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 (8 th floor) 1205, rue St Denis Montréal For additional information, please contact: • Emilie Robert: [email protected]• Anne-Marie Turcotte-Tremblay (GHR-CAPS coordinator): [email protected]
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
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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:
• 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.
The realist approach: epistemological foundations and conceptual tools
GHR-CAPS seminars
The realist approach and its application in global health (Montréal, November 2012)
1. Grasping the complexity of social interventions
Social phenomena are complex…
… So are social interventions.
5
SOCIETY
COMMUNITY
INSTITUTION
FAMILY
INDIVIDUAL
Socio-ecological model
• They are theories. • They are active. • They consist of a series of processes that are thickly populated. • They are non-linear and go into feedback loops. • They are embedded into several layers of context and social systems. • They are leaky and prone to be borrowed. • They are open systems.
1. Grasping the complexity of social interventions
The example of user fee exemption policies
6 Adapted from Ridde et al. (2012)
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 that are thickly populated.
consist of formulating the policy, implementing the activities by different players, monitoring and evaluating etc.
are non-linear and go into feedback loops.
transform and adapt through the action and the influence of stakeholders.
are embedded into several layers of context and social systems.
are implemented in countries that have different populations living in different social realities and having distinct worldviews.
are leaky and prone to be borrowed.
are implemented in paralell with other health policies that 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.
Ontology ‘Naive’ realism – Real but apprehendable reality
Critical realism – Real reality but only imperfectly apprehendable
Relativism – Local and specific constructed reality
Epistemology Objectivist Findings true
Objectivity as a ‘regulatory guardian’ Critical tradition Findings probably true
Transactional / subjectivist Created findings
Methodology Experimental / manipulative Verification of hypotheses Chiefly quantitative methods
‘Critical multiplism’ Inquiry in more natural settings, more situational information, soliciting more emic viewpoints Falsification of hypotheses Include qualitative methods
MECHANISM: element of the reasoning of the actor facing an intervention. A mechanism: (1) is generally hidden, (2) is sensitive to context variations (3) produces outcomes.
« 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)
What works? How? For whom? Under what circumstances? Why?
« Set of hypotheses that explain how and why the intervention is expected to produce outcomes. » from Robert et al. (2011)
« The theory in question is the set of beliefs and assumptions that undergird program activities […] They are the hypotheses on which people, consciously or unconsciously, build their program plans and actions.» from Weiss (1997)
BASIC INTERVENTION THEORY
Identify and reach target population
Risk screening Health coaching
Signposting to services and
micro-interventions
Enhanced participant knowledge, confidence
and understanding
Improvements in lifestyle
Reduction in CHD risks
Reductions in health
inequalities
from Pawson & Sridharan (2009)
Building of the teams’ technical capacities
Utilization of HIS data
The legitimacy of the Obs. is established.
Better utilization of knowledge in decision-making on user fee exemption measures
The credibility of knowlege is ensured.
Process utilization
National dissemination workshop
Conduct of studies by the Observatory teams
Adaptation and dissemination of
knowledge
Support to the Observatory to produce
knowledge
Involvement of local stakeholders in
producing knowledge
Knowledge is accessible.
Supervision of the production of knowledge
Administrative and financial support during 12 months; UdeM / MoH / MSF-B / ECHO partnership ; human resources; equipments; consumables; infrastructures
EXPE
CTE
D
RES
ULT
S O
BJE
CTI
VE
Prioritizing needs for knowledge with
Observatory teams
PRO
CES
S
Implication of target users in identifying needs for
knowledge
Preparation of protocoles by the Observatory teams
Middle-range theory « Level of theoretical abstraction that provides an explanation of demi-regularities in the context – mechanism – outcome interactions of a set of interventions. » from Robert et al. (2011)
« theory that lies between the minor but necessary working hypotheses (...) and the all-inclusive systematic efforts to develop a unified theory that will explain all the observed uniformities of social behavior, social organization and social change » from Merton (1968)
« 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. »
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.
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.
22
Bibliography
1 To view this presentation on Prezi, please consult the following link: http://prezi.com/6fgvsoch6kf1/the-‐concept-‐of-‐mechanism-‐from-‐the-‐realist-‐approach-‐what-‐are-‐we-‐talking-‐about/
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.
Presentation Outline
! Working definition of participatory research;
! Middle range theory
! Findings (Demi-regularities 1-7)
! So what?
PR
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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
Demi-regularity 1
PR generates culturally and logistically appropriate research characteristics related to:
! Shaping the scope and direction of research
! Developing program and research protocols
! Implementing program and research protocols
! Interpreting and disseminating research findings
The coalition members acknowledged widespread problems associated with community-based research, particularly research conducted in communities of color 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).
