Realist Synthesis Review Research Articles

Interventions to Increase Physical Activity in Community-Dwelling Older Adults in Regional and Rural Areas: A Realist Synthesis Review Protocol.

The importance of physical activity (PA) for the health and wellbeing of older adults is well documented, yet many older adults are insufficiently active. This issue is more salient in regional and rural areas, where evidence of the most critical components of interventions that explain PA participation and maintenance in older populations is sparse. This realist review will (1) systematically identify and synthesise literature on PA interventions in community-dwelling older adults in regional and rural areas, and (2) explore how and why those interventions increase PA in that population. Using a realist synthesis framework and the behaviour change wheel (BCW), context-mechanism-outcome (C-M-O) patterns of PA interventions for older adults in regional and rural areas will be synthesised. Thematic analysis will be employed to compare, contrast, and refine emerging C-M-O patterns to understand how contextual factors trigger mechanisms that influence regional and rural community-dwelling older adults' participation in PA interventions. This realist review will be the first to adopt a BCW analysis and a realist synthesis framework to explore PA interventions in community-dwelling older adults in regional and rural areas. This review will provide recommendations for evidence-based interventions to improve PA participation and adherence by revealing the important mechanisms apparent in this context. Systematic review registration: (PROSPERO CRD42023402499).

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis.

Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy. We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice. Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches). The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus. Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust. Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available. Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models. The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice. This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176. This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.

Factors of Engagement in Synchronous Online Learning Conversations and Distance Debriefing: A Realist Synthesis Review.

The COVID-19 pandemic propelled remote simulation and online distance debriefings. Like in-person debriefings, faculty seek to facilitate effective reflective discourse. The online learning environment, however, presents challenges to learner engagement that differ considerably from in-person debriefing, yet little research exists in this area. In an effort to identify factors that influence debriefing engagement in the online environment, we conceptualized distance debriefings as complex social interactions and performed a realist review of the literature for evidence in the fields of online learning, healthcare simulation, instructional design, and other teaching and learning fields to see whether we might discern factors that influence engagement in online learning conversations that might inform online distance debriefing best practices. Eighteen articles were found through our search of 5 online databases (MEDLINE, CINAHL, ERIC, Google Scholar). We conducted iterative purposeful searching and continued to do so throughout the review to try to identify any additional studies that would contribute to our understanding. A thematic analysis of the findings of our included articles revealed indicators categorized using the community of inquiry framework, enabling us to understand and explain them in the context of online learning and propose their application to distance debriefing engagement. We also propose a new dimension to the framework: internal and external factors of engagement. Our findings demonstrate that online learning can positively influence engagement of learners if essential factors are implemented. These factors may inform recommendations for best practices toward learner engagement during healthcare simulation distance debriefing.

Designing for engagement: A Realist Synthesis Review of how context affects the outcomes of multi-stakeholder forums on land use and/or land-use change

This Realist Synthesis Review (RSR) examines the scholarly literature on multi-stakeholder forums (MSFs) set up to support efforts towards more sustainable land use. In this review, we focus on subnational MSFs that include at least one grassroots and one government actor. MSFs have been presented, especially by practitioners, as a panacea to address land-use change and support climate mitigation, such as through “landscape” or jurisdictional approaches. However, it is not clear that these initiatives are learning from past experience, particularly from research analyzing the effect of context on the ability of such approaches to reach their objectives. To address this gap, the academic literature was assessed using the RSR method to elucidate the key contextual variables affecting outcomes. In addition to analyzing context, this review identifies four common lessons learned for MSFs: the importance of commitment (to the people, the process and its goals); engaging the implementers (key middle level brokers and government officials who determine what happens on the ground); openness to learn from and listen to stakeholders; and having a design that is adaptive to this context, with time and resources to do so. Findings suggest that the most successful MSFs are those that are recognized as part of a wider process that seeks to transform practices at multiple levels; entail a period of research and meetings at upper levels to identify potential roadblocks and existing capacities with those who would implement the project locally; build consensus and commitment from higher levels, and thus political will; and are designed as adaptive learning processes. The central lesson, then, is not one of how to design initiatives, given such different and distinct contexts. Rather, it is about how to design for engagement to address context, whatever its distinct features, in order to develop and implement initiatives with greater chance of success.

