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Emilie Robert The realist approach 2012
 

Emilie Robert The realist approach 2012

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This presentation was given in the frame of a seminar on the realist approach and its application in global health. It was organized by Valéry Ridde and I for the GHR-CAPS program in November 2012 in ...

This presentation was given in the frame of a seminar on the realist approach and its application in global health. It was organized by Valéry Ridde and I for the GHR-CAPS program in November 2012 in Montréal (Canada).

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    Emilie Robert The realist approach 2012 Emilie Robert The realist approach 2012 Presentation Transcript

    • © Robert E., 2012 GHR-CAPS seminars The realist approach and its application in global health (Montréal, November 2012) The realist approach: epistemological foundations and conceptual tools 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 2
    • © Robert E., 2012 1. Grasping the complexity of social interventions What are we talking about? Social phenomena, interactions and interventions 3
    • © Robert E., 2012 1. Grasping the complexity of social interventions Social phenomena are … So are social complex… interventions. SOCIETY •  They are theories. •  They are active. COMMUNITY •  They consist of a series of processes that are thickly populated. INSTITUTION •  They are non-linear and go into feedback FAMILY loops. •  They are embedded into several layers of context and social systems. INDIVIDUAL •  They are leaky and prone to be borrowed. •  They are open systems. Socio-ecological model Adapted from Pawson et al. (2004) 4
    • © Robert E., 2012 1. Grasping the complexity of social interventions The example of user fee exemption policies 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 consist of formulating the policy, implementing the activities by that are thickly populated. different players, monitoring and evaluating etc. are non-linear and go into transform and adapt through the action and the influence of feedback loops. stakeholders. are embedded into several layers are implemented in countries that have different populations living of context and social systems. in different social realities and having distinct worldviews. are leaky and prone to be are implemented in paralell with other health policies that borrowed. 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. Adapted from Ridde et al. (2012) 5
    • © Robert E., 2012 2. Critical realism and generative causation Critical realism in the philosophy of science Positivism Postpositivism Constructivism Ontology ‘Naive’ realism – Critical realism – Relativism – Real but Real reality but only Local and specific apprehendable reality imperfectly apprehendable constructed reality Epistemology Objectivist Objectivity as a ‘regulatory Transactional / Findings true guardian’ subjectivist Critical tradition Created findings Findings probably true Methodology Experimental / ‘Critical multiplism’ Hermeneutical / manipulative Inquiry in more natural settings, dialectical Verification of more situational information, hypotheses soliciting more emic viewpoints Chiefly quantitative Falsification of hypotheses methods Include qualitative methods Adapted from Guba & Lincoln (1994) 6
    • © Robert E., 2012 2. Critical realism and generative causation Generative causation Context (C) MECHANISM: element of the reasoning Mechanism of the actor facing an intervention. (M) A mechanism: Outcome (1) is generally hidden, (O) (2)  is sensitive to context variations (3)  produces outcomes. from Robert et al. (2011) Adapted from Pawson & Tilley (1997) 7
    • © Robert E., 2012 2. Critical realism and generative causation Logic of realist explanation What works? How? For whom? Under what circumstances? Why? « 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) 8
    • © Robert E., 2012 2. Critical realism and generative causation Mode of inquiry DEDUCTIVE REASONING INDUCTIVE REASONING Theory Theory Tentative Hypothesis hypothesis Observation Pattern Confirmation Observation 9
    • © Robert E., 2012 2. Critical realism and generative causation Mode of inquiry RETRODUCTIVE REASONING (ABDUCTION) Theory Observation 10
