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

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.

[1]  R. Sugden.  Commodities and Capabilities , 1986 .

[2]  Amartya Sen,et al.  Capabilities, Lists, and Public Reason: Continuing the Conversation , 2004 .

[3]  E. Goyder,et al.  Citizens advice in primary care: a qualitative study of the views and experiences of service users and staff. , 2011, Public health.

[4]  Michael Marmot,et al.  Fair society, healthy lives : the Marmot Review : strategic review of health inequalities in England post-2010. , 2010 .

[5]  I. Buchan,et al.  Trends in mortality from 1965 to 2008 across the English north-south divide: comparative observational study , 2011, BMJ : British Medical Journal.

[6]  L. Hiller,et al.  The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): development and UK validation , 2007, Health and quality of life outcomes.

[7]  Eun-Hyun Lee.  Erratum to review of the psychometric evidence of the perceived stress scale [asian nursing research 6 (2012) 121-127]. , 2013, Asian nursing research.

[8]  S. Abbott,et al.  What is the impact on individual health of services in general practice settings which offer welfare benefits advice? , 2006, Health & social care in the community.

[9]  P. Allmark,et al.  Building Realist Program Theory for Large Complex and Messy Interventions , 2017 .

[10]  S. Abbott.  Prescribing welfare benefits advice in primary care: is it a health intervention, and if so, what sort? , 2002, Journal of public health medicine.

[11]  Clare Bambra,et al.  Due North: Report of the inquiry on health equity for the North , 2014 .

[12]  Christopher R Burton,et al.  Exploring the use of Soft Systems Methodology with realist approaches Dalkin, Sonia ; Lhussier, Monique; Williams, Lynne; Burton, Christopher; Rycroft-Malone, Joanne Evaluation , 2018 .

[13]  K. Schwegler,et al.  Effect of psychological stress on glucose control in patients with Type 2 diabetes , 2012, Diabetic medicine : a journal of the British Diabetic Association.

[14]  A. Manzano,et al.  The craft of interviewing in realist evaluation , 2016 .

[15]  S. Court.  Inequalities in health. Report of a research working group. , 1981, Archives of disease in childhood.

[16]  P. Crawshaw,et al.  The Impact of Welfare Reform in the North East , 2013 .

[17]  Homi K. Bhabha.  The Location of Culture , 1994 .

[18]  Pete Philipson,et al.  Reducing inequalities in care for patients with non-malignant diseases: Insights from a realist evaluation of an integrated palliative care pathway , 2016, Palliative medicine.

[19]  Joanne Greenhalgh,et al.  What’s in a mechanism? Development of a key concept in realist evaluation , 2015, Implementation Science.

[20]  Joanne Greenhalgh,et al.  RAMESES II reporting standards for realist evaluations , 2016, BMC Medicine.

[21]  R. Hurley.  The decision to trust. , 2011, Harvard business review.

[22]  Ray Pawson,et al.  Functionality and feedback: a realist synthesis of the collation, interpretation and utilisation of patient-reported outcome measures data to improve patient care , 2017 .

[23]  Joel E Dimsdale,et al.  Psychological stress and cardiovascular disease. , 2008, Journal of the American College of Cardiology.

[24]  G. Wong,et al.  Interventions to improve antimicrobial prescribing of doctors in training: the IMPACT (IMProving Antimicrobial presCribing of doctors in Training) realist review , 2015, BMJ Open.

[25]  Jean Adams,et al.  A systematic review of the health, social and financial impacts of welfare rights advice delivered in healthcare settings , 2006, BMC public health.

[26]  K. Ecclestone,et al.  The Many Faces of Vulnerability , 2017, Social Policy and Society.

[27]  M. Turshen.  Development as Freedom , 2001 .

[28]  S. Abbott,et al.  Who uses welfare benefits advice services in primary care? , 2003, Health & social care in the community.

[29]  G. Scambler,et al.  Can welfare-rights advice targeted at older people reduce social exclusion? , 2008, Ageing and Society.

[30]  F. Dhabhar,et al.  How psychological stress via hormones and nerve fibers may exacerbate rheumatoid arthritis. , 2005, Arthritis and rheumatism.

[31]  Richard Elmore,et al.  How to Manage Urban School Districts , 2006 .

[32]  S. Sowden,et al.  A qualitative study of the impact of the UK ‘bedroom tax’ , 2015, Journal of public health.

[33]  Eun-Hyun Lee,et al.  Review of the psychometric evidence of the perceived stress scale. , 2012, Asian nursing research.

[34]  Tor D Wager,et al.  Brain-Body Pathways Linking Psychological Stress and Physical Health , 2015, Current directions in psychological science.

[35]  Bill Cunningham,et al.  Understanding integrated care pathways in palliative care using realist evaluation: a mixed methods study protocol , 2012, BMJ Open.

[36]  T. Kamarck,et al.  A global measure of perceived stress. , 1983, Journal of health and social behavior.

[37]  Elizabeth Goyder,et al.  Assessing the health benefits of advice services: using research evidence and logic model methods to explore complex pathways , 2013, Health & social care in the community.

[38]  A. Sharples,et al.  Citizens Advice Bureaux in general practice: an illuminative evaluation. , 2000, Health & social care in the community.

[39]  N. Emmel.  Sampling and Choosing Cases in Qualitative Research: A Realist Approach , 2013 .

[40]  M. Khondoker,et al.  Impact of co-located welfare advice in healthcare settings: prospective quasi-experimental controlled study , 2017, British Journal of Psychiatry.

[41]  I. Vogel,et al.  Reflections from a Realist Evaluation in Progress: Scaling Ladders and Stitching Theory , 2016 .

[42]  N. Emmel.  Empowerment in the Relational Longitudinal Space of Vulnerability , 2017, Social Policy and Society.

[43]  R Core Team,et al.  R: A language and environment for statistical computing. , 2014 .

[44]  Lyndall Strazdins,et al.  Your money or your time? How both types of scarcity matter to physical activity and healthy eating. , 2017, Social science & medicine.