Correction to: Considering Methodological Accommodation to the Diversity of ASD: A Realist Synthesis Review of Data Collection Methods for Examining First-Person Experiences

Drawing on a realist synthesis approach, this review identified qualitative data collection approaches that inform “first-person” lived experience in autism spectrum disorder (ASD) across phenotypic expression. It further drew upon methodologic approaches used in other conditions that similarly represent individuals with impaired verbal expression. The aim of this realist synthesis approach was to identify methods with relevance to participants across the autism spectrum. Methods that emerged for eliciting first-hand perspectives consisted of photovoice, Talking Mats, “deep assessment,” SenseCam, and TimeSlips. Applying these methodologies in ASD has the potential to advance knowledge about the quality of life, priorities and needs of people with ASD, and advanced qualitative approaches beyond methods that are not inclusive of cognitive and expressive diversity.

Considering Methodological Accommodation to the Diversity of ASD: A Realist Synthesis Review of Data Collection Methods for Examining First-Person Experiences

Considering Methodological Accommodation to the Diversity of ASD: A Realist Synthesis Review of Data Collection Methods for Examining First-Person Experiences

Fisheries’ Property Regimes and Environmental Outcomes: A Realist Synthesis Review

Our paper describes the application of a realist approach to synthesizing evidence from 31 articles examining the environmental outcomes of marine protected areas governed under different types of property regimes. The development of resource tenure interventions that promote sustainable management practices has been challenged by the difficulties of determining how contextual factors affect environmental outcomes given the complexity of socio-ecological systems. Realist synthesis is a promising evidence review technique for identifying the mechanisms that influence policy intervention outcomes in complex systems. Through a combination of inductive and deductive analysis of the links between context, mechanisms, and outcomes, realist synthesis can help clarify when, how, where, and why property regime interventions are likely to result in positive environmental outcomes. Our study revealed the importance of disaggregating property regimes into sub-categories, rather than treating them as homogenous categories. More importantly, use of a realist synthesis approach allowed us to gain a deeper understanding of the ways in which three mechanisms—perceptions of legitimacy, perceptions of the likelihood of benefits, and perceptions of enforcement capacity—interact under different socio-ecological contexts to trigger behavioral changes that affect environmental conditions. The approach revealed the multi-faceted and interactive nature of perceptions of legitimacy, in which legal legitimacy, social acceptability, and ecological credibility combined to create robust legitimacy. The existence of robust legitimacy in turn appeared to be an important contributor to the success of regulatory systems reliant on voluntary compliance. Our study contributes to the field of natural resources governance by demonstrating the utility of a systematic review method which has received little attention by property scholars but which has promise to clarify understanding of how complex systems work. Our study also highlights that achieving long-term sustainability requires paying greater attention to the mechanisms that support or undermine people’s willingness to voluntarily engage in conservation behaviors.

Developing core economic outcome sets for asthma studies: a protocol for a systematic review

IntroductionCore outcome sets are standardised lists of outcomes, which should be measured and reported in all clinical studies of a specific condition. This study aims to develop core outcome sets...

The Impact of Caring for People with Spinal Cord Injury (SCI) on Carer’s Subjective Well-Being and Physical Health: A Realist Synthesis Review

The Impact of Caring for People with Spinal Cord Injury (SCI) on Carer’s Subjective Well-Being and Physical Health: A Realist Synthesis Review

Beyond the simulation laboratory: a realist synthesis review of clinical outcomes of simulation-based mastery learning.

