A critical realist approach to understanding and evaluating heart health programmes

Abstract

Secondary prevention programmes for Coronary Heart Disease (CHD) aim to reduce cardiovascular risks and promote health in people with heart disease. Though programmes have been associated with health improvements in study populations, access to programmes remains low, and quality and effectiveness is highly variable. Current guidelines propose significant modifications to programmes, but existing research provides little insight into why programme effectiveness varies so much. Drawing on a critical realist approach, this article argues that current research has been based on an impoverished ontology, which has elements of positivism, does not explore the social determinants of health or the effects on outcomes of salient contextual factors, and thereby fails to account for programme variations. Alternative constructivist approaches are also weak and lacking in clinical credibility. An alternative critical realist approach is proposed that draws on the merits of subjectivist and objectivist approaches but also reflects the complex interplay between individual, programme-related, socio-cultural and organizational factors that influence health outcomes in open systems. This approach embraces measurement of objective effectiveness but also examines the mechanisms, organizational and contextual-related factors causing these outcomes. Finally, a practical example of how a critical realist approach can guide research into secondary prevention programmes is provided.

Transactive memory systems and Web 2.0 in knowledge sharing: A conceptual model based on activity theory and critical realism

“…Thus, critical realism can contribute to activity theory ontologically as the stratified ontology provides the opportunity for researchers to investigate how the different elements of the activity system interact in order to enact or obstruct the outcome (Clark et al, 2007). Critical realism allows for ontological depth as it goes beyond the events and explores the underlying structures and mechanisms that enable or obstruct the occurrence of events.…”

What heart failure programme works best? Wrong question, wrong assumptions

“…28 Complexity-driven approaches in health, 20 economics, 21 and criminology 22 view programmes as complex systems in which outcomes are generated by numerous factors related to programmes, settings, and the people involved in providing and receiving programmes. 29,30 Outcomes from programmes are moderated by elements of context, such as place of residency, social support, and health systems, which affect willingness and capacity for effective heart failure self-care. 31,32 Focusing future efforts on arguing at a high level of generality that programmes 'work' or on identifying the characteristics of the type of programme that 'works best' does not take account of these contextual factors or the complexity of programmes.…”

Cardiac rehabilitation: into the future

“…But, in order to optimise uptake, or to appeal to non-attenders, alternative modes of programme delivery need to be explored and evaluated to identify what works for whom, when and where 49. A brief, patient-centred, modular programme, designed on the basis of individual need and collaborative goal setting, would appear an attractive option.…”