These are the presentations given in the frame of a GHR-CAPS seminar on the realist approach and its application in global health. The seminar was held in Montréal (Canada) in November 2012. Information on the GHR-CAPS program can be found on the following link: http://www.pifrsm-ghrcaps.org/home.html
Emilie Robert Devis de recherche qualitative et mixte 2012
GHR-CAPS seminar on the realist approach
1. The realist approach and its application in global health
Methodological seminar organized by Valéry Ridde and Emilie Robert
Thursday 29th of November 2012
PROGRAM
9 – 9.15 AM Welcome participants
9.15 – 9.30 Introduction of participants and speakers
9.30 – 11.00 Epistemology, theory and concepts of the realist approach
1. The realist approach, epistemological foundations and conceptual tools (Emilie Robert)
2. The concept of ‘mechanism’ from the realist approach: what are we talking about? (Eric
Breton and Anthony Lacouture)
3. Discussion period
11.00 – 12.00 Practical examples of the use of the realist approach in global health
1. Free care in Africa: a realist review of the mechanisms involved in patients’ healthcare-
seeking behaviours (Emilie Robert)
2. Uncovering the benefits of participatory research: implications of a realist review for
health research and practice (Paula Bush)
3. Discussion period
12.00 – 1.00 PM Lunch
The seminar will take place at Université du Québec à Montréal (UQAM):
Room N-7050, Pavillion N (8th floor)
1205, rue St Denis
Montréal
For additional information, please contact:
• Emilie Robert: emilie.robert.3@umontreal.ca
• Anne-Marie Turcotte-Tremblay (GHR-CAPS coordinator):
programmesantecap@gmail.com
2. Speakers:
• Eric Breton is a research professor and currently holds the "Health Promotion" Inpes
Chair (National Institute for Prevention and Health Education) at the Ecole des Hautes
Etudes in Public Health (EHESP) in France. He holds a Ph.D. in Public Health (Health
Promotion) from the University of Montreal.
• Paula Bush is a Ph.D. candidate in the Department of kinesiology and physical education
at McGill University. She holds a scholarship from Participatory Research at McGill
(PRAM).
• Anthony Lacouture is a research engineer with the "Health Promotion" Inpes Chair at the
EHESP in France. He holds a Masters of Public Health with a specialization in evaluation
of actions and health systems (ISPED Bordeaux).
• Valery Ridde is an Associate Professor at the Department of Social and Preventive
Medicine at University of Montreal and a researcher at the Research Centre of the
Centre hospitalier de l'Universite de Montreal (CRCHUM).
• Emilie Robert is a Ph.D. candidate in Public Health at University of Montreal. She is a
senior fellow of the GHR-CAPS program and holds a scholarship from the Fonds de
recherche pour le Québec – Société et Culture.
Required readings:
Astbury, B., & Leeuw, F. L. (2010). Unpacking Black Boxes: Mechanisms and Theory Building in
Evaluation. American Journal of Evaluation, 31(3), 363–381.
doi:10.1177/1098214010371972
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
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
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
Additional readings:
Evans, D., & Killoran, A. (2000). Tackling health inequalities through partnership working:
Learning from a realistic evaluation. Critical Public Health, 10(2), 125–140.
doi:10.1080/09581590050075899
Jagosh, J., Macaulay, A. C., Pluye, P., Salsberg, J., Bush, P. L., Henderson, J., Sirett, E., et al.
(2012). Uncovering the benefits of participatory research: implications of a realist review for
health research and practice. The Milbank quarterly, 90(2), 311–46.
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.