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).
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).
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).
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
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).
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).
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)
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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.+
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.
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
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
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
Gratuité des soins de santé en Afrique
Emilie Robert Valéry Ridde
GHR-CAPS seminars
The realist approach and its application in global health (Montréal, November 2012)
! Les pays d’Afrique abolissent les paiements directs dans le secteur de la santé pour améliorer l’accès aux soins. " ‘an official reduction in direct payments for health care, which is targeted
by group, area or service’ (Witter, 2009)
" Plus de 15 pays africains concernés (Robert & Samb, in press)
" Un corpus de données scientifiques hétérogène (Ridde & Morestin, 2010)
! Les revues systématiques traditionnelles n’ont donné qu’un aperçu limité. " Centré sur l’efficacité des interventions " Exclusion des études utilisant des méthodes considérées ‘moins robustes’ " ‘Most studies included in this review suffered from serious methodological
! Planification de la politique et mise en oeuvre (exemples) Fonctions du
système de santé Pressions exercés sur le système de santé
Information sanitaire
Manque d’information sur le nombre et le type de services fournis dans les formations sanitaires et sur le montant des remboursements
Médicaments et vaccins
Problèmes de disponibilité des médicaments Médicaments insuffisants et kits qui ne répondent pas aux besoins Délais et sous-distribution des consommables
Financement Financement imprévisible, insuffisant et discontinu Réintroduction des paiements pour les services et les médicaments Délais de remboursement
Gouvernance
Planification et communication déficientes; mauvaise compréhension des PEP Supervision inadéquate Complexité des procédures de financement
Ridde, Robert et al, 2012
Ces éléments (C) contribuent à influencer les attitudes du personnel de santé et de la population.
! Observance du personnel de santé (exemples) Comportements et attitudes Exemples de données empiriques
Adhésion à / satisfaction des PEP
Inquiétudes / insatisfaction liées aux termes de la politique
"It was reported that registration fees were too low, were often insufficient to meet the running costs of the facility, and that budgetary allocations from the government were inadequate" (Chuma, 2009)
Insatisfaction liées aux retombées professionnelles et/ou personnelles
"... increased workloads were seen to have had direct negative effects at a personal level for the majority of nurses" (Walker, 2004)
Insatisfaction liée à la mise en œuvre
"They do not reject the policy or its goals so much as expressing concern about the direct impacts they perceive it to have had on them and the processes through which it has been implemented." (Nimpagaritse, 2011)
Stratégies d’adaptation
Ajustement des prix des services
"... policy modification was by fully exempting some children from all fees while others received a partial or no exemption." (Agyepong, 2010)
Ces éléments (C) contribuent à influencer les comportements et attitudes de la population.
Les délais et l’imprédictibilité dans le financement de la politique au niveau des formations sanitaires (remboursement ou distribution des intrants) (C) encourage le personnel de santé à adjuster le prix des services de santé (strategie d’adaptation -M). En conséquence, les usagers ne bénéficie pas systématiquement de la gratuité des soins(O).
"After the introduction of the exemptions, funds did not suffice to buy all the drugs needed and the management team at Muramvya Hospital decided that children under 5 simply could not be offered free care at the hospital outpatient clinic. […] Therefore, these financial issues did not allow for the provision of drugs for free to ambulatory patients under 5, although this was included in the announced reform. " (Nimpagaritse, 2011)
L’ajustement du prix des services de santé par le personnel (C) entraîne les usagers à se protéger des coûts potentiels liés au recours aux soins (M) et limite ainsi leur opportunité à bénéficier des services de santé(O).
"Inconsistent patterns of public service uptake and partial protection from direct costs were, finally, also influenced by specific health service weaknesses including drug […] exemption implementation failures at hospitals" (Goudge, 2009)
L’augmentation de l’utilisation des services de santé par les patients associé aux défaillances de mise en œuvre (C) entraîne un détérioration de l’enthousiasme initial du personnel de santé pour les PEP (M), ce qui contribue notamment à la détérioration de leur relation avec les usagers (O).
" The increase in patient load and reduced drug supply made nurses’ relationships with their patients very difficult ." (Walker, 2004)
! Dans la mesure où elles sont combinées à d’autres mesures ciblant d’autres barrières à l’accès aux soins, les PEP ont un potentiel fort de produire les effets attendus.
! Les défaillances de mise en œuvre compromettent la propension des usagers à recourir aux soins de santé moderne du fait de l’incertitude et de la défiance.
! La théorie du ‘street-level bureaucracy’ et les déterminants du recours aux soins fournissent les pièces manquantes pour comprendre comment les PEP fonctionnent.
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.