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Table 1 Hypotheses defined in terms of context, mechanisms and outcomes (CMOs) with related sources and findings

From: The SMART personalised self-management system for congestive heart failure: results of a realist evaluation

Context Findings related to context Mechanisms Findings related to mechanisms Outcomes Findings related to outcomes
C1. Limited access to technical support during deployment of the system Telephone support on weekdays, potential for face to face visits M1. Systems that have technical problems can result in low usability, and poor engagement. Therefore the system will be glitch free and fully functioning. There were technical problems and usability was reduced. O1. Engagement with system. Data sources: Interview; system data; System Usability Scale. Low SUS scores, interview data showed users were engaged with the content.
C2. Differing levels of computer literacy amongst users All participants had high levels of computer literacy M2. User-centred design process undertaken to identify a touch screen system with simple instructions designed to be operated by those with little or no computer knowledge Could not be tested O2. All are able to use the system and continue to use it for the duration of the evaluation. Data sources: Interview; System Usability Scale. This was supported, but all participants had high computer literacy.
C3. Over exertion on days when users are feeling well can result in a negative impact on subsequent days (the `over activity/ rest cycle') Not supported, at this stage M3. Pacing is taught by the system by providing feedback on activity, and showing users weekly plans, highlighting instances of over activity. Activity planner was not used as intended. Following initial set up participants did not keep it up to date resulting in an inaccurate record O3. Balance between activity and rest. Data sources: Interview; system data Not supported, further research needed to investigate context and potential mechanisms
C4. Loss of fitness and sedentary lifestyle of users resulting in fewer hobbies and interests Not supported with the post-deployment interviews, but had been mentioned in CMO development interviews and focus groups M4. Walking intervention to increase physical fitness Most people reported completing the walking intervention, although not all walks were recorded by the system O4. Ability to walk further. Data sources: Walking data, interview Some reported improvements, objective data was unavailable due to technical problems.
C5. Lack of recognition in users of worsening condition resulting in exacerbations of symptoms and potential for admission to hospital Not supported, participants were stable and had good awareness of symptoms that could lead to exacerbation M5. Increasing awareness of blood pressure, weight and symptoms through self-monitoring and tailored feedback provision Some participants reported this in the interviews O5. Improved symptom control thus reducing need for health professional involvement. Data sources: Interview; system data Could not be objectively tested. One person reported going to the Dr as a result of high blood pressure readings.
C6. Lack of knowledge as user is left alone to self-manage when their heart failure is stable, resulting in fewer opportunities for the health care professional to educate patients. Although participants acknowledged they self-managed their heart failure, it was felt that as they were stable, this was appropriate, most participants had high levels of heart failure related knowledge M6. Information and advice section contains educational material and quizzes, feedback from this and other sections should increase awareness. Information was looked at and quizzes completed pre and post-deployment O6. Increased levels of knowledge about self management. Data sources: Interview; Knowledge of Heart Failure questionnaire (TELER method). Significant increase in knowledge between pre and post-deployment quizzes for those with low levels initially
C7. Self-management of heart failure involves engagement with a variety of lifestyle changes, e.g., adhering to a medication regime, restrictions to diet, monitoring weight and taking regular exercise. Not challenged by participants. Interview data suggests participants felt behaviour change was important. M7. The SMART2 system incorporates the following behaviour change techniques: 1. Self-monitoring of symptoms; 2. setting and reviewing goals related to user's lifestyle; 3. providing regular feedback on performance. Some problems with self-monitoring. Goal-setting generally supported, feedback not always attended to. Interview data reported that the system did increase walking behaviour. O7. Behaviour change that is sustainable over the long term. Data source: Interview. Could not be objectively tested. Interview data suggested participants perceived this as possible, if current problems were addressed.