23. 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
21
24. Bibliography
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. (2009). 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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25. To view this presentation on Prezi, please consult the following link: 1
http://prezi.com/6fgvsoch6kf1/the-‐concept-‐of-‐mechanism-‐from-‐the-‐realist-‐approach-‐what-‐are-‐we-‐talking-‐about/
47. Project Partnership:
Academic Co-Applicants and Trainees:
! Ann C. Macaulay, Pierre Pluye, Jon Salsberg, Justin Jagosh, Jim Henderson,
Robbyn Seller, Erin Sirett, Paula L. Bush, Geoff Wong, Trish Greenhalgh,
Margaret Cargo, Carol P. Herbert, Lawrence W. Green.
Knowledge-User Co-Applicants:
! Sarena Seifer, Susan Law, David Clements, Marielle Gascon-Barré, David L.
Mowat, Sylvie Stachenko, Sylvie Desjardins, Ilde Lepore.
Acknowledgements:
This review and post-doctoral fellows Drs. Jagosh and Seller, were supported by a Canadian
Institutes of Health Research KT-Synthesis Grant (# KRS-91805), funding from Participatory
Research at McGill (PRAM), and the Department of Family Medicine, McGill University.
We also thank David Parry BA (Hons) for his comments on the grant proposal.
48. Presentation Outline
! Working definition of participatory research;
! Middle range theory
! Findings (Demi-regularities 1-7)
! So what?
52. Middle Range Theory: Challenge # 2
Partnership synergy theory (Lasker, Weiss, & Miller, 2001)
! Combining the perspectives, resources, and skills of a group
of people to “create something new and valuable together—
a whole that is greater than the sum of its individual parts.”
! Applied to participatory health interventions, the theory holds
that multiple stakeholder collaboration creates or enhances
research outcomes beyond what could be achieved by a
single person or organization working under similar
conditions
53. Demi-regularity 1
PR generates culturally and logistically appropriate research
characteristics related to:
! Shaping the scope and direction of research
The coalition members acknowledged widespread
! Developing program and research protocols
problems associated with community-based research,
! Implementing program and research protocols
particularly research conducted in communities of color
! Interpreting and disseminating research findings
by predominantly white researchers (context).
They demonstrated sensitivity (mechanism) to this
history of mistreatment and, through mutual respect
(mechanism), used their collective expertise to identify a
locally relevant research agenda (outcome).
54. Demi-regularity 2
PR generates capacity to recruit:
! community members to the advisory board
! community members for implementation
! community members as recipients of programs
Despite the difficult experiences at the end of life (C),
residents at the facility felt safe (M) participating, with the
assurance of the endorsement from the nursing staff,
which generated very high enrollment (O).
55. Demi-regularity 3
PR generates the capacity of:
! the community partners
! the academic partners
The partnership offered formal and informal opportunities for
training (C) that community health workers recognized and
valued (M), which resulted in a sense of empowerment (O)
and a search for additional training and employment
positions (O).
The partnership provided opportunities and experiences for
academic partners to learn how to collaborate (C), which
they valued (M), resulting in their developing new and
informed perspectives on community knowledge and
leadership (O).
56. Demi-regularity 4
PR generates disagreements between the co-governing
stakeholders during decision-making processes, resulting in:
! positive outcomes for subsequent programming
! negative outcomes for subsequent programming
Stakeholders had no prior history together and lacked established trust
in the group (C). Academic researchers were also unaware of
community interests (C). By recognizing the value of coming to
consensus on a research focus (M), the researchers were able to
create a change in direction and a new agenda to focus on health
promotion/disease prevention efforts in the community (O). New trust
was built among coalition members from the consensus-building
process (O).
57. Demi-regularity 5
PR synergy accumulates in cases of repeated successful
outcomes in partnering, thus increasing the quality of
outputs and outcomes over time
C1-M1-O1 C2-M2-O2 C3-M3-O3
58. To overcome barriers to conducting a community RCT, a decision was
made at the outset to hire only African-Americans familiar with the
community as project staff (C1).
Because of their prior history in the community, the project staff were
glad to assist community members beyond the scope of the study (M1).
