Using Intersectionality Theory and Critical Realism for Exploring Heart Failure Telehealth Interventions for Vulnerable Patient Populations: A Scoping Review, Intersectionality-based Analysis, and A Rapid Realist Review
Creators: Allana, Saleema Mansoor
Publisher: name: University of Alberta Library
Year: 2022

<p>Background: Heart Failure (HF) is at epidemic levels among older adults, globally. Heart Failure Disease Management Interventions (HFDMIs) enhance self-care and quality of life as well as reduce hospital readmissions, through patient education and follow up, effective treatment, psychosocial support, and enhanced access to care. Over the last two decades, telehealth is widely applied to HFDMIs. HF telehealth interventions are complex with multi-layered complexity attributed to the telehealth technology as well as to the complex patient population of frail older adults suffering with HF. Another layer of complexity is added when HFDMIs are developed and implemented for vulnerable patients with intersecting social identities. Critical realism (CR) with its explanatory focus serves as the most appropriate philosophical underpinning for intersectionality-based research, uncovering the underlying structures of power that give rise to health inequities in HF care. </p>

<p>Purpose: This dissertation is aimed at utilizing the meta-theory of CR to ground intersectionality-based HF telehealth research with vulnerable groups of HF patients.</p>

<p>Methods: This literature synthesis utilized a scoping review to map the existing body of literature around HF telehealth interventions for marginalized patient populations (such as racialized minorities, rural patients, gender minorities, poor or deprived etc.). The studies that were retrieved as a result of the scoping review, then went through an intersectionality-based analysis utilizing an intersectionality-informed checklist by Ghasemi et al., 2021. This intersectionality-based analysis was meant to identify the extent to which intersectionality has been applied to this body of research. Lastly, a rapid realist synthesis was undertaken for the same body of literature to explore the underlying mechanisms and contexts that make HF telehealth interventions work or not work for marginalized groups of HF patients.</p>

<p>Findings: A total of 22 studies were selected to be included in this review. As per the quality appraisal, the overall body of studies included in the review was of high quality. Most included studies were conducted in USA. Only two studies have employed qualitative methods and one study has utilized mixed methods. A few specific populations have been involved in most studies as participants, such as, African Americans, Hispanics, and rural low-income populations. The review findings demonstrate that though the principles of intersectionality have been applied to the stages of problem identification and intervention development and implementation; however, very few studies have applied these principles at the stage of intervention evaluation. Very few studies included in the review involved stakeholders including vulnerable populations as part of the problem identification and implementation of the intervention. Only six out of the 22 studies in this review had a measure of success based on reducing health inequities. The realist review findings indicate that vulnerable patients require simple interventions that can be easily adopted by them. The findings also suggest that for effective utilization of telehealth and remote monitoring services, these patients require simplified training that could increase their confidence in using this technology effectively. The review findings have also demonstrated that involving patients’ family members in the delivery of telehealth interventions ensures success, especially when it pertains to the vulnerable groups such as racialized minorities and rural populations. This review has highlighted the fact that most telehealth programs are offered at large academic medical centres; whereas, typical heart failure patients, especially the vulnerable groups of HF patients mostly present at primary care clinics in community settings.</p>

<p>Conclusion: In conclusion, the findings from this scoping review suggest that the research around HF telehealth interventions for vulnerable populations is not adequately grounded in appropriate philosophical and theoretical underpinning. The principles of intersectionality have been applied mostly to the problem identification and the intervention development and implementation stages, and not so much at the evaluation stage. Future research with vulnerable populations should be underpinned by the critical/ intersectionality theory, and should apply the principles of intersectionality at all stages of the research process, including evaluation and analysis. This review also urges HF practitioners to apply the principles of intersectionality and health equity in clinical practice, such that the interventions are simple, personalized, involve family members, include an in-person component, include patients’ and health professionals’ training, and integrate telemonitoring data in care team’s work flow.</p>