Translational educational outcomes have been defined as starting in simulation laboratories (T1) and moving downstream to improved patient care practices (T2), patient outcomes (T3), and cost/other value outcomes (T4). The authors conducted a realist synthesis review of the literature to evaluate the translational effect of simulation-based mastery learning (SBML) principles beyond the laboratory. They also sought to address future directions in SBML to improve patient care processes and outcomes and, thus, the quality of health care delivery. The authors searched multiple databases for simulation-based medical education (SBME) studies published through April 2013. They screened articles using the PICO method-population (P), intervention (I), control (C), outcome (O)-to answer the research question: For (P) any health care providers, does the (I) implementation of SBML training, compared with (C) other training methodologies or no extra training, result in (O) a change in patient care practices or T2-T4 outcomes? Studies implementing SBME interventions with training methodologies that met all SBML principles and reporting T2-T4 outcomes were identified. The 14 included studies used pre/post or cohort study designs; the majority were limited to individual performance and procedural competency. They reported improvement after SBML training in procedure performance, task success, patient discomfort, procedure time, complication rates, or T4 impacts (e.g., cost reduction). Findings suggest health professions education conducted using SBML methodology can improve patient care processes and outcomes. Further research is needed to understand the translational impact of SBML for nontechnical skills, including teamwork, and skill retention.

The application of realist synthesis review methods in public health economics

BackgroundTraditional systematic reviewing methods tend to focus on measurement and reporting of programme effectiveness, or cost effectiveness in the case of health economic literature. Findings often show mixed results and do not provide a clear indication of why the invention worked under a certain setting. The realist research question is often summarised as “What works for whom, under what circumstances, how and why?” Programme theories are developed that make assumptions about how interventions work in practice. These programme theories are then tested against empirical evidence to populate a theoretical framework. The empirical evidence will support, contradict, or lead to modification of the programme theories through a highly iterative process. With regards to complex social interventions, realist review methods can provide a rich, detailed understanding of the intervention itself, which can be utilised during planning and implementation stages. The aim of this review is to inform the development of a novel multidisciplinary intervention for rehabilitation after hip fracture in the elderly, as part of a larger feasibility trial. MethodsAn ongoing realist review of multidisciplinary rehabilitation packages after hip fracture in the elderly will be used as a case study to show this method's application. Programme theories of behavioural economics (eg, welfare judgments, expected utility gains, and choice architecture) and theories relating to additional costs (eg, due to setting, delivery team, staff training, and additional resources such as time, equipment, or technology) with implications for cost effectiveness were developed as part of the Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR) realist review. Medline, Embase, AMED, CINAHL, Cochrane Library, and PEDro were searched for studies including the population (elderly adults with proximal hip fracture), intervention (multidisciplinary rehabilitation), and outcomes of interest (mortality, pain, functional status, quality of life, health utility, health service use, costs, patients' experiences). Identified references were transferred to bibliographic software (Endnote) and duplicates removed. References were included if they involved the population of interest, used any type of rehabilitation programme to support re-enablement after proximal hip fracture, and contained any elements of the developed programme theories. With regards to economic evidence, references were excluded if they were not full economic assessments or cost comparative studies. After independent screening by two reviewers and discussion of discrepancies, the full articles were then categorised independently by two reviewers on the basis of their conceptual richness into three categories: rich, thick, and thin. Any discrepancies were resolved by discussion. Data were then extracted until a particular programme theory reached saturation, whereby the inclusion of further references does not add anything new to the understanding of the theory. Findings11 294 references were screened after de-duplication. 620 were included for categorisation. Of these, 20 economic articles were categorised as thin and six as thick. Thick articles discussed implications of setting and delivery team with regards to costs and cost analyses. Thin articles reported economic analyses; however, no explicit programme theories were apparent. None contained elements of behavioural economic theories. InterpretationThe inclusion of health economic programme theories in the FEMuR realist review provides insight into economic mechanisms and contextual factors of multidisciplinary rehabilitation of hip fracture in the elderly, which has previously not been explored. This finding is of particular importance because previous research recommendations from National Institute for Health and Care Excellence guidance relevant to hip fracture rehabilitation interventions specifically highlight the need for evidence of cost effectiveness. FundingThis project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (funder reference: 11/33-03) and will be published in full in Health Technology Assessment. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, the NHS, or the Department of Health.