Emilie Robert The realist approach 2012

The realist approach: epistemological foundations and conceptual tools

GHR-CAPS seminars

The realist approach and its application in global health (Montréal, November 2012)

Emilie Robert

© Robert E., 2012

Outline

1.  Grasping the complexity of social interventions

2.  Critical realism and generative causation

3.  A theory-driven approach

4.  Realistic evaluation and realist synthesis

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© Robert E., 2012

1. Grasping the complexity of social interventions

What are we talking about?

3 Social phenomena,

interactions and interventions

© Robert E., 2012


Social phenomena are complex…

… So are social interventions.

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SOCIETY

COMMUNITY

INSTITUTION

FAMILY

INDIVIDUAL

Socio-ecological model

•  They are theories. •  They are active. •  They consist of a series of processes that are thickly populated. •  They are non-linear and go into feedback loops. •  They are embedded into several layers of context and social systems. •  They are leaky and prone to be borrowed. •  They are open systems.

Adapted from Pawson et al. (2004)

© Robert E., 2012


The example of user fee exemption policies

5 Adapted from Ridde et al. (2012)

Interventions… User fee exemption policies… are theories. aim to improve access to health services while reducing the

financial burden of households.

are active. involve governments, NGOs, the population, health staff, etc.

consist of a series of processes that are thickly populated.

consist of formulating the policy, implementing the activities by different players, monitoring and evaluating etc.

are non-linear and go into feedback loops.

transform and adapt through the action and the influence of stakeholders.

are embedded into several layers of context and social systems.

are implemented in countries that have different populations living in different social realities and having distinct worldviews.

are leaky and prone to be borrowed.

are implemented in paralell with other health policies that influence them (and vice versa).

are open systems. are systems where actors learn from their past experience, which influence the way interventions are conceived, implemented and perceived.

© Robert E., 2012

2. Critical realism and generative causation

Critical realism in the philosophy of science

Positivism Postpositivism Constructivism

Ontology ‘Naive’ realism – Real but apprehendable reality

Critical realism – Real reality but only imperfectly apprehendable

Relativism – Local and specific constructed reality

Epistemology Objectivist Findings true

Objectivity as a ‘regulatory guardian’ Critical tradition Findings probably true

Transactional / subjectivist Created findings

Methodology Experimental / manipulative Verification of hypotheses Chiefly quantitative methods

‘Critical multiplism’ Inquiry in more natural settings, more situational information, soliciting more emic viewpoints Falsification of hypotheses Include qualitative methods

Hermeneutical / dialectical

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Adapted from Guba & Lincoln (1994)

© Robert E., 2012


Generative causation

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Context (C)

Outcome (O)

Mechanism (M)

Adapted from Pawson & Tilley (1997)

MECHANISM: element of the reasoning of the actor facing an intervention. A mechanism: (1) is generally hidden, (2)  is sensitive to context variations (3)  produces outcomes.

from Robert et al. (2011)

© Robert E., 2012


Logic of realist explanation

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« The basic task of social inquiry is to explain interesting, puzzling, socially significant regularities. Explanation takes the form of positing some underlying mechanism which generates the regularity and thus consists of propositions about how the interplay between structure and agency has constituted the regularity. Within realist investigation there is also investigation of how the workings of such mechanisms are contingent and conditional, and thus only fired in particular local, historical or institutional contexts. » (p.71) (Pawson & Tilley, 1997)

What works? How? For whom? Under what circumstances? Why?

© Robert E., 2012


Mode of inquiry

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Theory

Confirmation

Observation

Hypothesis

DEDUCTIVE REASONING

© Robert E., 2012

Observation

Pattern

Tentative hypothesis

Theory

INDUCTIVE REASONING


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Mode of inquiry

RETRODUCTIVE REASONING (ABDUCTION)

© Robert E., 2012

Theory

Observation

3. A theory-driven approach

Program theory

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BASIC INTERVENTION THEORY

Identify and reach target population

Risk screening Health coaching

Signposting to services and

micro-interventions

Enhanced participant knowledge, confidence

and understanding

Improvements in lifestyle

Reduction in CHD risks

Reductions in health

inequalities

© Robert E., 2012

« Set of hypotheses that explain how and why the intervention is expected to produce outcomes. » from Robert et al. (2011)

« The theory in question is the set of beliefs and assumptions that undergird program activities […] They are the hypotheses on which people, consciously or unconsciously, build their program plans and actions.» from Weiss (1997)

Building of the teams’ technical capacities

Utilization of HIS data

The legitimacy of the Obs. is established.

Better utilization of knowledge in decision-making on user fee exemption measures

The credibility of knowlege is ensured.

