Realist matrix
| Study | Agency | Context | Resources | Mechanisms | Outcome (anticipated change related to self-management and self-efficacy) |
| Telehealth studies | |||||
| Eakin et al, 200934 | Unclear – based on the interaction between the study counsellor delivering the intervention and the patient. | Ethnically diverse patients with type 2 diabetes from a region on the outskirts of a state capital city in Australia. Comparatively elevated indicators of social disadvantage including a greater percentage of single-parent families, unemployment and foreign-born residents. Participants usually supported through a fee for service primary healthcare practice although intervention is home based and unsupervised. Counsellors (master’s-level graduates with a background in nutrition) trained in physical activity promotion and motivational interviewing techniques. | Detailed workbook to promote education on physical activity and healthy eating; pedometer. Telephone support providing assessment (and feedback); advice on physical activity and diet; and assistance with goal setting and a personalised plan for modifying physical activity and diet. Follow-up support in the form of subsequent telephone contacts. | Unknown | Behaviour change – increased physical activity and improved diet (decreased calories from fat and increased intake of fruit, vegetables and fibre). |
| Eakin et al, 201435 | Unclear – based on the interaction between the counsellor delivering the intervention and the patient. | Ethnically diverse patients with type 2 diabetes from a region on the outskirts of a state capital city in Australia. Comparatively elevated indicators of social disadvantage including a greater percentage of single-parent families, unemployment and foreign-born residents. Participants usually supported through a fee for service primary healthcare practice although intervention is home based and unsupervised. | Detailed patient workbook. Accelerometer was worn by patients to collect physical activity (PA) data and record use of device. Motivational interviewing providing support and managing expectations; identifying health benefits of weight loss; setting goals for diet and PA; self-monitoring progress; focusing on achievements and rewards. | Unknown. Authors propose that engagement and motivation of participants was low and only motivated patients should be included in such programmes. | Behaviour change – loss of weight, increase in moderate/vigorous physical activity, and diet quality. Improved clinical biomarkers: HbA1c, lipids and BP. |
| Sheldon et al, 201444 | Unclear – based on the interaction between the therapist delivering the intervention and the patient. | Low-income, culturally diverse, medically underserved patients with depression in US (Medicaid). Self-nomination offered to patients through clinics and direct referral options by PCP. Multidisciplinary contact and therapists trained. | Behavioural activation delivered as brief intervention to reduce self-punishment and increase positive reinforcement by teaching mood monitoring and social engagement (form of CBT). Protocol-driven incorporating language skills to foster collaboration and motivation. Motivational interviewing to enhance medication adherence. Flexible timeframes for patients who were more difficult to re-direct – up to 75mins. Pleasant activities list. | Motivation: I want to talk about my problems and seek advice. Doing things when I don’t really feel like it will still help me achieve my goals. Rapport with a ‘warm and objective’ therapist (this person understands my issues and is there to help me). ‘The self-help resources give me a sense of purpose’. These skills will be useful in the future (skill mastery). | Improved engagement with depression management and increased self- management especially in relation to medication management leading to improved adherence. |
| Wolf et al, 201429* | Unclear – based on the interaction between the primary care clinic staff and the patient. | Patients with type 2 diabetes attending federally qualified health centres (urban, suburban and rural) designed to cater for underserved US communities. Diabetes champion to deconstruct tasks and assign responsibilities to clinic staff. Clinic staff trained in counselling—teach back—positive encouragement, problem solving and coaching of patients to develop action plans. Semistructured script to encourage standardised interactions with patients. No financial support received to sustain staff roles. | Carve in: diabetes guide reviewed between patients and PC staff. Colourful 48-page diabetes guide tailored to low literacy levels (fifth-grade level) with descriptive photographs to depict self-care concepts. Patient engagement activities delivered by a nurse: brief counselling intervention and action plans and iterative counselling process to identify individual behavioural goals that are easily attainable and increase their confidence. Tracking system to follow-up patients. | Patient desires to have care provided within the PC practice as opposed to care from an outsourced service (even if more specialised). | Improved knowledge self-management for people with low health literacy. Improved access/uptake of service. Improved clinical biomarkers: HbA1C, PB and cholesterol. Patient satisfaction. |
