Realist Methodology Research Articles

Critical realist approaches to global learning: A focus on education for sustainability

Critical realism offers a useful epistemology and ontology for conceptualizing theoretical and methodological considerations in global learning and may help to bridge the quantitative/qualitative divide that plagues social science. This article elaborates critical realist principles, concepts and methodologies to explain how they can be employed within global learning, with examples from education for sustainability.

Supporting Resident Research Learning in the Workplace: A Rapid Realist Review.

Residents are increasingly expected to engage in practice-based research; however, engagement in research whilst also fulfilling clinical duties is often challenging. Evidence suggests that residents require specific developmental experiences, along with clinical practice, to become effective researchers. The authors therefore conducted a rapid realist review to explore strategies and key mechanisms supporting effective resident research activities in clinical settings. They examined relationships amongst different clinical contexts, learning mechanisms, and research engagement outcomes to provide evidence-based, theory-informed recommendations for improving resident research engagement and extending understandings of workplace learning in health care settings. In 2015-2016, the authors used a rapid realist methodology informed by workplace learning theory to review international literature published between January 2005 and December 2015. The review drew upon sources from OVID Medline, ERIC, Embase, and AustHealth. The authors screened articles for eligibility using inclusion criteria and appraised articles using realist review quality criteria. The authors included 51 articles in the review. The review process identified three key mechanisms for effective integration and support of resident research engagement, as informed by workplace learning theory: (1) opportunities to engage in practice-informed research supported by longitudinal curricula, (2) guidance by clinician-researchers, and (3) assessing residents' research readiness and promoting their intentionality for engagement. This review extends existing literature and informs workplace-based research engagement strategies for residents whilst demonstrating the applicability of workplace learning theory to improving residents' research engagement. The authors propose a learning model to support effective resident research engagement through clinical practice.

Realist Research Design and Evaluation for Integrated Care SIG (RIC) - Part 2: Realist Quantitative Methods for Integrated Care Design and Evaluation

Background: Realist research methodology is increasingly being used for the design and evaluation of integrated care initiatives. Much of current realist research and evaluation is qualitative in nature and yet many realist methodologists, including Pawson, Tilley, Sayer and Olsen, have argued for the use of mixed methods. There remains much debate regarding the role of quantitative methods, including statistics, within a critical realist philosophical framework. For many realist researchers the use of quantitative methods is both a philosophical and methodological stumbling block. Yet quantitative methods can contribute to realist theory building,, design and theory testing through their ability to use observable events to infer the existence of underlying mechanisms and to detect changes in both context and outcomes. This workshop will examine debates about the use of quantitative methods in realist research and evaluation, either as part of a mixed-method design or on their own. Examples of their use for both theory development and theory testing will be provided. The workshop will provide practical demonstration of the use of quantitative methods for both small and large scale studies. Knowledge, techniques and practices to be addressed include: The philosophical debates concerning the use of quantitative methods for realist research and evaluation Quantitative methods used for explanatory theory building research Construction of quantitative tools from qualitative data Quantitative methods used for evaluation and theory testing Application of quantitative methods within realist mixed method study designs Practical application of quantitative analysis to infer mechanistic action. By the conclusion of the workshop, participants should be able to: Understand the philosophical rejection of quantitative methods for both natural and social scientific realms Determine how to interpret quantitative methods and incorporate them into realist research and evaluation while maintaining a distinction between method and methodology Describe quantitative methods for inclusion in realist mixed method research and/or evaluation study designs Undertake practical realist analysis of quantitative study data using simple statistical methods. Aims and Objectives: 1) To examine debates about the use of quantitative methods in realist research and evaluation, either as part of a mixed-method design or on their own. 2) To demonstrate the use of realist quantitative methods for both integrated care design and evaluation. Format: 90 minutes, one speaker and facilitator, Group work at tables using problem-based learning. Discussion, debate and learning resources. Target Audience: Integrated care design and evaluation practitioners and researchers. Qualitative and quantitative researchers. Mixed methodologists. Learning and Takeaway: Increased understanding of how quantitative methods can be appropriately used with realist methodology. Introduction to the use of advanced quantitative methods for design and evaluation of integrated care initiatives including latent class analysis, latent variable pathways, and discontiuity quasiexperimental designs.

