Realist Synthesis: Building the D&I Evidence Base

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1 Realist Synthesis: Building the D&I Evidence Base Justin Jagosh, Ph.D Participatory Research at McGill (PRAM) Department of Family Medicine, McGill University McGill University, Montréal, Canada.

2 Session Objectives To explain the logic and key ingredients of realist synthesis: What is the underlying philosophy of realism? What does realist review purport to solve? Key ingredients (Context-Mechanism-Outcomes configuring, Demi-Regularities and Middle-Range Theory) To explore when and why realist review is useful for D&I research To address specific questions concerning your interest, past experience and future use of realist review and realist evaluation methods.

3 What is Realist Review? It is derived from the philosophy of Critical Realism; It is theory-driven and qualitative; And can be characterized as flexible, iterative, and adaptable to the nature of the evidence being studied.

4 How Realist Review is Conducted By building or testing (middle-range) theories or hypotheses pertaining to what drives programs to their outcomes By identifying program mechanisms, the contexts in which they are (or are not) activated, and the outcomes to which they lead: [Context-Mechanism-Outcome (CMO) configurations] If warrented, by categorizing and building these C-M-O clusters into Demi-Regularities Not hard evidence, but that which tends to happen in a semipredictable manner (which leaves room for contextual variation) And then refining the middle-range theories identified based on the synthesized evidence to advance an understanding what works, for whom and in what circumstances.

5 The Relevance of Realist Synthesis to D&I Research: To explore the workings of implicit or explicit theories of dissemination/implementation strategies To uncover the contextual factors which impede or promote the transfer of knowledge into practice To uncover the mechanisms of change the key triggers which set knowledge transfer in motion To study the outcomes of D&I research and to see how they are Ultimately to understand for whom, when, and in what circumstances knowledge dissemination or implementation is successful (or not).

6 The Product of a Realist Review Middle-range theory (hypothesis) Evidence-base Refined middle-range theory

7 What is Realism? Critical realism (Bhaskar 1975) is a philosophy of science which deals with the nature of knowledge (epistemology), the nature of reality (ontology) and the relationship between the two. Reality is viewed as ultimately objective. yet our ability to approach, perceive and derive meaning from it is continuously constructed and situated by the contexts in which we exist. Realism is thus neither entirely positivist, nor constructivist, but works in between both these positions. Taking a critical realist perspective dismantles the hierarchy of evidence, to treat with equal weight a wide range of data, including experimental evidence as well as rich contextual (qualitative) understanding of meaning Taking this approach also assumes that the objects of investigation have internal mechanisms that produce particular outcomes within situated contexts. The role of the realist evaluator or reviewer is to uncover those mechanisms

8 The underlying philosophy of realism: Realism: a philosophical stance concerning the fallibility of knowledge Positivism Realism Constructivism

9 The Logic Behind Realist Review: What causes something to happen has nothing to do with the number of times we observe it happening (Sayer, 2000 p. 14). Not: does it work or not? But rather, what works, for whom, and in what circumstances? Not the logic of aggregation, rather the logic of configuration

10 Realist reviews vs. Cochrane-style reviews Empirically-focussed systematic reviews (e.g. Cochrane reviews) are more suitable for assessing simple interventions such as drug trials. Empirically-driven systematic reviews are less suitable for assessing complex social interventions......this is because such reviews, which metaanalyse outcomes from multiple studies, have limited capacity in accounting for the effects of culture, community history, geo-political contexts, study design, program theory etc., which characterize complex social interventions

11 What counts as evidence? The realist approach does not exclude studies based on a hierarchy of methodological quality Even bad research can yield good evidence (Pawson 2006)

12 A Realist approach means synthesizing complexity of interventions......to go beyond reportage and summary of existing states of affairs. The point after all is to support fresh thinking to revise policy and launch it in new circumstances (Pawson, p. 74)...from multiple forms of evidence: research findings, author reflections, and description of program processes and contexts....by using abductive reasoning and redaction to synthesize the evidence;...by assuming from the outset that key answers to assessment questions are shrouded in a black box of programmatic unknowns. The goals is to unpack this black box

13 How do you do that? By identifying the basic logic (theory) behind programs under review; By configuring the contextual features and mechanisms which determine outcomes (C-M-O configuring); By refining the theory that was originally identified, based on the CMO synthesis.

14 Identifying the theory: For a realist evaluation of a single case, the underlying logic is understood as program theory. Every program has a theory, whether it is obvious or not For a realist review which synthesizes multiple studies, the underlying theory is considered Middle-range Middle-Range Theory: not abstract to the point of being disconnected from the actual on-the-ground realities of program planning and implementation, yet, not specific to the point of being relevant to only one example in a cohort of cases. Middle-Range Theory According to Merton * : theory involves abstraction, of course, but it is close enough to observed data to be incorporated in propositions that permit empirical testing. * Merton R. On Theoretical Sociology. Five Essays, Old and New. New York: The Free Press, 1967.

