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... [ view full abstract ]

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.