Skip to main content

Table 4 Realist matrix

From: Health service brokerage to improve primary care access for populations experiencing vulnerability or disadvantage: a systematic review and realist synthesis

Study Agency Context Resources Mechanisms Outcome (anticipated change)
Screening interventions
Braun 2015 [36] Interaction between lay navigator and participant Asian and Pacific Islander Medicare beneficiaries with low screening participation on the medically underserved island of Moloka’i in Hawaii.
Bilingual LHWs from the community. They received training from an evidence-based navigator training program.
Small geographic area made it easy for navigators to drive to people’s homes to transport to appointments or provide education.
Culturally compatible components- bilingual lay health workers.
Navigators performed outreach, education, made appointments, sent reminders, provided transportation to appointments, communicated with providers and completed paperwork.
“Continuous outreach and education and finding elderly adults willing to “take a leap of faith to get screened” overcame reluctance of elderly adults to discuss cancer or participate in screening. That the majority of those screened did not have or get cancer helped convince others to try it.” P.369
Dimensions of candidacy addressed: Identification of candidacy; navigation; appearances at health services.
Increased screening prevalence; satisfaction with navigation services
Han 2009 [37] Interaction between lay health worker and participant Korean-American women in the United States (predominately first-generation immigrants).
Bilingual LHWs from the community. Received training and followed the project’s lay health worker manual designed to guide the in-class education and individualized follow up counselling.
2 h education sessions and individually tailored follow-up counselling via telephone or home visits (3–9 sessions) for 6 months.
Culturally compatible components- bilingual lay health workers.
Information provided on mammogram facilities near participants’ homes and low-income state cancer screening programs.
Interpersonally orientated method combining theory-based behavioural tailoring with use of culturally sensitive, trained LHWs addressed the particular issues often experienced by recent Korean immigrants.
Dimensions of candidacy addressed: Identification of candidacy; navigation
Improved screening behaviours, improved breast cancer knowledge and beliefs
Mason 2013 [34] Interaction between community patient navigator and participant Underserved African American women in Georgia.
Patient navigators from community. Received training in breast cancer facts and statistics and how to deliver support and follow-up with community members while encouraging them to make and attend mammogram appointments.
Telephone follow-up delivered to encourage community members to make and keep their mammogram appointments (48 h after hosting a community event).
Low-cost screening program.
Literature distributed about importance of breast health.
Authors propose that patient navigator intervention addresses barriers to care through instruction and engagement of community member in understanding breast health and breast cancer combined with targeted follow up to encourage importance of receiving a mammogram.
Dimensions of candidacy addressed: Identification of candidacy; navigation
Increased mammogram uptake
General management interventions
Findley 2011 [32] Interaction between community health worker and participant Low income and ethnically diverse group with poorly managed asthma.
CHWs from the community. Trained to provide low literacy asthma education, environmental interventions and care coordination.
Culturally competent, tailored asthma education.
Environmental interventions- home visits to reduce home environmental triggers.
Referrals to health, educational, social and community resources.
Regular follow up contact (home visits or telephone). Frequency varied by site.
Asthma action plans.
Authors propose that care coordinators improved families’ ability to communicate with providers and provided follow-up to families regarding provider instructions.
Skill mastery: Authors also propose that care coordinators may have reduced absences through “increased confidence in managing asthma amongst caregivers, leading to more comfort in sending a child to school despite a flare-up; better understanding of asthma and the need to help children stay involved in school and sports; and better day-to-day management of asthma.” P.60S
Dimensions of candidacy addressed: Identification of candidacy; navigation
Increased caregiver confidence; change in health service utilisation (reduction in ED visits and hospitalisation); reduction in school absences; improved asthma management
Johnson 2012 [39] Interaction between community health worker and participant High users of health services such as ED, people with high consumption of controlled substances, poorly controlled chronic diseases and people with high use of disease management referrals, family or provider referrals, and care coordination referrals.
Community health workers from the community. Received training in HIPAA laws/compliance, communication/learning styles, motivational interviewing, organizational skills, safety, community resources, behavioural health, personal growth.
Informational materials about community and clinical resources.
Education, advocacy and social support.
None proposed or able to be extrapolated.
Dimensions of candidacy addressed: Identification of candidacy; navigation; appearances at healthcare
Decreased/more appropriate use of health services
Jordan 2013 [33] Interaction between transition coordinator/patient care coordinator and participant People with HIV returning home from jail.
Transition coordinator/patient care coordinator from community. Received training in ‘warm transitions’ approach to linkages, motivational interviewing techniques and stages of engagement in care.
Discharge planning services addressing housing, food and clothing needs along with medical and social services.
Transportation, accompaniment to primary care appointments and home visits.
Culturally compatible components- bilingual transition coordinator/patient care coordinator.
Discharge kit on release- medical summary, 7 day supply of medications and 21 day-prescriptions, condoms, health passport, listing of STD clinics and syringe exchange programs, a pocket guide to services designed for the criminal justice involved, and key words to use (“Jail Release Services”) when calling the NYC service telephone line.
Motivational interviewing.
Empathy: “Caring, non-judgmental staff familiar with the needs of the population and the communities to which they return” p.S218
Face to face sessions beginning right away with pre-trial detainees.
Dimensions of candidacy addressed: Identification of candidacy; navigation; permeability of services; appearances at health services
Greater percentage of releases to the community with a discharge plan; increased linkages to primary care; greater percentage of linkages to the community/releases to the community.
Krantz 2013 [30] Interaction between community health worker and participant Residents in 34 primarily rural Colorado counties.
Community health worker from the community. Undertook core curriculum components of a CHW certification program and also received additional coronary heart disease specific content expertise and formalized training in motivational interviewing techniques.
Health screenings and re-test screenings within 3–12 months after initial screening.
Medical referrals and informational materials about community and clinical resources.
Motivational interviewing to identify values and goals to promote healthy behaviour change.
Follow up phone call after 2 weeks to check on status of referrals and action plans.
None proposed or able to be extrapolated. Authors note that the many embedded elements in the program make it difficult to isolate individual contributions of program components to improved outcomes.
Dimensions of candidacy addressed: Identification of candidacy; navigation
Change in Framingham Risk Score (reduction in risk), change in other health outcomes: reduced BMI, weight, systolic BP, diastolic BP and cholesterol levels.
Wang 2012 [35] Interaction between community health worker and participant Individuals who were recently released from prison.
Community health worker from the community (with a personal history of incarceration). Received training on navigating the local health care and social service delivery system.
Case management (including referrals), chronic disease self-management support (including home visits) and health care navigation (including accompanying to appointments). None proposed or able to be extrapolated.
Dimensions of candidacy addressed: identification of candidacy; navigation; appearances at health services
Increase in primary care utilisation, reduction in ED utilisation, difference in return to jail rates, reduction in number of hospitalisations. ED.