Realist Research Design and Evaluation for Integrated Care RIC SIG - Part 1: Establishing a Special Interest Group

Background: Realist philosophy and methodology is increasingly being explicitly used in the field of integrated care to research the extant context, structure and mechanisms at play, and to design and evaluation interventions. Philosophic realism is the view that entities exist independently of our perception or our theories about them. While the realist philosophy underpins much of modern health and social science, it is only recently that this philosophical approach has been popularised within main stream health and social science literature. Realist research methodology is increasingly being described in research areas that are relevant to the study of integrated care, namely, organisational management, information science, social epidemiology, economics, and health services evaluation. Importantly realist approaches are increasingly being used in mixed method research designs and to elucidate the processes at play in experimental and quasi-experimental studies. Realist researchers seek to explain the underlying “cause” or mechanisms that generate observed phenomenon. The realist understanding of how the world is ontology includes the notion of a hidden or “real” domain where mechanisms generate forces that result in the phenomena which we observe. Realists also view the world as consisting of strata or layers of reality which may interact with other layers to produce new mechanism. This approach is proving useful for studying and developing theory about complex health and social care systems, and then designing and evaluating possible interventions. Over the last number of years a number of realist studies have been presented at the International Foundation of Integrated Care conferences including: realist studies of context and mechanisms; realist design of integrated care interventions; realist synthesis of literature; and realist evaluations of integrated-care interventions. The methodologies, and the dialectical debates, are complex, and therefore, deserving of special consideration within the Integrated Care community. This preliminary workshop will support evaluators and researchers to use realist methods in integrated care and other complex evaluations. Because realist evaluation was initially developed using smaller-scale programs, methods need to be modified for large scale programs, while remaining consistent with underlying methodological principles. The workshop will discuss the value of and the dilemmas involved in using realist methods for large and complex programs, and demonstrate strategies to address the dilemmas. Aims and Objectives: 1- Present and discuss the basic tenants of realist research, design and evaluation as it applies to the large scale and complex programs such as integrated care 2- Discuss the scope and purpose of a Realist Research, Design and Evaluation for Integrated Care Special Interest Group RIC-SIG 3- Modify the scope and purpose of a Realist Research, Design and Evaluation for Integrated Care - SIG Format: Group Discussion Target Audience: Integrated care practitioners and researchers who are familiar with realist research including the current focus on critical realism and realist evaluation Learning and Takeaway: The workshop will define the scope and purpose of a SIG for Realist Research, Design and Evaluation for Integrated Care

Knowledge translation for realist reviews: a participatory approach for a review on scaling up complex interventions

BackgroundKnowledge syntheses that use a realist methodology are gaining popularity. Yet, there are few reports in the literature that describe how results are summarised, shared and used. This paper aims to inform knowledge translation (KT) for realist reviews by describing the process of developing a KT strategy for a review on pathways for scaling up complex public health interventions.MethodsThe participatory approach used for the realist review was also used to develop the KT strategy. The approach included three main steps, namely (1) an international meeting focused on interpreting preliminary findings from the realist review and seeking input on KT activities; (2) a targeted literature review on KT for realist reviews; and (3) consultations with primary knowledge users of the review.ResultsThe international meeting identified a general preference among knowledge users for findings from the review that are action oriented. A need was also identified for understanding how to tailor findings for specific knowledge user groups in relation to their needs. The literature review identified four papers that included brief descriptions of planned or actual KT activities for specific research studies; however, information was minimal on what KT activities or products work for whom, under what conditions and why. The consultations revealed that KT for realist reviews should consider the following: (1) activities closely aligned with the preferences of specific knowledge user groups; (2) key findings that are sensitive to factors within the knowledge user’s context; and (3) actionable statements that can advance KT goals, activities or products. The KT strategy derived from the three activities includes a planning framework and tailored KT activities that address preferences of knowledge users for findings that are action oriented and context relevant.ConclusionsThis paper provides an example of a KT strategy for realist reviews that blends theoretical and practical insights. Evaluation of the strategy’s implementation will provide useful insights on its effectiveness and potential for broader application.

