Outpatient virtual care among people living with and beyond cancer from culturally and linguistically diverse backgrounds in Australia: a protocol for a realist evaluation

Background: Virtual care is increasingly being used to deliver outpatient cancer services, yet people from culturally and linguistically diverse (CALD) backgrounds can experience inequities in accessing these services. A range of complex and context-specific factors impact the effectiveness of virtual care and equity in its use and outcomes. This study draws on the methodological principles of realist evaluation to provide contextual understanding and account of how, why and in what circumstances outpatient virtual care services work (or not) for people from CALD backgrounds accessing cancer services in Australia.

Design: Realist evaluation, a theory-driven approach, allows researchers to provide a nuanced understanding of how, for whom and why different interventions work (or not) under different circumstances. We propose an iterative and stakeholder-driven four-phase study design that is exploratory and sequential, following the Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES II) quality standards for realist studies. Phase 1 will generate the initial program theory from a realist synthesis of theories for how virtual care interventions are implemented into routine care and semi-structured interviews with key stakeholders, including CALD service providers, service leaders and people with cancer and/or their carers who are from CALD backgrounds. Phase 2 will use semi-structured realist interviews and focus group discussions with stakeholders and retroductive, theory-driven realist analysis to test and refine the initial program theory. Phase 3 will validate the program theory with a small purposive participant sample outside those who participated in phases 1 and 2. The final phase will coproduce theory-informed actionable recommendations and guidelines for effective virtual models of care implementation through interactive workshops with consumers, managers, service leaders and providers.

Discussion: Knowledge of the contexts and mechanisms that produce optimal outcomes from virtual care is essential to guide the design, adjustment and implementation of virtual care models that provide equitable care outcomes for all patients. Outputs from this realist evaluation, including the program theory and actionable recommendations and guidelines, will inform policy and practice about implementing or adjusting virtual care models and policies or procedures in Australian healthcare to make them more accessible and equitable.

Patient or Public Contribution: The conceptualisation and design of this study were developed with healthcare consumers from diverse cultural and linguistic backgrounds, healthcare providers and academics as part of a national project in Australia. Multicultural consumers who have lived experience of accessing cancer services contributed to the project's design as investigators and are coauthors of this protocol paper. Patients and the public are also represented as Project Steering Group members who will inform the data collection processes, development, and refinement of our program theory.