Exposing the impact of Citizens Advice Bureau services on health: a realist evaluation protocol

Introduction Welfare advice services can be used to address health inequalities, for example, through Citizens Advice Bureau (CAB). Recent reviews highlight evidence for the impact of advice services in improving people's financial position and improving mental health and well-being, daily living and social relationships. There is also some evidence for the impact of advice services in increasing accessibility of health services, and reducing general practitioner appointments and prescriptions. However, direct evidence for the impact of advice services on lifestyle behaviour and physical health is currently much less well established. There is a need for greater empirical testing of theories around the specific mechanisms through which advice services and associated financial or non-financial benefits may generate health improvements. Methods and analysis A realist evaluation will be conducted, operationalised in 5 phases: building the explanatory framework; refining the explanatory framework; testing the explanatory framework through empirical data (mixed methods); development of a bespoke data recording template to capture longer term impact; and verification of findings with a range of CAB services. This research will therefore aim to build, refine and test an explanatory framework about how CAB services can be optimally implemented to achieve health improvement. Ethics and dissemination The study was approved by the ethics committee at Northumbria University, UK. Project-related ethical issues are described and quality control aspects of the study are considered. A stakeholder mapping exercise will inform the dissemination of results in order to ensure all relevant institutions and organisations are targeted

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

Shrinking state spending in the UK has been accompanied by a profound restructuring of the welfare system, leading to financial insecurity for many people, culminating in extreme stress and serious deterioration of physical and mental health. Theory surrounding the impact of welfare advice on stress is lacking; this paper undertakes an in depth exploration of the experiences of stress among welfare advice seekers, considering these in light of existing substantive theories of stress and coping to generate new insight. A thematic analysis explored the experiences of stress in welfare advice seekers. Four overarching themes and twelve subthemes emerged. They are further understood utilising traditional theories of stress (Transactional Model of Stress and Coping and the Conservation of Resources theory), which then underpin the development of a ‘Stress Support Matrix’ and a holistic theory related specifically to welfare, stress and coping

Resting state correlates of subdimensions of anxious affect

Resting state fMRI may help identify markers of risk for affective disorder. Given the comorbidity of anxiety and depressive disorders and the heterogeneity of these disorders as defined by DSM, an important challenge is to identify alterations in resting state brain connectivity uniquely associated with distinct profiles of negative affect. The current study aimed to address this by identifying differences in brain connectivity specifically linked to cognitive and physiological profiles of anxiety, controlling for depressed affect. We adopted a two-stage multivariate approach. Hierarchical clustering was used to independently identify dimensions of negative affective style and resting state brain networks. Combining the clustering results, we examined individual differences in resting state connectivity uniquely associated with subdimensions of anxious affect, controlling for depressed affect. Physiological and cognitive subdimensions of anxious affect were identified. Physiological anxiety was associated with widespread alterations in insula connectivity, including decreased connectivity between insula subregions and between the insula and other medial frontal and subcortical networks. This is consistent with the insula facilitating communication between medial frontal and subcortical regions to enable control of physiological affective states. Meanwhile, increased connectivity within a frontoparietal-posterior cingulate cortex-precunous network was specifically associated with cognitive anxiety, potentially reflecting increased spontaneous negative cognition (e.g., worry). These findings suggest that physiological and cognitive anxiety comprise subdimensions of anxiety-related affect and reveal associated alterations in brain connectivity

Layering programme, pathway and substantive theories in realist evaluation

Developing programme theory is an essential part of any realist project. Often researchers can struggle with this process of initial generation, particularly when theory from different levels of abstraction is desired or required. The RAMESES guidelines for synthesis state that excellent refinement of programme theory requires the relationship between the programme theory and relevant substantive theory to be identified. Furthermore, developing realist informed programme theories in CMO configurations can aid the researcher throughout the evaluation or synthesis process, however the operationalisation of this has not always been clear. Using the example of a realist evaluation of a Citizens Advice Bureau project we illustrate how programme theories were developed and how theory development can be layered in order to enhance sense making of how the programme works, for whom, in which circumstances. Thus we use programme, pathway and substantive theories to shape and enhance our understanding prior to data collection and theory testing. Programme theories consist of informed ‘hunches’ about how the programme works, which sat underneath a layer of pathway theories which were defined in the JRF report ‘How Does Money Influence Health’ (Benzeval et al., 2014). A range of substantive theories were identified using ‘ABC of Behaviour Change Theories’ (Michie et al., 2014) and the project teams own theory knowledge. Layering theories prior to testing using mixed methods allowed for (1) a greater understanding of the programme and (2) the testing of not only programme but also pathway and substantive theories. This demonstration of theory layering will help researchers to engage with substantive theory earlier in the realist research process and throughout