    • © Robert E., 2012 3. A theory-driven approach Program theory « The theory in question is the set of « Set of hypotheses that explain how beliefs and assumptions that undergird and why the intervention is expected to program activities […] They are the produce outcomes. » hypotheses on which people, from Robert et al. (2011) consciously or unconsciously, build their program plans and actions.» from Weiss (1997) BASIC INTERVENTION THEORY Enhanced Signposting to participant Identify and Reductions in Health services and knowledge, Improvements Reduction in reach target Risk screening health coaching micro- confidence in lifestyle CHD risks population inequalities interventions and understanding 11
    • © Robert E., 2012 INPUTS COMPLEX INTERVENTION THEORY Administrative and financial support during 12 months; UdeM / MoH / MSF-B / ECHO partnership ; human resources; equipments; consumables; infrastructures Participative process PROCESS Implication of target users in Involvement of local Support to the Adaptation and identifying needs for stakeholders in Observatory to produce dissemination of knowledge producing knowledge knowledge knowledge Preparation of protocoles Building of the teams’ Publication of policy briefs Workshop for the by the Observatory teams technical capacities on new knowledge identification of needs for ACTIVITIES knowledge Presentations at local Conduct of studies by the Supervision of the Observatory teams production of knowledge meetings Prioritizing needs for knowledge with Utilization of HIS data Conduct of independant National dissemination Observatory teams studies by UdeM workshopEXPECTED RESULTS Knowledge is useful to The legitimacy of the The credibility of Knowledge is Process target users. Obs. is established. knowlege is ensured. accessible. utilization Better utilization of knowledge in decision-making on user fee exemption measures OBJECTIVE At the At the local At the © Robert, 2011 internat. level national level level
    • © Robert E., 2012 3. A theory-driven approach Middle-range theory « theory that lies between the minor « Level of theoretical abstraction that but necessary working hypotheses provides an explanation of demi- (...) and the all-inclusive systematic regularities in the context – mechanism efforts to develop a unified theory that – outcome interactions of a set of will explain all the observed interventions. » uniformities of social behavior, social from Robert et al. (2011) organization and social change » from Merton (1968) 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) 13
    • © Robert E., 2012 3. A theory-driven approach The elements of realist cumulation THEORY Abstraction Realist approach C M O Middle-range theories C1 M1 O1 C2 M2 O2 C3 M3 O3 Empirical studies identifying C-M-O configurations C1 M1 O1 C2 M1 O1 C3 M1 O1 C4 M1 O2 C3 M1 O2 CA MB OC CD ME OF CG MH OI CJ MK OL Specification DATA 14 Adapted from Pawson & Tilley (1997)
    • © Robert E., 2012 4. Realistic evaluation and realist synthesis RE RR Pawson & Tilley (1997) Pawson (2006) 15
    • © Robert E., 2012 4. Realistic evaluation and realist synthesis 16 Adapted from Pawson and Tilley (1997) and Pawson (2006).
    • Emilie Robert is a Ph.D. student in public health at Montreal University and is a fellowof the Global Health Research Strengthening Program, funded by the CanadianInstitutes of Health Research and the Population Health Research Network of Quebec.Contact: emilie.robert.3@umontreal.ca 17
    • BibliographyMarchal, B., Dedzo, M., & Kegels, G. (2010). A realist evaluation of the management of a well-performingregional hospital in Ghana. BMC health services research, 10, 24. doi:10.1186/1472-6963-10-24Merton, R.K. (1968). On sociological theories of the middle range. In R.K. Merton (Ed.), Social Theory andSocial 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. ERSCResearch 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/9780199563623.003.04Ridde, V., Robert, E., Guichard, A., Blaise, P., & Van Olmen, J. (2012). Théorie et pratique de l’approcheRealist pour lévaluation des programmes. In V. Ridde & C. Dagenais (Eds.), Approches et pratiques enévaluation de programmes: nouvelle édition revue et augmentée (pp. 255–275). Montréal: Les Presses del’Université de Montréal.Robert, E., Ridde, V., Marchal, B., & Fournier, P. (2012). Protocol: a realist review of user fee exemptionpolicies for health services in Africa. BMJ open, 2(1), e000706. doi:10.1136/bmjopen-2011-000706Weiss, K. (1997). How Can Theory-Based Evaluation Make Greater Headway? Evaluation Review, 21, 501. 18