Realist inquiry

In this dossier you will find different full text resources on themes in one way or another related to realist inquiry.

• Realist RCTs of complex interventions
  Marchal B., Westhorp G., Wong G. et al.
  Bonell et al. discuss the challenges of carrying out randomised controlled trials (RCTs) to evaluate complex interventions in public health, and consider the role of realist evaluation in enhancing this design. They argue for a "synergistic, rather than oppositional relationship between realist and randomised evaluation" and that "it is possible to benefit from the insights provided by realist evaluation without relinquishing the RCT as the best means of examining intervention causality." We present counter-arguments to their analysis of realist evaluation and their recommendations for realist RCTs. Bonell et al. are right to question whether and how (quasi-)experimental designs can be improved to better evaluate complex public health interventions. However, the paper does not explain how a research design that is fundamentally built upon a positivist ontological and epistemological position can be meaningfully adapted to allow it to be used from within a realist paradigm. The recommendations for "realist RCTs" do not sufficiently take into account important elements of complexity that pose major challenges for the RCT design. They also ignore key tenets of the realist evaluation approach. We propose that the adjective 'realist' should continue to be used only for studies based on a realist philosophy and whose analytic approach follows the established principles of realist analysis.
  Social Science & Medicine | July 2013 
• Thoughts about conceptual models, theories, and literature reviews
  Fawcett J.
  This essay focuses on various types of literature reviews, including scoping reviews, realist reviews, and integrative reviews. As contributions to understanding the state of nursing science about a particular topic, each literature review should be but rarely is guided by a nursing conceptual model, and the research findings should be but rarely are interpreted as theories that were generated or tested. Examples that are exceptions to usual literature reviews are given
  Nursing Science Quarterly | July 2013
• Factors affecting learning and teaching for medicines supply management training in Pacific Island Countries - a realist review
  Brown A., Ward-Panckhurst L., Cooper G.
  A 'realist methodology' consisting of a systematic investigation of the published literature and a targeted review of the 'grey' literature was used. All relevant literature was retrieved and coded manually using broad thematic analysisThe results of this 'realist methodology' review provide insights into learning approaches and cultural influences on student learning within PICs. The themes generated will be used to develop a set of principles to inform educators and health personnel involved in pharmaceutical training within Pacific Island Countries.
  Rural and Remote Health | June 2013
• Realist review to understand the efficacy of culturally appropriate diabetes education programmes
  Pottie K., Hadi A., Chen J., et al.
  Minority populations often face linguistic, cultural and financial barriers to diabetes education and care. The aim was to understand why culturally appropriate diabetes education interventions work, when they work best and for whom they are most effective. This review used a critical realist approach to examine culturally appropriate diabetes interventions. Minority patients with language barriers and limited access to diabetes programmes responded to interventions using health workers from the same ethnic group and interventions promoting culturally acceptable and financially affordable food choices using local ingredients. Programme incentives improved retention in the programmes and this was associated with improved HbA1c levels at least in the short term. Adopting a positive learning environment, a flexible and less intensive approach, one-to-one teaching in informal settings compared with a group approach in clinics led to improved retention rates.
  Diabetic Medicine | March 2013
• Narrative approaches to systematic review and synthesis of evidence for international development policy and practice
  Snilstveit B., Oliver S., Vojtkova M.
  This article argues that systematic review methods can be applied to answer a range of different questions for international development and pays particular attention to methods of synthesizing qualitative evidence that apply the key principles of systematic reviewing of being comprehensive, systematic and transparent. The article introduces readers to the types of questions for which reviews of qualitative evidence might be appropriate, the types of evidence such reviews might include and the range of methods available for their synthesis.
  Journal of Development Effectiveness | 2012 | 409-429 pp.
• Healthcare improvement and rapid PDSA cycles of change: a realist synthesis of the literature
  Curnock E., Ferguson J., McKay J., Bowie P.
  Conclusion by the authors: PDSA may be more successful in smaller, defined settings with stable staff and patient groups. Culture seems more important than size. Success is more likely where: evidence linking process goals to intended outcomes exists; is understood and visible to staff; the workforce is actively engaged; and, staff have prior QI experience. Although difficult to achieve, quicker and shorter PDSA cycles may lead to faster/more sustained practice change. Improvements are spread and sustained more when progress and associated data are shared and visible. Existing support structures and additional resources lead to greater success.