Variações no calibre das varizes esôfago-gástricas após tratamentos cirúrgicos de hipertensão portal

Um dos mais importantes fatores que levam à hemorragia digestiva por hipertensão portal é o calibre das varizes esôfago-gástricas. Visamos, no presente trabalho, avaliar endoscopicamente as variações de calibre antes e após diferentes cirurgias de hipertensão portal, realizadas em 73 pacientes com esquistossomose hépato-esplênica, no contexto de um estudo controlado e aleatorizado, sendo 24 deles submetidos a Anastomose Espleno-Renal (AER), 24 a Descompressão Portal Seletiva (DPS) e 25 a Desconexão Azigo-Portal com Esplenectomia (DAPE). As avaliações endoscópicas foram realizadas antes e até 10 anos após as cirurgias. O calibre das varizes foi classificado, segundo Palmer como de grau 1- até 3mm, grau 2 de 3 a 6 mm e grau 3 quando maiores do que 6mm de diâmetro, analizadas em quatro localizações anatômicas a saber: terços inferior, médio e superior do esôfago e estômago proximal. A somatória do número de pontos na gradação pré-operatória menos a somatória dos pontos na gradação evolutiva forneceu um número correspondente ao diferencial, que permitiu a comparação estatística entre os diferentes grupos cirúrgicos. Na avaliação qualitativa, bons resultados, correspondendo ao desaparecimento ou diminuição do calibre da varizes, foram encontrados mais freqüentemente após a AER do que DPS ou DAPE - respectivamente 95,8%, 83,3% e 72%. A análise estatística dos diferenciais de gradação demonstrou diferença estatisticamente significante favorecendo a AER em relação à DAPE, não havendo diferenças entre AER e DPS. Em conclusão, as cirurgias de anastomose ("shunt") foram mais eficientes do que a desvascularização, em termos de diminuir o calibre de varizes esôfago-gástricas.The size of gastroesophageal varices is one of the most important factors leading to hemorrhage related to portal hypertension. An endoscopic evaluation of the size of gastroesophageal varices before and after different operations for portal hypertension was performed in 73 patients with schistosomiasis, as part of a randomized trial: proximal splenorenal shunt (PSS n=24), distal splenorenal shunt (DSS n=24), and esophagogastric devascularization with splenectomy (EGDS n=25). The endoscopic evaluation was performed before and up to 10 years after the operations. Variceal size was graded according to Palmer's classification: grade 1 -- up to 3 mm, grade 2 -- from 3 to 6 mm, grade 3 -- greater than 6 mm, and were analyzed in four anatomical locations: inferior, middle or superior third of the esophagus, and proximal stomach. The total number of points in the pre-operative grading minus the number of points in the post-operative grading gave a differential grading, allowing statistical comparison among the surgical groups. Good results, in terms of disappearance or decrease of variceal size, were observed more frequently after PSS than after DSS or EGDS - 95.8%, 83.3%, and 72%, respectively. When differential grading was analyzed, a statistically significant difference was observed between PSS and EGDS, but not between proximal and distal splenorenal shunts. In conclusion, shunt surgeries were more efficient than devascularization in diminishing variceal size

Using Computer Assisted Qualitative Data Analysis Software (CAQDAS; NVivo) to assist in the complex process of realist theory generation, refinement and testing.

There have been several calls for more transparency in realist methods, particularly in the complex process of programme theory development and refinement. This paper will describe the way in which Computer Assisted Qualitative Data Analysis Software, specifically, NUD*IST Vivo (NVivo), was used to build and refine programme theories (using literature and interview data) in a realist evaluation. This article presents the evolving and complex process of coding several data sources to nodes and child nodes, whilst writing ‘attached memos’ to highlight the process of theory generation. In this project, NVivo helped create an explicitly documented and evidenced audit trail of the process of programme theory refinement, answering to calls for further transparency in realist anal. RAMESES I and II have provided a platform to improve transparency in reporting realist research, by developing consensus and evidence-based reporting guidelines. We propose that the use of NVivo in realist approaches can help structure the iterative and by nature ‘messy’ process of generating, refining and testing complex programme theories when drawing on multiple data sources simultaneously. This effectively creates a structured track record of the analytical process, which increases its rigour and transparency in the analysis process

40Ar/39Ar thermochronology in the ios basement terrane resolves the tectonic significance of the south cyclades shear zone

