Abstract
Background: In Scotland 80% of GP consultations and 60% of all deaths are attributed to Long-Term Conditions (LTC). Almost 22% of all premature deaths are attributed to cardiovascular disease (CVD), which has a higher prevalence in deprived areas. To meet the many challenges presented by CVD including burden of disease, disability, high mortality and morbidity and related health inequalities, health policy and practice should ensure that safe, effective and person-centred services are in place. Short term benefits of public health interventions have been found; however, long-term evidence-based policy actions are needed, especially in socioeconomically deprived areas. Contemporary mainstream public health interventions to reduce health inequalities and prevent CVD usually apply traditional evaluation methods, mainly experimental designs using a successionist approach to explaining the theory of causation. This results in a '‘black box” (a knowledge gap) in our understanding of how an intervention may work as it only focusses on what worked and what did not. The successionist approach generally measures input and what outcomes have been achieved and limited consideration is given to exploring and explaining stakeholder’s powers, capacities and liabilities while evaluating public health interventions. There is limited evidence of theory based evaluation actions that primary health care (PHC) can take to reduce CVD inequalities. This evidence and knowledge gap reflects a strong bias in health inequalities research towards measuring and describing differences rather than explicitly defining and evaluating the interventions to understand how they work, for whom, in what context and why.Aim: To explore, identify and inform Scottish health policy and practice about the contribution that a primary healthcare organisation makes, and should be making, to reduce health inequalities related to cardiovascular disease (CVD).
Research questions 35:
i. How is Scottish health policy, intended to reduce long-term conditions inequities, interpreted in primary healthcare?
ii. How, for whom and under what circumstances does the Keep Well Scottish national public health programme address CVD health inequalities in adults?
iii. What are the contexts and mechanisms that explain the observed outcomes of Keep Well?
Methodology: Realist Evaluation (RE) methodology was applied using a mixed-methods design conducted in two Phases. During Phase 1, a retrospective thematic Policy Document Analysis (PDA) was completed, by selecting the 10 most relevant policies, to develop health inequality policy theory for LTCs with a focus on CVD. Selection and analysis of the NHS Health Scotland Keep Well (KW) programme’s documentation was also undertaken in this Phase, to develop the programme theory/context-mechanism-outcome (CMO) hypotheses. During Phase 2 a RE of the NHS Highland KW programme was undertaken to test and refine the CMO hypotheses in practice. The evaluation comprised 23 in-depth interviews with service users, KWH practitioners, managers and the KWH delivery partner agency staff and a survey of 1223 service users to test the extent to which the (CMO) hypotheses were implemented as intended and whether they were supported or not in practice. The outcome of this evaluation was the development and configuration of a refined set of CMO theories to inform what works, how, for whom and in what circumstances.
Key results: Phase 1, the PDA/programme theory development, identified that although some policy documents aimed to deal with health inequalities through Health and Social Care Partnership (HSCP) integration and joint working, Scottish health policy overall did not provide guidance on how to achieve this in practice, how these mechanisms underpinning integration and joint working achieved the outcomes and under which conditions they worked or didn’t work. Phase 2, the KWH programme evaluation, found positive outcomes from the intervention for service users in terms of improved confidence, self-esteem, self-control, improved access for vulnerable groups, better mutual support and community connectedness, through the mechanisms of building trust and confidence, particularly in areas where community engagement was applied. Service user’s involvement in an anticipatory care social environment was effective; especially when co-production and assets-based approaches were applied, practitioner led social prescriptions were carried out and wider determinants of C VD health inequalities were identified and addressed. These strategies empowered service users in two of the five targeted areas and established a connecting system between wider services II and communities through the mechanisms of collaborative partnerships, provision of social and lifestyle support services and mutual trust.
Conclusion: The current study contributed to the existing knowledge in the field, especially focussing on the ‘hidden mechanisms’ of effect such as trust, confidence and fear. By identifying the ‘resources’ and ‘reasoning’ separately it was possible to describe the causal social and psychological triggers and determinants of health inequalities related to CVD, which are usually unexplained in traditional evaluation studies. The RE framework has particular implications for policy, practice and programme evaluation that explains how the KWH programme components work differently in different localities or with different population groups who have differing socio-economic status, or different contexts, values or influencing factors. Further research on the potential positive impact of community engagement and developments targeting vulnerable groups will be of benefit by considering how targeted interventions can address CVD related health inequalities. This should be done by focusing on and explaining the mechanisms, by disaggregating the ‘resources and reasoning’ to learn transferable lessons.
| Date of Award | 2021 |
|---|---|
| Original language | English |
| Awarding Institution |
|
| Supervisor | Jo Booth (Supervisor), Lisa Kidd (Supervisor) & Nicola Roberts (Supervisor) |