| Unclear – based on the interaction between | Practice redesign to incorporate brief diabetes education and counselling. Referral to diabetes educator. Trained research staff delivered counselling. At the time of the intervention, there had been an injection of state funding that had resulted in more resources than had been previously available. | Carve out: diabetes guide reviewed between patients and diabetes educator. Colourful 48-page diabetes guide tailored to low literacy levels (fifth-grade level) with descriptive photographs to depict self-care concepts. Patient engagement activities delivered by diabetes educator: brief counselling intervention and action plans, iterative counselling process to identify individual behavioural goals that are easily attainable and increase their confidence. | Authors propose that the outsourced intervention worked better for patients who had not reached glycaemic control to reach it and those who were stable remained well managed (goal attainment). | ||
| eHealth plus telehealth | |||||
| Cherrington et al, 201540 | Unclear – based on the interaction between the patient and the peer CHW; the CHW and the diabetes team as an advocate for the patient; the CHW is influenced by their interaction with the primary care team. | African-American patients from underserved/safety net organisations in southern USA. Patients were part of a safety net neighbourhood/CHWs were also peers from the same location and either had diabetes or cared for someone with diabetes. Intervention free of cost but managed by peer support/CHWs. Male and female. 67.1% of participants and CHWs were female. High levels of mobile phone ownership but low use of text messaging or internet use. | Self-management group education and support with goal setting, motivational interviewing and coaching. Peers who also had life experience with diabetes and its management. Community-based diabetes self-management education session. | Shared experience, emotional supportiveness and availability; family-focused dynamic. | Increased access to the primary care team via the CHW, better follow-up. Improved knowledge/understanding and adherence by patients around diet, physical activity, self-monitoring of blood glucose, medication/insulin adjustment. |
| Chong and Moreno, 201232 | Unclear – based on the interaction between the psychiatrist and patient. | Hispanic, low-income, uninsured patients with depression in a rural setting. 88% were women, married or with a partner. Low rates of education and employment. Poorer representation of men due to restriction from low level employment. Patients oriented more to Mexican than to Anglo culture. No previous treatment for mental health. Telemedicine had been operating within the clinic for some time (organisational readiness), and for 5 years, the clinic had been trying to increase access to depression treatment for patients. No costs incurred by patients. Care provided in a clinic – patients taken to telemedicine room from the recruiter’s office and not directly from the waiting room to reduce stigma. | Culturally compatible components – Hispanic-speaking psychiatrists (one male, one female). The clinic was housed in an agency located within the community with ease of transport so it was – easy to get there. Virtual meeting space. | Patients said the programme made them feel better and it helped me feel supported. | Increased access to depression management via culturally relevant service. Decrease in depression symptoms and improved medication adherence. Patient satisfaction. |
| Davis et al 56, 2011 | Unclear – based on the interaction between the clinic nurse/clinical pharmacist and patient. | Veterans from minority groups in a rural setting with depression. | Stepped care depression module with care escalated for those not responding to lower levels of care by involving more professionals with additional expertise. | Unknown – authors propose these may relate to education and activation. | Increased adherence to medication and better response to treatment. |
| Fortney et al, 201328* | Unclear – based on the interaction between the PCP and on-site nurse depression care manager and the patient. | Medically underserved population in a remote setting (Arkansas’ Mississippi Delta, Ozark Highlands) with depression and numerous comorbidities. High unemployment/lack of insurance. Half time-funded depression care manager (nurse) – no prior MH training but received study training. Decision support used to guide treatment – no clinical supervision. Patients could choose ‘watchful waiting’ or antidepressant treatment. Patients preference for face-to-face or telephone encounters. | Practice-based collaborative care. Up-skilled staff at clinic education/activation, self-management goal setting. | Unknown – authors propose that patients were more likely to engage in self-management activities because the depression care manager (despite being off-site) practiced a more intensive programme and provided more encouragement to undertake physical, rewarding and social activities. | Changes in depression severity, treatment response and remission. Self-management. Patient satisfaction. |