15 Context-Mechanism-Outcome Configuring: Context (C) Mechanism (M) Outcome (O) Figure 1: Basic components of realist causal explanation Pawson R, & Tilley N [2003]. Realistic Evaluation. Thousand Oaks, CA: Sage Publications.

16 Understanding Mechanisms: Mechanism may be defined as: underlying entities, processes, or structures which operate in particular contexts to generate outcomes of interest. * Mechanism: Are usually hidden Sensitive to variations in context Generate outcomes For social interventions, mechanism typically refer to a cognitive process or what turns on in the mind of program participants to make them want to participate in the program *Astbury B, Leeuw F. Unpacking Black Boxes: Mechanisms and Theory Building in Evaluation American Journal of Evaluation (3):

17 CMO categories are fluid, flexible and overlapping e.g., Outcome from one CMO can become context of another: Context 1 (c) Context 1 (C) Mechanism 1 (M) Context 2 (C) Mechanism 2 (M) Outcome 1 (O) Outcome 2 (O) timeline Figure 1: Basic components of realist causal explanation

18 From CMO to Demi-Regularities Demi-regularities = What we expect to find in a semipredictable manner: Demi-regularity 3 Demi-regularity 1 Demi-regularity 2

19 Steps in the review process: Step one: identifying the review question Step two: searching the literature A search to track program or middle-range theories A search for primary studies Step three: quality appraisal Assessment of relevance Assessment of rigour Step four: extracting the data Annotation, Collation, Reportage Step five: synthesis Pawson, R. (2006). Evidence-Based Policy: A realist perspective. Sage Publications: London.

20 Step five: possible goals of synthesis: To question program theory integrity; To adjudicate between rival program theories; To consider the same theory in comparative settings; To compare official expectations with actual practice.

21 Example map of CMO configuring:

22 An example of CMO configuring CONTEXT: the Vietnamese Community Health Promotion Partnership (VCHPP) has been in existence for 15 years before the planning of the current intervention. It was already a known and trusted source of health information and it's members were from the community. Additionally, VCHPP staff members came from the community and thus were effective in establishing contacts with community organizations. This capacity led to appropriate choices when research requirements and community priorities conflicted and eased the transfer of decision-making power to the coalition. (Nguyen; p. 50; pa 2) MECHANISM: community trusted the VCHPP due to its previous work and members' insider status. OUTCOME: community agrees to participate in the research; researchers respond to needs of community. For example, during survey development, researchers were sensitive to community concerns to balance the need between asking more questions for research purposes and the need to limit respondent burden." (Nguyen; p. 50; pa 2--p. 40;) CMO: Preexisting relationships and experiences lead to active and relevant partnerships Tung T. Nguyen, Stephen J. McPhee, Ngoc Bui-Tong, Thien-Nhien Luong, Tuyet Ha-Iaconis, Thoa Nguyen,Ching Wong, Ky Q. Lai, Hy Lam. Community-Based Participatory Research Increases Cervical Cancer Screening among Vietnamese-Americans. Journal of Health Care for the Poor and Underserved; 2006, 17:

23 Take home messages... There is no one way to conduct a realist review Context, mechanism, and outcome categories are fluid, overlapping and are closely interrelated; Use review concepts heuristically (i.e., only if useful and relevant) The logic of realism must be understood and adopted in order to carry out synthesis

24 Take home messages continued: Realist Review is a qualitative-style approach, typically requiring small sample of cases for in-depth analysis; Hand-picking and snowball sampling techniques are accepted sampling strategies in realist review. The definitions of quality appraisal and systematic procedure are used differently in realist review as compared to traditional empirical reviews.

25 Publications Commentary: AC Macaulay, J Jagosh, R Seller, J Henderson, M Cargo, T Greenhalgh, G Wong, J Salsberg, LW Green, C Herbert, P Pluye. (2011). Assessing the Benefits of Participatory Research: A Rationale For a Realist Review. Global Health Promotion. 18(2) Protocol: Jagosh J, Macaulay AC, Pluye P, Salsberg J, Sirett E, Bush PL, Henderson J, Greenhalgh T, Wong G, Herbert C, Cargo M, Seifer S, Green LW, (2011). Assessing the Outcomes of Participatory Research: Protocol for Identifying, Selecting, and Appraising the literature. Implementation Science IS, 6, 24. Findings: Jagosh, J., AC. Macaulay, P. Pluye, J. Salsberg, P. Bush, J. Henderson, E. Sirett, G. Wong, M. Cargo, C. Herbert, S. Seifer, L. Green, and T. Greenhalgh. (2012) Uncovering the Benefits of Participatory Research: Implications of a Realist Review for Health Research and Practice. Milbank Quarterly, 90(2),

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