Building Realist Program Theory for Interventions for Vulnerable Children and Families in Sydney, Australia

Abstract

Introduction: We have previously reported on the study design and findings of a critical realist multi-level mixed method study in Sydney Australia that constructed a middle-range theoretical framework with realist causal propositions and models explaining neighbourhood context, stress, depression and the developmental origins of health and disease (1). The purpose of this study is to describe middle range program theory that draws on that study and other extant works. Theory/Methods: Realist causal propositions are described drawing on our previous work, and extant social theory. Published literature and abstract thinking (i.e. abduction, retroduction) was used to propose program mechanisms which if applied may improve outcomes. Based on this analysis, intervention activity and design elements are proposed. The programme design propositions and hypotheses will be expressed, in realist terms, as context-intervention-mechanisms and outcome (CIMO) conjectures, which will thus render the full constituents of the programme theory. Results: Causal mechanisms analysed included: expectations, loss, being alone, lifetime trauma, discrimination, mastery, sense of control, mattering, trust, isolation, access to services, information literacy, social capital, social exclusion. Preliminary realist program mechanisms were identified that have the potential to improve outcomes for vulnerable families in metropolitan Sydney. Program mechanisms identified included: family-peer trust, family-provider trust, willingness to share power, co-operation, Information, building self-help skills. Examples of intervention activities that might deliver these program mechanisms include: strengthening peer and family support, client centred workers, home visiting, and telephone support. Design Elements identified included: wrap around services, place-based initiatives, Care coordination, sustained nurse home visiting, family group conferencing, targeted parenting, social media, and workforce training. Discussion: We have used critical realist meta-theory to assist in the translation of previously reported empirical explanatory theory building to theory driven interventions. We will situate these interventions in the socially disadvantaged regions of Sydney where the local child and family inter-agencies are collaborating to design and implement new programme interventions based on earlier studies of perinatal, child, youth and family outcomes. Conclusions: The analysis described here seeks to bridge the translational research gap from theory building to program design and subsequent theory testing. The study demonstrates the application of the Confirmatory Phase of our previously described Explanatory Theory building Method (1). Lessons learned: In undertaking this study we identified that it is important to include a wide range of domains of reality including: biological, psychological, psychosocial, situated setting, service context, culture, and macro-organisation. It is also important to analyse both horizontal and vertical mechanism across those domains. Limitations: In undertaking this study we identified a complex range of relevant middle range causal theories. It proved necessary to limit the analysis to a selected number of relevant causal theories. Suggestions for future research: The analysis identified a lack of realist evaluation and realist synthesis studies from which to identify relevant integrated care program theory for interventions with vulnerable families.