  NHS Education for Scotland, Department of Postgraduate General Practice Education | 2012
• How does capacity building of health managers work? A realist evaluation study protocol
  Prashanth N., Marchal B., Hoeree T.et al.
  There has been a lot of attention on the role of human resource management interventions to improve delivery of health services in low- and middle income countries. However, studies on this subject are few due to limited research on implementation of programmes and methodological difficulties in conducting experimental studies on human resource interventions. The authors present the protocol of an evaluation of a district-level capacity-building intervention to identify the determinants of performance of health workers in managerial positions and to understand how changes (if any) are brought about.
  BMJ Open | 2012 | 12 pp.
• Realist synthesis: illustrating the method for implementation research
  Rycroft-Malone J., McCormack B., Hutchinson A., et al.
  Realist synthesis is an increasingly popular approach to the review and synthesis of evidence, which focuses on understanding the mechanisms by which an intervention works (or not). There are few published examples of realist synthesis. This paper describes, in detail, the process used for a realist review and synthesis to answer the question ‘what interventions and strategies are effective in enabling evidence-informed healthcare?’ The strengths and challenges of conducting realist review are also considered.
  Implementation Science | 2012 | 21 pp.
• The use and limitation of realistic evaluation as a tool for evidence-based practice: a critical realist perspective
  Porter S. and O'Halloran P.
  In this paper, the authors assess realistic evaluation's articulation with evidence-based practice (EBP) from the perspective of critical realism. We argue that the adoption by realistic evaluation of a realist causal ontology means that it is better placed to explain complex healthcare interventions than the traditional method used by EBP, the randomized controlled trial (RCT).
  Nursing inquiry | 2012 | pp. 18-28 
• A critical realist approach to knowledge: implications for evidence-based practice in and beyond nursing
  Nairn S.
  This paper will identify some of the key conceptual tools of a critical realist approach to knowledge. I will then apply these principles to some of the competing epistemologies that are prevalent within nursing. There are broadly two approaches which are sometimes distinct from each other and sometimes inter-related. On one side, there is the view that all healthcare interventions should be judged on the principles of randomised controlled trials and the other is a preoccupation with language in which healthcare interventions are subjected to a discursive interrogation.
  Nursing inquiry | 2012 | pp. 6-17
• Assessing the benefits of participatory research: a rationale for a realist review
  Macaulay A., Jagosh J., Seller R., Henderson J. et al.
  A different approach to assessing the benefits of PR is needed. Realist review is a theoretically-driven, qualitative approach to synthesizing qualitative, quantitative, and mixed-methods evidence from program interventions. The authors are using realist review to generate, test, and refine theory on the benefits of participation using the empirical evidence of completed PR projects.
  Global Health Promotion | 2011
• A realist evaluation of the role of communities of practice in changing healthcare practice
  Ranmuthugala G., Cunningham F., Plumb J. et al.
  Realist evaluation is being used increasingly to study social interventions where context plays an important role in determining outcomes. This study further enhances the value of realist evaluations by incorporating a social network analysis component to quantify the structural context associated with CoPs. By identifying key mechanisms and contexts that optimise the effectiveness of CoPs, this study will contribute to creating a framework that will guide future establishment and evaluation of CoPs in healthcare.
  Implementation Science | 2011
• Realist review and synthesis of retention studies for health workers in rural and remote areas
  Dieleman M., Kane S., Zwanikken P., Gerretsen B.
  This report uses a realist review, which is a theory-based method, to address the questions of “why” and “how” certain rural retention interventions work better in some contexts and fail in others. Through applying a realist perspective to the review of these retention studies, a greater understanding is gained of the contextual factors and the main mechanisms that triggered the effects of retention strategies. The report provides strong support for the assertion that a bundle of retention strategies should be used in order to successfully attract and retain health workers in remote and rural areas.
   WHO | 2011
• Policy guidance on threats to legislative interventions in public health: a realist synthesis
  Wong G., Pawson R., Owen L.
  The authors aimed to produce a coherent and transferable evidence based framework of threats to legislative interventions to assist the decision making process and to test this through the ‘case study’ of legislation to ban smoking in cars carrying children.
  BMC Public Health | 2011
• Implementing successful intimate partner violence screening programs in health care settings: Evidence generated from a realist-informed systematic review
  O’Campo P., Kirst M., Ahmad F. et al.
