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).

1. © 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

2. © 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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3. © Robert E., 2012
1. Grasping the complexity of social
interventions
What are we talking about?
Social phenomena,
interactions and interventions 3

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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)
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5. © 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

6. © 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)
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7. © 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)
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8. © 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)
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9. © 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
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10. © Robert E., 2012
2. Critical realism and generative
causation
Mode of inquiry
RETRODUCTIVE REASONING
(ABDUCTION)
Theory
Observation
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11. © 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
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12. © 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 workshop
EXPECTED
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

13. © 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

14. © 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
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Adapted from Pawson & Tilley (1997)

15. © Robert E., 2012
4. Realistic evaluation and realist
synthesis
RE RR
Pawson & Tilley (1997) Pawson (2006)
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16. © Robert E., 2012
4. Realistic evaluation and realist
synthesis
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Adapted from Pawson and Tilley (1997) and Pawson (2006).

17. 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: emilie.robert.3@umontreal.ca
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Merton, R.K. (1968). On sociological theories of the middle range. In R.K. Merton (Ed.), Social Theory and
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Pawson, R. (2004). Evidence-based Policy: A Realist Perspective. London: SAGE Publications.
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