Learning from a ‘complex’ intervention targeted at a complex group and reported through a heterogenous
literature base – a realist synthesis
Lhussier M, Forster N, Carr SM, Northumbria University & Fuse, UK
This paper reports on a realist synthesis of the literature on outreach interventions for Traveller
Communities (TC) (http://www.journalslibrary.nihr.ac.uk/phr/volume-2/issue-3). A thorough search
of the literature was undertaken, and key stakeholders, including Traveller Community members,
outreach workers and members of Traveller organisations were involved in a number of Expert
Hearing events formed an important element of the project. They contributed crucial insights into
Traveller Community members’ decision making processes around trust and engagement,
helping to validate and refine emerging findings.
MRT: Neufeld’s cycle
of engagement*
Gradual building of
trust and engagement
Trust
building
Evaluation
The literature was overwhelmingly anecdotal, with only one RCT identified. The
evidence on outreach was under theorised and lacked process detail.
TC are a complex group, defined on a number of lifestyles and
ethnic dimensions, described through a literature
rich in statements of cultural distinctiveness
and need.
Participation
Disengagement
entrenched
Four initial theories:
The cultural distinctiveness and particular needs of Traveller Communities mean
that outreach forms a key ‘bridge’ between them and statutory health services (To
Whom)
Mobility is a key distinguishing factor of TC, not as a crude lifestyle descriptor, but its
impact on the formation, development and maintenance of social networks is key.
The cultural background of outreach workers (being a peer) is key to the success of
their intervention because it enables them to use the right communication tools (By
Whom)
Trust is a key in explaining why some interventions work. This is not only linked to
who the outreach worker is, but also their history of working with TC.
The degree of intervention formality and responsiveness to need are key levers for
participation (How)
Engagement is an important process tool and negotiation (responsiveness) is part of
this. Engagement (behavioural, cognitive, emotional) decision making determines
the outcome.
Key aims of outreach are to tackle health inequalities through engagement, advocacy
and education (What for)
Three levels of engagement could be identified (participation, behaviour change,
social capital development)
The emergence of lay or peer roles in public health is an instinctively appealing format in a context of hard-to-reach groups facing increasing inequalities. Outreach is a typical example of this,
and the heterogeneous literature base typical of such ill defined and individualised interventions. The key challenges this represented to the review process were linked to teasing out C-M
combinations with satisfactory explanatory potential, when O were rarely measured. The development of an explanatory framework required the combination of three sets of substantive
theories; a model of person – environment engagement, a typology of individual engagement and a model of trust development. Drawing on these and making extensive use of Expert Hearings
to supplement our data – poor literature base led to the development of an explanatory framework with strong face validity and translational potential.
* Neufeld J, Rasmussen H, Lopez S, Ryder J, Magyar-Moe J. The engagement model of
person-environment interaction. The Counseling Psychologist. 2006;34(2):245-59.
Corresponding author: Monique Lhussier, monique.lhussier@northumbria.ac.uk;
+44 191 2156036