  The authors undertook a synthesis of existing studies to re-evaluate the evidence on program mechanisms of intimate partner violence universal screening and disclosure within a health care context by addressing how, for whom, and in what circumstances these programs work. The review is informed by a realist review approach, which focuses on program mechanisms.
  Social Science and Medicine | 2011
• A realist synthesis of randomised control trials involving use of community health workers for delivering child health interventions in low and middle income countries.
  Kane S., Gerretsen B., Scherpbier R. et al.
  This paper examines evidence from randomized control trials on community health workers interventions in childhood illnesses in low and middle income countries from a realist perspective with the aim to see if they can yield insight into the working of the interventions, when examined from a different perspective.
  BMC Health Services Research | 2010
• A realistic evaluation: the case of protocol-based care
  Rycroft-Malone J., Fontenla, M., Bick D. et al.
  This paper describes the application of a realistic evaluation approach to the study of protocol-based care, whilst sharing findings of relevance about standardizing care through the use of protocols, guidelines, and pathways.
  Implementation Science | 2010
• Applicability and generalizability of the results of systematic reviews to public health practice and policy: a systematic review
  Ahmad N., Boutron I., Dechartres A., et al. 
  The purpose of the study was to evaluate systematic reviews of research into two public health priorities, tobacco consumption and HIV infection, in terms of the reporting of data related to the applicability of trial results (i.e., whether the results of a trial can be reasonably applied or generalized to a definable group of patients in a particular setting in routine practice, also called external validity or generalizability).
  Trials | 2010
• District nurses' role in palliative care provision: a realist review
  Walshe C., Luker K.
  The aim of this review is to construct a detailed account of the role of the district nurse (generalist registered nurse providing nursing care in primarily home settings) in providing palliative care, to determine if and how district nursing care provides effective care to such patients at home, and to examine the utility of a realist review for the above purpose.
  International Journal of Nursing Studies | 2010
• Innovations in health care: design theory and realist evaluation combined
  Keller C., Gare, K., Edenius M. et al.
  The aim of the paper is to present a design-evaluation framework for complex innovations in health care in order to understand what works for whom under what circumstances combining design theory and realist evaluation. The framework is based on research findings of a case study of a complex innovation, a health care quality register, in order to understand underlying assumptions behind the design of the innovation, as well as the characteristics of the implementation process.
  Sprouts: Working papers on Information Systems | 2010
• Ten steps to making evaluation matter
  Sridharan S., Nakaima A.
  This paper proposes ten steps to make evaluations matter. The ten steps are a combination of the usual recommended practice such as developing program theory and implementing rigorous evaluation designs with a stronger focus on more unconventional steps including developing learning frameworks, exploring pathways of evaluation influence, and assessing spread and sustainability.
  Evaluation and Program Planning | 2010
• Human resource management interventions to improve health workers' performance in low and middle income countries: a realist review
  Dieleman M., Gerretsen B., Wilt G.J. van der
  In the literature on human resource management (HRM) interventions to improve health workers' performance in Low and Middle Income Countries (LMIC), hardly any attention has been paid to the question how HRM interventions might bring about outcomes and in which contexts. Such information is, however, critical to assess the transferability of results. The aim of this paper was to explore if realist review of published primary research provides better insight into the functioning of HRM interventions in LMIC.
  Health Research Policy and Systems | 2009
• Can we systematically review studies that evaluate complex interventions?
  Shepperd S., Lewin S., Straus S. et al.
  This PLoS Medicine Debate considers the challenges facing systematic reviewers and suggests several ways of addressing them.
  Plos Medicine | 2009
• Exploring the science of complexity: Ideas and implications for development and humanitarian efforts
  Ramalingam B., Jones H.
  The application of complexity science to human realms has by no means been non-contentious: it has its champions, pragmatists and critics (for more on this, see the conclusions to this executive summary). This paper explores and explains the key concepts of complexity science, then moving on to reflect on the implications of the concepts, before arriving at some general conclusions about what complexity science means for development and humanitarian efforts.
  Overseas Development Institute | 2008  
• Greater than the sum: systems thinking in tobacco control
  Best A. Clark, P. and Leischow S. et al.
  The ISIS project was undertaken to examine the value and potential impact of systems thinking for tobacco control, both to improve its outcomes and as a template for strategies to apply these methods to other public health issues.
