Interrogating intervention delivery and participants’ emotional states to improve engagement and implementation: A realist informed multiple case study evaluation of Engager

Lauren Weston*, Sarah Rybczynska-Bunt, Cath Quinn, Charlotte Lennox, Mike Maguire, Mark Pearson, Alex Stirzaker, Graham Durcan, Caroline Stevenson, Jonathan Graham, Lauren Carroll, Rebecca Greer, Mark Haddad, Rachael Hunter, Rob Anderson, Roxanne Todd, Sara Goodier, Sarah Brand, Susan Michie, Tim KirkpatrickSarah Leonard, Tirril Harris, William Henley, Jenny Shaw, Christabel Owens, Richard Byng, Dylan A. Mordaunt (Editor)

*Corresponding author for this work

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Background: ‘Engager’ is an innovative ‘through-the-gate’ complex care intervention for male prison-leavers with common mental health problems. In parallel to the randomised-controlled trial of Engager (Trial registration number: ISRCTN11707331), a set of process evaluation analyses were undertaken. This paper reports on the depth multiple case study analysis part of the process evaluation, exploring how a sub-sample of prison-leavers engaged and responded to the intervention offer of one-to-one support during their re-integration into the community.

Methods: To understand intervention delivery and what response it elicited in individuals, we used a realist-informed qualitative multiple ‘case’ studies approach. We scrutinised how intervention component delivery lead to outcomes by examining underlying causal pathways or ‘mechanisms’ that promoted or hindered progress towards personal outcomes. ‘Cases’ (n = 24) were prison-leavers from the intervention arm of the trial. We collected practitioner activity logs and conducted semi-structured interviews with prison-leavers and Engager/other service practitioners. We mapped data for each case against the intervention logic model and then used Bhaskar’s (2016) ‘DREIC’ analytic process to categorise cases according to extent of intervention delivery, outcomes evidenced, and contributing factors behind engagement or disengagement and progress achieved.

Results: There were variations in the dose and session focus of the intervention delivery, and how different participants responded. Participants sustaining long-term engagement and sustained change reached a state of ‘crises but coping’. We found evidence that several components of the intervention were key to achieving this: trusting relationships, therapeutic work delivered well and over time; and an in-depth shared understanding of needs, concerns, and goals between the practitioner and participants. Those who disengaged were in one of the following states: ‘Crises and chaos’, ‘Resigned acceptance’, ‘Honeymoon’ or ‘Wilful withdrawal’.

Conclusions: We demonstrate that the ‘implementability’ of an intervention can be explained by examining the delivery of core intervention components in relation to the responses elicited in the participants. Core delivery mechanisms often had to be ‘triggered’ numerous times to produce sustained change. The improvements achieved, sustained, and valued by participants were not always reflected in the quantitative measures recorded in the RCT. The compatibility between the practitioner, participant and setting were continually at risk of being undermined by implementation failure as well as changing external circumstances and participants’ own weaknesses.

Trial registration number: ISRCTN11707331, Wales Research Ethics Committee, Registered 02-04-2016—Retrospectively registered
Original languageEnglish
Article numbere0270691
Number of pages20
JournalPLoS One
Issue number7
Early online date14 Jul 2022
Publication statusPublished - Jul 2022


  • Research Article
  • Social sciences
  • Biology and life sciences
  • Medicine and health sciences
  • Research and analysis methods
  • Computer and information sciences


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