Combining soft systems approaches with realist evaluation principles to understand a childhood accident prevention programme

Background Healthcare organisations have been charged with reducing the rate of death and injury from accidents. This paper reports the first stage of a Knowledge Transfer Partnership project, an evaluation of a child home... [ view full abstract ]

Background
Healthcare organisations have been charged with reducing the rate of death and injury from accidents. This paper reports the first stage of a Knowledge Transfer Partnership project, an evaluation of a child home safety intervention and the development of a transferable model for accident prevention.

Aim
Using realist principles, to evaluate the home safety equipment scheme available within the Action on Children's Accident Prevention (ACAP) programme. The analytical task was to uncover what aspects of the programme worked, for whom and in what circumstances. Using a theory-led approach enabled the identification of effective accident prevention practices that could be transferred to other settings.

Methods
Soft systems approaches were used to enagge with stakeholders to identify 'prosaic theories', about how the programme worked. The theories were used to guide the collection of qualitative data, collected using documentary analysis, observation of programme delivery (n=20), interviews with service users (n=19), programme staff (n=10), health visitors (n=8) and service partners (n=12). Data were thematically analysed and set within context, mechanism and outcome configurations to explain their meaning. Approval to proceed was granted by the programme's host organisation and the University Faculty of Health Ethics committee.

Findings
ACAP was identified as a multi-layered dynamic programme that capitalised on the local availability of both human and financial resources. A shared vision between ACAP stakeholders meant that approaches to accident prevention practice were comprehensive and consistent. The programme was predicated on a preventive model, where resources are most effectively directed at reducing risks across a deprived demography. This was dependent on health visitor use of referral criteria and professional judgement, which enabled universal access to assessment and targeted delivery of the intervention (provision and fitting of reduced cost safety equipment in conjunction with a personalised home safety talk provided by health visitor team paraprofessionals). Service users demonstrated programme participation and adoption of safety practices when interactions with programme staff were facilitative and encouraged active learning.

Conclusions
Soft systems methodology was useful for formulating initial programme theories that were needed for proceeding with the theory led realist evaluation. The accident prevention programme was based on five key transferable elements, each with operating CMOs that collectively explained how the overall programme worked. They were: 1) a whole systems approach involving team and partner agency working shared visions, synergies and integrated efforts. 2) The use of social marketing supported the commissioning of service and promoted active public response to the initiative. 3) Incentives encouraged accident prevention resources to be used, whilst 4) proficient practices that enabled learning facilitated attitudes to be changed. The overall effect was a focus on 5) promoting collective behaviour change, through informed decision making, which was sustained over time. By identifying contextual influences on programme strengths it has enabled the creation of a service model for accident prevention, theoretically transferable across populations and settings. The whole system approach towards home safety and education has contributed to a social movement embedding consistent messages, normalising safer behaviour, and improving health outcomes for the local population.