  National Cancer Institute | 2007
• The good indicators guide: Understanding how to use and choose indicators
  Pencheon D.
  This guide is intended to be a short, practical resource for anyone in any health system who is responsible for using indicators to monitor and improve performance, systems or outcomes. A guide this size can’t give all the answers to indicators. However, it can help you ask the important questions.
   Institute for Innovation and Improvement | 2008
• Why use theories in qualitative research?
  Reeves S., Albert M., Kuper A. et al.
  This article discusses the role and use of three theoretical approaches commonly used by qualitative researchers in health domains: interactionism, phenomenology, and critical theory. It also explains why such theories are important for clinicians, for health policy, and for patient care.
  BMJ | 2008
  Evaluation and negotiated order: developing the application of complexity theory
  Callaghan, G.
  This article aims to suggest an alternative to empiricist local description which draws explicitly on complexity paradigm and allows us to build on previous work on the relevance of complexity to evaluation. It further identifies a potential for understanding the relationship of structure and agency in complexity consistent terms through an approach to social theory based on Strauss’ work on negotiated order.
  Evaluation | 2008  
• Health sector reforms and human resources for health in Uganda and Bangladesh: mechanisms of effect
  Ssengooba F., Rahman S., Hongoro C. et al.
  Despite the expanding literature on how reforms may affect health workers and which reactions they may provoke, little research has been conducted on the mechanisms of effect through which health sector reforms either promote or discourage health worker performance. This paper seeks to trace these mechanisms and examines the contextual framework of reform objectives in Uganda and Bangladesh, and health workers' responses to the changes in their working environments by taking a 'realistic evaluation' approach.
  Human Resources for Health | 2007
  Understanding what works--and why--in quality improvement: the need for theory-driven evaluation
  Walshe K.
  This paper argues that in all research, our starting point should be to match our research methods to the questions or issues being investigated (and not the other way around). Before selecting an experimental research design, we should ask whether it fits the intervention we want to study. In particular, we need to consider the context in which the intervention is used, the content of the intervention itself, the process by which it is applied and the nature of its results or outcomes.
  International Journal for Quality in Health Care | 2007
• Realist review to understand the efficacy of school feeding programmes
  Greenhalgh T., Kristjansson E., Robinson V.
  A recent Cochrane review found that school feeding programmes significantly improve the growth and cognitive performance of disadvantaged children. This paper looks more closely at the highly heterogeneous trials to see what works, for whom, and in what circumstances.
  BMJ | 2007
  The stepped wedge trial design: a systematic review
  Brown C.A., Lilford R.J.
  This paper presents a review of 12 studies (or protocols) that use (or plan to use) a stepped wedge design. One aim of the review is to highlight the potential for the stepped wedge design, given its infrequent use to date.
  BMC Medical Research Methodology | 2006
  Wanted—new methodologies for health service research. Is complexity theory the answer?
  Kernick, D.
  This paper explores alternative perspectives and methodological opportunities that arise from viewing health service as a complex non-linear system. This approach may offer new research insights that more accurately reflect underlying mechanisms and may help to explain the limitations of current analytical techniques.
  Family Practice | 2006
• Responsive evaluation: Its meaning and special contribution to health promotion
  Abma T.A.
  This article presents the theory and methodology of responsive evaluation and discusses several controversial issues among them the nature of evidence and the political question: who should determine what counts as evidence? The value and meaning of responsive evaluation are illustrated by a case example. It concerns the evaluation of an injury prevention program for students in two performing art schools. 
   Evaluation and Program Planning | 2005
• The 'most significant change' (MSC) technique: a guide to its use
  Davies R., Dart J.
  This publication is aimed at organisations, community groups, students and academics who wish to use MSC to help monitor and evaluate their social change programs and projects, or to learn more about how it can be used.
  CARE International (and other organizations) | 2005
• Realist review – a new method of systematic review designed for complex policy interventions
  Pawson R., Greenhalgh T., Harvey G., Walshe, K.
  This paper offers a model of research synthesis which is designed to work with complex social interventions or programmes, and which is based on the emerging ‘realist’ approach to evaluation. It provides an explanatory analysis aimed at discerning what works for whom, in what circumstances, in what respects and how.
  Journal of Health Services Research & Policy | 2005