| Unclear – based on the interaction between multiple PC providers, off-site depression care manager and patient. | Medically underserved population in a remote setting (Arkansas’ Mississippi Delta, Ozark Highlands) with depression and numerous comorbidities. High unemployment/lack of insurance. Off-site team funded by study. | Telemedicine-based collaborative care. Full-time depression care manager. CBT delivered by videoconferencing. | |||
| Shea et al, 200942 | Unclear – based on the interaction between the off-site nurse manager and the patient. | Older ethnically diverse medically underserved patients with type 2 diabetes receiving Medicare. ¾ spoke primarily Spanish. Nurses trained in computer-based case management tools and to facilitate interactions through videoconferencing. PCPs kept full responsibility of intervention patients – tried to avoid disruption of relationships. | Web-enabled computer and modem connection to existing telephone line – web cam and videoconferencing capacity. Home glucometer, BP cuff connected to the telemedicine unit. Direct upload of data to clinical database. Educational web page in English and Spanish and in regular or low literacy versions in each language. | Unknown | Improved clinical biomarkers: HBA1c, BP and LDL cholesterol. |
| Sheeran et al, 201142 | Unclear – based on the interaction between the telehealth nurse and patient. | Ethnically diverse sample of older patients with depression – homebound. Three Medicare-certified home care agencies (urban, suburban and rural). Nurses trained on telehealth protocol. | Spanish and English versions of telemonitoring tools and materials. Touch screen and/or synthetic voice to prompt patients – online interactive screen can ‘ask’ patients questions. Basic education and behavioural activation/goal setting. | I felt more connected to the agency. The frequent checks from the telemonitor were comforting, reassuring. I better understood my depression. I was able to be more honest about my feelings with a machine. I don’t like using a machine to discuss my feelings. Telemonitoring reduces the sense of stigma. | Change in behaviour. Satisfaction. Reduction in depression severity. |
| mHealth | |||||
| Wayne et al, 201541 | Unclear – based on the interaction between patients, HCs, exercise groups and web-based programme. | Patients with type 2 diabetes. The population was from a lower SES neighbourhood (90% of participants) and a midlevel SES community (10% of participants). All patients under the age of 70 years. Patients included first nation, African, Caribbean, Caucasian, Hispanic, South Asian, South East Asian, West Indian. 36% unemployed Clients determined their own health related goals. 24/7 monitoring allowed intervention based on desirable progress, relapse and resistance. Interactive system | Health coaching protocol highlighting behaviour change for individuals with type 2 diabetes mellitus. Concurrent exercise education programme with trainers and blood glucose testing before and after exercise sessions. | Meal photographing to enforce food portions and carbohydrate intake. Reminder messages. Self-awareness of habitual behaviours. ‘Feedback was motivating’, reduced feelings of isolation and being misunderstood. Emotional happiness. Therapeutic alliance. Activation through comonitoring. | Improved HbA1c, reduced weight and waist circumference. Satisfaction, improved mental health outcomes and QoL. Increased knowledge and self-management, control and confidence. |
| mHealth and eHealth | |||||
| Davis et al, 201533 | Unclear – based on the interaction between patients, web-based programmes, monitors and physicians. | Underserved, low SES, English and Spanish speaking patients. Predominantly older, retired, unemployed and with disability. Participants were all recruited in hospital as they were being discharged after experiencing acute exacerbations of illness. Patients were all uninsured in the US system of healthcare and hence part of medical insurance programmes. | Interactive educational component in which information was verbally transmitted to the patient with tips on symptom management via the RMD. Programme and information folder, contact information and preprinted education materials about symptom management provided free of charge. Support and information from monitoring staff. | Upfront loading of information and attention by the PC at the home visits. Personalised consistent feedback reinforced through habitual process of symptom reporting. | Reduced hospital admission and emergency department use. Symptom management/self-management and confidence to manage their symptoms. Satisfaction and improved QoL. |
*Assesses two intervention arms.
CBT, cognitive–behavioural therapy; CHWs, community health workers; LDL, low-density lipoprotein; QoL, quality of life; SES, socioeconomic status; PCP, primary care provider; HC’s, health coaches; HbA1c, glycated haemoglobin; FB