Exposing the impact of intensive advice services on health: A realist evaluation

Abstract

Attention has turned to welfare advice as a potential health and social care intervention. However, establishing direct evidence of health impact has proven difficult. This is compounded by the need to understand both the facilitative contexts and mechanisms through which this impact occurs. This study investigated if, how and in which circumstances an intensive advice service had an impact on stress and well‐being (as precursors to health impacts), for clients attending a branch of Citizens Advice, located in the North East of England. A mixed methods realist evaluation of three intensive advice services offered by Citizens Advice (CA) was operationalised in five phases: (a) Building programme theories, (b) refining programme theories, (c) Development of a data recording tool, (d) Testing programme theories with empirical data, (e) Impact interviews. This paper focuses on phase 4. The Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) and Perceived Stress Scale (PSS) were completed by 191 clients, with a 91% follow‐up rate (data collected: February 2016 to March 2017). Twenty‐two CA clients participated in interviews (data collected: October 2015 to November 2016). The PSS indicated a significant decrease in stress from initial consultation to approximately 4–6 weeks post advice from 31.4 to 10.3 (p < 0.001) and the WEMWBS indicated a significant increase in client well‐being from a mean of 26.9 to 46.5 (p < 0.001). Nine refined programme theories are presented which combine the qualitative and quantitative analysis; they are underpinned by three abstract theories: Capabilities model, The Decision to Trust Model, and Third Space. An explanatory framework is presented covering the micro, meso, and macro levels of CA. Use of a stress and well‐being lens has allowed insight into the precursors of health in those receiving intensive advice. Using these measures whilst explaining contextual and mechanistic properties, begins to build a complex and real picture of how advice services impact on health.

“If you are on duty, you may be afraid to come out to attend to a person”: fear of crime and security challenges in maternal acute care in Nigeria from a realist perspective

“…Mechanism includes two aspects, first the process of reasoning of how subjects interpret and act upon programme intervention, at a given time, in a given context, and secondly how they interact with available programme resources. Outcomes are described as the patterns of intended and unintended consequences that result from mechanisms triggered in different contexts, and may be proximal, intermediate or distal [32,35]. Theories about how programmes are expected to work ("programme theories") are developed based on this configuration and are then iteratively tested and refined with empirical data gathered through appropriate methods and triangulated with available literature [32,36].…”

“If you are on Duty, you may be Afraid to Come out to Attend to a Person”: Fear of Crime and Security Challenges in Maternal Acute Care in Nigeria from a Realist Perspective.

“…Mechanism includes two aspects, rst the process of reasoning of how subjects interpret and act upon program intervention, at a given time, in a given context, and secondly how they interact with available program resources. Outcomes are described as the patterns of intended and unintended consequences that result from mechanisms triggered in different contexts, and may be proximal, intermediate or distal outcomes [24,28]. Theories about how programs are expected to work ( "program theories") are developed based on this con guration and are then iteratively tested and re ned with empirical data gathered through appropriate methods and against available literature [24,29].…”

‘Everything takes too long and nobody is listening’: Developing theory to understand the impact of advice on stress and the ability to cope

“…In the period of October 2017 to September 2018, the service as a whole provided 4,141,044 consultations, 55% of which related to state benefits, Universal Credit and debt [31]. Recent research has found that a CA service had a positive impact on its clients through increasing wellbeing and reducing stress [32]. This paper delves further into this experience of stress, and stress relief through the service, concurrently developing further understanding in stress theory and research.…”

“…This article reports on a secondary data analysis. The original study was a realist evaluation of a CA service in the North East England [32,33]. It is pertinent to look at this geographical location, as it is one of the areas most prominently affected by cuts in the UK [34].…”

“…Data from the study included qualitative interviews with clients in receipt of CA support. Whilst the initial focus was to elucidate how, why and in what circumstances the service worked best, one key finding was that there was a marked improvement in wellbeing and reduction in stress for welfare advice seekers after accessing the service [32,33]. Currently, theory surrounding stress, ability to cope and advice is sparse.…”