We conducted 39Ar diffusion experiments using potassium feldspar from the South Cyclades Shear Zone on Ios, in the Cyclades, Aegean Sea, Greece. Irradiated samples were step-heated in an ultra-high-vacuum resistance furnace attached to a mass spectrometer, thus also allowing 40Ar/39Ar geochronology. Conjoint inversion of these datasets allowed estimation of the relevant diffusion parameters, which were then used to forward model the effect of arbitrary temperature–time histories. Simulations used Monte Carlo methods to improve approximations to the observed age spectra. Two periods of rapid cooling could be inferred. The South Cyclades Shear Zone commenced operation during or shortly after the Eocene–Oligocene transition. Episodes of south-directed movement continued into Early Miocene time, however, with the footwall still hot enough to cause biotite ± garnet metamorphic mineral growth at the base of the overlying, already substantially exhumed, eclogite–blueschist unit. Since its footwall continued to cool, the South Cyclades Shear Zone was an extensional shear zone during both episodes of its operation.Support from an Australian Research Council Discovery Project, DP12010187

Uncovering the contexts and mechanisms through which an intensive citizens advice service has health impacts -emerging theories

Introduction: Welfare advice is suggested to improve people’s health through action on the wider determinants of health and reducing stress and anxiety. However, due to the distal nature of health outcomes, and as advice services are highly tailored and nested in a wider system of health provision, evidencing the potential health impact of advice services has proven difficult. Methods: A realist evaluation will test if, how, for whom and in what circumstances an intensive programme for clients with complex needs provided by the Citizens Advice Bureau impacts on various socio-economic determinants of health. Sixteen initial programme theories were developed based on the advice service literature and interviews with staff from the citizen’s advice bureau who deliver the programme. Theoretical literature was used to support theory development, where empirical evidence was not available. The programme theories were tested using a mixed methods design in phase 2 of the research, using questionnaire data and realist interviews with staff and clients. Findings: We describe three emerging findings: (1) Formal brief health interventions were often not used by case workers, who instead provided health advice through anecdotes and personal experience (resource). This was due to health interventions sometimes being perceived as intrusive and ‘preaching’. CAB case workers felt that they weren’t medically trained and therefore health interventions were not within their remit (context). The use of anecdotes avoided clients feeling judged for their health behaviour (reasoning) and resulted in them being more receptive to health information and engaged in discussions (outcome). This allowed case workers to retain the trust of the clients whilst still delivering health advice. (2) One route to health impact as a result of CAB advice and increased finances may be a reduction in social isolation. Often clients are socially isolated due to low income (context) which is increased after advice from CAB (resource). This prompted a decision by clients to engage in social activities they may have previously not been able to (reasoning), resulting in increased wellbeing (outcome). (3) In the context of a distrust of agents of the state (context 1) and/or where clients have a weak social support network (context 2) CAB acts as a ‘person of standing’ offering impartial and non-judgemental services (resource). This allows clients to feel supported and develop trust (reasoning). This results in a buffer between the person and the state (outcome 1) which allows access to benefits (outcome 2), less stress and anxiety (outcome 3) and potential re-referrals for longer standing issues related to health (such as counselling) (outcome 3). Conclusions: Emerging findings are beginning to make explicit the mechanisms through and contexts within which intensive advice services may impact on health. Although the chain of causality is likely to be long and convoluted, early findings suggest that key steps in the process seem to be trust development, engagement and stress reduction. Another pivotal factor in identifying health outcomes in this project is to take a broader definition of health which includes decreased social isolation and increased wellbeing

Moderate threat causes longer lasting disruption to processing in anxious individuals

Anxiety is associated with increased attentional capture by threat. Previous studies have used simultaneous or briefly separated (<1 s) presentation of threat distractors and target stimuli. Here, we tested the hypothesis that high trait anxious participants would show a longer time window within which distractors cause disruption to subsequent task processing, and that this would particularly be observed for stimuli of moderate or ambiguous threat value. A novel temporally separated emotional distractor task was used. Face or house distractors were presented for 250 ms at short (∼1.6 s) or long (∼3 s) intervals prior to a letter string comprising Xs or Ns. Trait anxiety was associated with slowed identification of letter strings presented at long intervals after face distractors with part surprise/part fear expressions. In other words, these distractors had an impact on high anxious individuals' speed of target identification seconds after their offset. This was associated with increased activity in the fusiform gyrus and amygdala and reduced dorsal anterior cingulate recruitment. This pattern of activity may reflect impoverished recruitment of reactive control mechanisms to damp down stimulus-specific processing in subcortical and higher visual regions. These findings have implications for understanding how threat-related attentional biases in anxiety may lead to dysfunction in everyday settings where stimuli of moderate, potentially ambiguous, threat value such as those used here are fairly common, and where attentional disruption lasting several seconds may have a profound impact