This 75 minutes workshop was given at the 22nd IUHPE World Conference on Health Promotion in Curitiba (Brazil) in May 2016.

1.
Using the realist approach to evaluate
public health policies with a health
promotion perspective
Concepts and keys to initiate a realist evaluation
IUHPE conference| Curitiba | 2016
Emilie Robert, Valéry Ridde, Ketan Shankardass, Anthony Lacouture, Emilie Renahy

2. The trainers
Emilie Robert
Postdoctoral fellow
(McGill University)
Contact:
emilierobert.udem@
gmail.com
Twitter:
@emilie_robert_
Valéry Ridde
Professor
(University of
Montreal)
Contact:
valery.ridde@
umontreal.ca
Twitter:
@ValeryRidde
Ketan Shankardass
Associate
professor (Wilfried
Laurier University)
Contact:
kshankardass@
wlu.ca
Anthony Lacouture
Ph.D. candidate
(University of
Montreal / EHESP)
Contact:
anthony.lacouture@
umontreal.ca
Twitter:
@Anthony_Lact
IUHPE conference| Curitiba | 2016

3. Objectives of the workshop
• Generative causation
• Middle-range theory & intervention theory
• Mechanism
To clarify some of the
main concepts of the
realist approach
• Group work 1 on theories
• Group work 2 on C-M-O configurations
To apply these
concepts
• Tips / questions to ask before starting
• Reading recommendations
To provide keys to
initiate a realist
evaluation
IUHPE conference| Curitiba | 2016

4. (Adapted from World Health Organization, 2013)
Why is the realist approach useful for health
promotion research?
IUHPE conference| Curitiba | 2016
In All Policies

5. Health
Education
Transport
Taxation
Housing
Policy “silos”
• Unique budgets
• Unique mandates
Health
Education
Transport
Taxation
Housing
IUHPE conference| Curitiba | 2016
The challenge for health promotion researchers in
studying HiAP implementation
“Integrated governance”
• Shared budgets
• Overlapping mandates

6. A focus on the development of middle-range theory to
understand what works, for whom, in what circumstances and
why.
v Acknowledgement of interventions as complex adaptive
systems
v Explanations for how and why HiAP governance structures
and strategies work (and don’t work) in unique case settings
(think: context)
v Recognition of a plurality of outcomes related to success/
failure of HiAP implementation
IUHPE conference| Curitiba | 2016
The value of scientific realism in studying the
implementation of HiAP

7. Scientific realism
• The external world exists independently of our sense
experience, ideation, and volition.
Ontology
(nature and form of reality)
• The external world is only perceptible through our
senses.
• Our knowledge of it is thus partial and progressive.
Epistemology
(nature of the relationship
between the researcher and
knowledge)
• Research takes place in natural contexts.
• It takes into account the emic perspective.
• Both quant. & qual. methods are useful.
Method
(research means to acquire
knowledge)
IUHPE conference| Curitiba | 2016

8. • Causal tendencies in the
occurrence of an outcome in a
specific context, through the
firing of a mechanism from an
intervention!
• An intervention does not
« work » in itself and does not
produce outcomes on its own.
Generative causation
Context A
Outcome 1
Intervention
Outcome 2
Context A
M1
Context B
Outcome 2
M2
IUHPE conference| Curitiba | 2016

9. • Objective of a realist evaluation:
Ø To identify tendencies in the
interactions between contexts,
mechanisms and outcomes, in
empirical data
• Objective of realist review:
Ø To identify tendencies in the
interactions between contexts,
mechanisms and outcomes, in
published articles, reports,
newspapers…
Realistic evaluation and realist review
Outcome
Mechanism
Context
IUHPE conference| Curitiba | 2016

10. • Starting point: an intervention theory
• End product: a middle-range theory
A theory-based evaluation approach
Group work 1!
Categorize the suggested theories
according to the typology:
Middle-range theory (MRT)
Intervention theory (IT)
Grand theory (GT)
IUHPE conference| Curitiba | 2016

11. Answers to Group work 1
Grand theories
Middle-range theories
Program theories
Habitus theory from Bourdieu
(Theory 1)
Systemic functionalism (theory
of social action) from Parsons
(Theory 3)
Partnership synergy applied to
participatory health interventions from
Jagosh et al (Theory 2)
Contextual influences on HiaP
implementation from Shankardass et
al (Theory 5)
Free health care seeking theory in
sub-Saharan Africa from Robert et al
(Theory 6)
Obervatories of free care
policies (Theory 4)
Influence of prior
experience with
intersectoral action on
implementation of HiaP
(Theory 7)
Meeting for Care and
Nuisance strategies
(Theory 8)
IUHPE conference| Curitiba | 2016

12. Different types of theories
• “Hypotheses on which people, consciously or
unconsciously, build their program plans and
actions.” (Weiss, 1997)
Program theory
• “Basic, usable structure of ideas, less abstract
than grand theory, and more abstract than
empirical generalizations or micro-range
theory.” (Stinchcombe, 1968, quoted by Moore et al., 2012)
Middle-range
theory
• “Unified theory that will explain all the observed
uniformities of social behavior, social organization,
and social change.” (Merton, 1969)
Grand theory
Ladderofabstraction
What about the Theory of Change? Or the Implementation Theory? Or the Logic Model?
IUHPE conference| Curitiba | 2016

13. • Step 1: developing the intervention theory with stakeholders, trying to
answer the following question: How is the intervention supposed to
work?
• Step 2: suggesting hypotheses to explain how the intervention is
supposed to produce the expected outcomes in certain contexts,
through the firing of mechanisms (initial middle-range theory).
• Step 3: testing hypotheses and refining the theory to clarify
interactions between contexts, mechanisms and outcomes (refined
middle-range theory)
From the starting to the end point of a realistic
evaluation
IUHPE conference| Curitiba | 2016

14. It is hidden but real.
It produces outcomes.
It is an element of reasoning and reactions of (an) individual or collective
agent(s) in regard of the resources available in a given context to bring
about changes through the implementation of an intervention.
It evolves within an open space-time and social system of relationships.
Lacouture et al. (2015)
The concept of mechanism
IUHPE conference| Curitiba | 2016
NOT a strategy nor an activity!

15. Examples
ACTORS
RESOURCES
• Promoting reflection
• Taking control
• Increasing motivation, interest and
satisfaction
• Building and increasing confidence
• Promoting mutual support
• Gaining acceptance of new information
• Creating a sense of belonging and respect
• Empowering subjects
• Etc.
Participation; Collaboration;
Partnership; Management
processes; Etc.
INTERVENTION
(Lacouture et al, 2015)
Mechanisms
Strategies
(M)
IUHPE conference| Curitiba | 2016
(C)
(O)

16. Identify patterns of interactions between C-M-O
Group work 2!
IUHPE conference| Curitiba | 2016

17. Identify patterns of interactions between C-M-O
Group work 2!
IUHPE conference| Curitiba | 2016
Tip 1: Start to look for an outcome or your
outcome of interest.

18. Identify patterns of interactions between C-M-O
Group work 2!
IUHPE conference| Curitiba | 2016
Tip 1: Start to look for an outcome or your
outcome of interest.
Tip 2: Remember the hidden nature of the
mechanism.

19. Wong et al., 2013
IUHPE conference| Curitiba | 2016
The hidden nature of the mechanism

20. Support to graphic design : Naira Santana http://www.atelierpaloma.com
IUHPE conference| Curitiba | 2016
We would like to acknowledge the contribution of our
colleagues in preparing the material for this training.
- Pierre Pluye, U. McGill