Process utilization

National dissemination workshop

Conduct of studies by the Observatory teams

Adaptation and dissemination of

knowledge

Support to the Observatory to produce

knowledge

Involvement of local stakeholders in

producing knowledge

Knowledge is accessible.

Supervision of the production of knowledge

Administrative and financial support during 12 months; UdeM / MoH / MSF-B / ECHO partnership ; human resources; equipments; consumables; infrastructures

EXPE

CTE

D

RES

ULT

S O

BJE

CTI

VE

Prioritizing needs for knowledge with

Observatory teams

PRO

CES

S

Implication of target users in identifying needs for

knowledge

Preparation of protocoles by the Observatory teams

Knowledge is useful to target users.

INPU

TS

Presentations at local meetings

© Robert, 2011

AC

TIVI

TIES

Participative process

Publication of policy briefs on new knowledge

Conduct of independant studies by UdeM

At the local level

At the national level

At the internat.

level

Workshop for the identification of needs for

knowledge

COMPLEX INTERVENTION THEORY © Robert E., 2012

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Middle-range theory « Level of theoretical abstraction that provides an explanation of demi-regularities in the context – mechanism – outcome interactions of a set of interventions. » from Robert et al. (2011)

« theory that lies between the minor but necessary working hypotheses (...) and the all-inclusive systematic efforts to develop a unified theory that will explain all the observed uniformities of social behavior, social organization and social change » from Merton (1968)

© Robert E., 2012

EXAMPLE – Human Resource Management

« Hospital managers of well-performing hospitals deploy organisation structures that allow decentralisation and self-managed teams and stimulate delegation of decision-making, good flows of information and transparency. Their HRM bundles combine employment security, adequate compensation and training. This results in strong organisational commitment and trust. Conditions include competent leaders with an explicit vision, relatively large decision-making spaces and adequate resources. »

from Marchal et al. (2010)


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The elements of realist cumulation

C1 M1 O1

C4 M1 O2

C2 M1 O1 C3 M1 O1

C3 M1 O2

CA MB OC CD ME OF CG MH OI CJ MK OL

Empirical studies identifying C-M-O configurations

C1 M1 O1 C2 M2 O2 C3 M3 O3

Middle-range theories

C M O

Realist approach

DATA

THEORY Abstraction

Specification

Adapted from Pawson & Tilley (1997)

© Robert E., 2012


Adapted from Pawson and Tilley (1997) and Pawson (2006).

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4. Realistic evaluation and realist synthesis

© Robert E., 2012

Emilie Robert is a Ph.D. student in public health at Montreal University and is a fellow of the Global Health Research Strengthening Program, funded by the Canadian Institutes of Health Research and the Population Health Research Network of Quebec.

Contact: [email protected]

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Marchal, B., Dedzo, M., & Kegels, G. (2010). A realist evaluation of the management of a well-performing regional hospital in Ghana. BMC health services research, 10, 24. doi:10.1186/1472-6963-10-24

Merton, R.K. (1968). On sociological theories of the middle range. In R.K. Merton (Ed.), Social Theory and Social Structures (pp. 39-72). New York: Free Press.

Pawson, R. (2004). Evidence-based Policy: A Realist Perspective. London: SAGE Publications.

Pawson, R., Greenhalgh, T., Harvey, G. & Walshe, K. (2004). Realist synthesis: an introduction. ERSC Research Methods Programme, University of Manchester.

Pawson, R., & Tilley, N. (1997). Realistic Evaluation. London: SAGE Publications.

Pawson, R., & Sridharan, S. (2010). Evidence-based Public Health: Effectiveness and efficiency. In A. Killoran & M. P. Kelly (Eds.), Evidence-based Public Health: Effectiveness and efficiency (pp. 43–62). Oxford: Oxford Scholarship Online. doi:10.1093/acprof:oso/9780199563623.003.04

Ridde, V., Robert, E., Guichard, A., Blaise, P., & Van Olmen, J. (2012). Théorie et pratique de l’approche Realist pour l'évaluation des programmes. In V. Ridde & C. Dagenais (Eds.), Approches et pratiques en évaluation de programmes: nouvelle édition revue et augmentée (pp. 255–275). Montréal: Les Presses de l’Université de Montréal.

Robert, E., Ridde, V., Marchal, B., & Fournier, P. (2012). Protocol: a realist review of user fee exemption policies for health services in Africa. BMJ open, 2(1), e000706. doi:10.1136/bmjopen-2011-000706

Weiss, K. (1997). How Can Theory-Based Evaluation Make Greater Headway? Evaluation Review, 21, 501.

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Emilie Robert The realist approach 2012

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