This led to the staff’s greater investment in the project (O1-C2) which led
to community members’ trust in the project (M2), resulting in closer
interactions between the staff and the community (O2-C3); leading to a
greater sense of trust and safety (M3), and thus some participants
revealed their desire to now enroll in the project (O3). This led to new
methods of recruitment being developed and higher than expected
enrollment (O3-C4).
This added to the project stakeholders’ desire to overcome attrition
obstacles (M4).
As a result, a new capacity to retain participants and prevent attrition in
a complex clinical trial was created in a mobile population by addressing
problems as they arose and through the project stakeholders’ increasing
sense of motivation, trust, and co-ownership of the project (O4).
59. Demi-regularity 6
Partnership synergy accumulates capacity to sustain
project goals beyond funded time frames and during gaps
in external funding
The involvement of trained lay health workers and church
groups who implemented the weight-loss intervention gained
leadership and expertise on weight-loss issues affecting their
community (C).
They felt inspired (M) to continue working for this cause after
the project ended, resulting in strengthened ties with one
another and other church organizations (O).
60. Demi-regularity 7
PR generates systemic changes and new unanticipated
projects and activity
From the success of the project (C), coalition members were motivated
to advocate system changes for cancer prevention in the Vietnamese
community (M), which had a lasting effect beyond immediate
intervention (O).
Project TEAL was very successful in acquiring high-quality, credible
scientific data (C). The coalition members wanted to capitalize on this
success (M) to work with other groups on lead poisoning prevention (O)
and to plan a book and documentary on their experiences (O).
In the context of an open and responsive partnership that encouraged
community members to contribute to the program’s design (C), elders
in the community felt safe and supported (M) in forming an elders’
council (O), which led to better cultural education of service staff (O),
and self-empowerment of the elders (O)
61. :#&3%;/*"#3&';%,<%
+#)$&*&+#$&,3%
PR stakeholders’ recognizing and valuing the
collective knowledge, resources, relationships, and
capacity through the alignment of purpose, values,
and goals.
Once established, such an alignment becomes a
feature of the research context in which partnerships
operate.+
62. So what?
! Our findings confirm what had been previously noted
regarding improved research quality and capacity
building in PR. (Demi regularities 1-3)
! We uncovered new benefits (Demi regularities 4-7)
! productive conflict and negotiation;
! long-term synergy building (the positive outcome of
one stage leads to a better context for the next);
! ability to mitigate funding gaps, invoke sustainability,
and extend programs;
! create new unanticipated projects and activity.
64. Findings:
Jagosh J, Macaulay AC, Pluye P, Salsberg J, Bush PL, Henderson J, Sirett E, Wong
G, Cargo M, Herbert CP, Seifer SD, Green LW, Greenhalgh T. Uncovering the
Benefits of Participatory Research: Implications of a Realist Review for Health
Research and Practice. Milbank Quarterly, 90(2) (in press for June 2012). 2012
Commentary:
AC Macaulay, J Jagosh, R Seller, J Henderson, M Cargo, T Greenhalgh, G Wong, J
Salsberg, LW Green, C Herbert, P Pluye. Benefits of Participatory Research: A
Rationale For a Realist Review. Global Health Promotion. 18(2) : 45-48. June. 2011
Protocol:
J Jagosh, P Pluye, AC Macaulay, J Salsberg, J Henderson, E Sirett, PL Bush, R Seller,
G Wong, T Greenhalgh, M Cargo, CP Herbert, SD Seifer, LW Green. Assessing the
Outcomes of Participatory Research: Protocol for Identifying, Selecting and Appraising
the Literature for Realist Review. Implementation Science, 6(24). 2011
84. 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
Valéry Ridde is a associate professor at Montreal University and a researcher at the
Research Center of Montreal University Hospital Center (CRCHUM).
Acknowledgments to the research team:
• Abel Bicaba, RESAO
• Pierre Fournier, CRCHUM
• Guy Kegels, ITM Antwerp
• Bruno Marchal, ITM Antwerp