How, and why, does capitation affect general dental practitioners' behaviour? A rapid realist review

From a formal evaluation of a capitation-based NHS dental contract, as part of a National Institute of Health Research funded project (HS&DR 14/19/12), data collected from a series of qualitative interviews suggest that general dental practitioners may behave differently in ways that vary from the results of previous studies. Drawing on realist methodology, a rapid realist review was conducted, enabling a programme to be developed to explain the effect of a capitation pilot on NHS dentists working in primary care. In essence, the theory postulates that general dental practitioners are affected by a number of competing interests and incentives and that this can influence their behaviour in a variety of ways. For example, a capitation-based contract may result in some general dental practitioners focusing more on prevention, as opposed to treatment, but for others it may not. It may, in practice, disincentivise some general dental practitioners to perform certain treatments, while for others no change to their clinical practice would occur. Further research is required to fully understand the causal mechanisms associated with divergent behaviour, as well as the underlying contextual conditions through which these mechanisms are activated.

Team interventions in acute hospital contexts: a systematic search of the literature using realist synthesis

BackgroundResearch on team effectiveness in healthcare has focussed on whether effective teams yield positive outcomes for patients and on the effectiveness of team interventions to improve performance. Limited understanding exists of what works for whom within an effective team, or how and why the context in which the team operates enables team members both as individuals and as a collective to enact behaviours that promote positive outcomes.MethodsThis realist synthesis of the literature explores the relationship between team interventions, underlying teamwork mechanisms generated by those interventions, and the resultant impact on patient outcomes in an acute hospital context. A systematic search of five healthcare and healthcare management academic databases: PubMed, PsychINFO, CINAHL, ABInform, Emerald Management and three grey literature databases: ERIC, OpenDOAR and Open Grey was undertaken. Five experts in the field were also contacted to source relevant literature. Using PRISMA guidelines, relevant studies published between January 2006 and January 2017 were systematically searched by a team of three people. Drawing on realist methodology, data were synthesised using context, mechanism and outcome configurations as the unit of analysis to identify enablers and barriers to effective team interventions.ResultsOut of 3347 papers retrieved, 18 were included in the final synthesis. From these, five contextual enablers were identified: an inter-disciplinary focus and flattened hierarchy; effective communication; leadership support and alignment of team goals with organisational goals; credibility of intervention; and appropriate team composition with physician involvement. Ten recurring mechanisms were identified, the most frequently occurring of which was shared responsibility.ConclusionsThe advantage of using realist synthesis to extrapolate data from the literature is that it considers the context and mechanisms that will impact effectiveness of healthcare team interventions. This methodological approach provides a different perspective to other types of syntheses and offers insight as to why certain contextual elements may yield more success than others. Findings therefore tend to have more practical implications. Specificity of detail in terms of how external drivers impact on healthcare team interventions was limited in the articles extracted for analysis. This broader perspective is therefore an important consideration for future research.

