ObjectiveTo identify and explain mechanisms and contextual factors that underpin the implementation of advance care planning for older people in long-term care facilities. DesignRealist review. Setting(s)Long-term care facilities. MethodsConsistent with realist review methodology, we developed the initial programme theory by scoping reviews, engaging UK and China stakeholders and utilising the Normalisation Process Theory. MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and Scopus were subsequently searched from 01/01/1990 to 11/06/2021. Inductive and deductive coding was used to generate context-mechanism-outcome configurations, which were iteratively tested to refine the programme theory. Results5459 records were identified, and 48 were retained for final synthesis. Seven context-mechanism-outcome configurations were identified: (1) carry out sensitive conversation gradually in a nonthreatening way; (2) identify ‘a window of opportunity’; (3) deliver sustainable and available training; (4) build a collaborative and multidisciplinary network; (5) conduct collaborative negotiation to achieve shared decision-making; (6) secure active leadership buy-in; (7) keep conversation and documentation on track. A logic model was developed to conceptualise the causal pathways between the contexts, mechanisms, and outcomes. ConclusionsNormalising conversations about death is paramount to mainstreaming advance care planning implementation in long-term care facilities. The key to achieving this is older people, family members and staff have a shared understanding of the aims, values, and potential benefits of advance care planning. Advance care planning should be introduced at a time that is important to older people and families, rather than being process-driven. Nurse facilitators play a vital role in ensuring older people's voices are heard and in building bridges between participants in advance care planning. The findings of this study inform the appropriate development and evaluation of advance care planning interventions for older people in long-term care facilities. Further research is needed to explore mechanisms that underpin the implementation of advance care planning in Asian countries. RegistrationThis review is registered with the International Prospective Register of Systematic Reviews (CRD42021214317).

OECD Case Studies of Integrated Regional and Strategic Impact Assessment: What Does ‘Integration’ Look Like in Practice?

Increasingly, protocols for assessing the impacts of land-uses and major resource development projects focus not only on environmental impacts, but also social and human health impacts. Regional and Strategic Environmental Assessment (RSEAs) are one innovation that hold promise at better integrating these diverse land-use values into planning, assessment, and decision-making. In this contribution, a realist review methodology is utilized to identify case studies of “integrated RSEA”—those which are strategic, have a regional assessment approach, and seek to integrate environmental, community and health impacts into a singular assessment architecture. The results of a systematic literature review are described and six RSEA-like case studies are identified: Kimberly Browse LNG SEA; HS2 Appraisal of Sustainability; Lisbon International Airport SEA; Beaufort Regional Environmental Assessment; Nordstream 2 Transboundary EIA; and the Portland Harbour Sustainability Project. The case studies are examined according to their unique contexts, mechanisms and outcomes of their assessment protocols to determine the degree to which they consider more than environmental valued components, and the means by which they were included. Findings suggest that RSEA has a contentious relationship with the integration of more than environmental values, but that there are significant lessons to be learned to support project planning, especially for assessment contexts characterized by large, transboundary projects.

Participatory mental health interventions in low-income and middle-income countries: a realist review protocol

IntroductionThe launch of the Movement for Global Mental Health brought long-standing calls for improved mental health interventions in low-and middle-income countries (LMICs) to centre stage. Within the movement, the participation...

One Size Does not Fit All – A Realist Review of Screening Asymptomatic Atrial Fibrillation in Indigenous Communities in Australia, Canada, New Zealand, and the USA

The true prevalence of atrial fibrillation (AF) is underestimated because asymptomatic AF is underdetected. Adverse consequences of AF such as stroke may occur before AF is diagnosed. Current guidelines recommend opportunistic screening of AF in the general population for patients 65 years and older; however, this might not be suitable for Indigenous people. Screening for AF meets the World Health Organization criteria for successful routine screening, yet little is known about successful implementation of AF screening in Indigenous communities. This study uses a realist review methodology and framework to identify what works, how, for whom, and under what circumstances for AF screening in Indigenous communities. Eight databases and gray literature were searched for studies targeted at AF screening in Indigenous communities. Realist analysis was used to identify context-mechanism-outcome configurations across 11 included records. Some mechanisms that improve AF screening in Indigenous communities were identified. Salient enablers of AF screening in Indigenous communities include opportunistic nonclinical settings, portable electrocardiogram devices, and increasing training in Indigenous health-care workers. Tailoring follow-up protocols that are geographically and culturally appropriate to the settings is important. Prominent barriers included lack of cultural safety, fear of abnormal results, and time-poor environments. A middle-range theory is proposed in combination with the Indigenous health promotion tool model. Indigenous populations require earlier screening and culturally safe approaches for AF detection and pathways to treatment. A novel AF screening strategy is required. This realist review provides lessons learned for the successful implementation of AF screening and treatment programs for Indigenous communities.

How to use remote patient monitoring successfully in cardiac and pulmonary patients: a realist review

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Queensland Health Background Remote patient monitoring (RPM) is an underutilised telehealth intervention that can enhance self-management of cardiovascular and pulmonary disease and reduce acute care use. However, studies of effectiveness of RPM interventions vary widely. This study aimed to explain the variation in outcomes related to RPM interventions within cardiac and pulmonary populations. Specifically, we aimed to answer why some RPM interventions are more successful than others in reducing demand on acute care services. Methods In brief, search terms for remote monitoring and acute care utilisation were used across three electronic databases: PubMed, EMBASE and CINAHL. The search, conducted in October 2020, included articles published in the last five years (2015-2020). Articles were included if they used RPM to monitor an individual’s biometrics (e.g. heart rate, blood pressure) from a distance while they are not in hospital. Realist review methodology was used to enable exploration of how, why and for whom interventions do and do not work. Outcomes were evaluated to determine contextual factors and potential mechanisms that led to variation in cardiac and pulmonary intervention outcomes. Results After screening, 91 articles met the eligibility criteria and were included. We found that across a broad range of RPM interventions 31 factors emerged that are likely to impact the effectiveness of cardiac and pulmonary RPM innovations. These were synthesised into six theories of intervention success: 1) targeting populations at high risk; 2) accurately detecting a decline in health; 3) providing responsive and timely care; 4) personalising care; 5) enhancing self-management and, 6) ensuring collaborative and coordinated care. Conclusion While RPM interventions are complex, if they are designed with patients, providers and the implementation setting in mind and with the key variables identified within this review incorporated, it is more likely that they will be effective at reducing acute hospital events.