Population health management guiding principles to stimulate collaboration and improve pharmaceutical care

PurposeA range of strategies to improve pharmaceutical care has been implemented by population health management (PHM) initiatives. However, which strategies generate the desired outcomes is largely unknown. The purpose of this paper is to identify guiding principles underlying collaborative strategies to improve pharmaceutical care and the contextual factors and mechanisms through which these principles operate.Design/methodology/approachThe evaluation was informed by a realist methodology examining the links between PHM strategies, their outcomes and the contexts and mechanisms by which these strategies operate. Guiding principles were identified by grouping context-specific strategies with specific outcomes.FindingsIn total, ten guiding principles were identified: create agreement and commitment based on a long-term vision; foster cooperation and representation at the board level; use layered governance structures; create awareness at all levels; enable interpersonal links at all levels; create learning environments; organize shared responsibility; adjust financial strategies to market contexts; organize mutual gains; and align regional agreements with national policies and regulations. Contextual factors such as shared savings influenced the effectiveness of the guiding principles. Mechanisms by which these guiding principles operate were, for instance, fostering trust and creating a shared sense of the problem.Practical implicationsThe guiding principles highlight how collaboration can be stimulated to improve pharmaceutical care while taking into account local constraints and possibilities. The interdependency of these principles necessitates effectuating them together in order to realize the best possible improvements and outcomes.Originality/valueThis is the first study using a realist approach to understand the guiding principles underlying collaboration to improve pharmaceutical care.

A realist evaluation of Healthy Homes and Neighbourhoods’ place-based initiative in an inner city public housing estate in Sydney

Introduction: The Healthy Homes and Neighbourhoods (HHAN) Integrated Care Program seeks to enhance vulnerable family access to and engagement with health and social services through a care coordination model. In addition to servicing families living in inner west Sydney, HHAN has also established two place-based initiatives (PBI) in areas of heightened disadvantage – one of which is located in Redfern. The Redfern PBI co-locates HHAN with housing, drug and alcohol services, financial and legal services. This integration aims to facilitate service access and provide multi-agency support for vulnerable families in the Redfern area and improve health and social outcomes for individuals and the community. This study aims to evaluate the role and impact of HHAN’s Redfern PBI and explore whether a place-based model and co-location translates into improved patient, service and community outcomes. Theory/Methods: The project utilised a critical realist methodology to undertake a qualitative evaluation of the impact of the PBI on clients, services and community health and social outcomes. Purposive sampling was used to identify 20 participants including HHAN clients, HHAN employees and stakeholders involved with the Redfern PBI. In-depth, semi-structured interviews were audio-recorded, transcribed, coded and analysed using NVivo. Results: Preliminary thematic analysis found that the PBI provided varied benefits for clients and other services. Positive outcomes for clients included better engagement with services, increased trust in health services, empowerment, improved outlook and planning for the future. Positive outcomes for services included easier referral pathways, knowledge transfer and increased integration with other services. Mechanisms by which these outcomes were achieved included proximity, flexibility, favourable interpersonal relationships and building trust by responding to need. Discussion: The HHAN place-based model has achieved early subjective successes in terms of individual client health and social outcomes and service outcomes. Whether this translates into objective health improvements and overall community benefit is yet to be determined. Conclusion (key findings): The delivery of an integrated care program via a place-based model has resulted in early positive outcomes for individual clients and other services. Lessons learned: This early qualitative evaluation provides an insight into the potential role that place-based initiatives can play in improving health and social outcomes in disadvantaged communities. Limitations: The applicability of the findings of the study in areas outside of the Redfern community is unknown, however, learnings could be applied when establishing PBI in suburbs with a similar demographic profile. Participant bias should also be considered given the most vulnerable clients or clients in crisis were unlikely to be suitable for participation. Suggestions for future research: A comprehensive evaluation of the HHAN initiative will require a mixed-methods approach. As such a quantitative review will provide further insight in regards to client outcomes and cost-benefit analysis. Additionally, given HHAN is a whole of family service, further investigation into family outcomes is required. Examining the role that a place-based initiative plays in improving overall community outcomes would also be beneficial.

Milton Friedman’s causal realist stance?

Since the 1990s, a causal realist interpretation of Milton Friedman’s 1953 essay ‘The Methodology of Positive Economics’ has been advocated. This article recounts three arguments for this interpretation and then critically examines them. The arguments are: (1) Friedman’s methodology is based upon Alfred Marshall’s own realist methodology; (2) key passages in Friedman’s 1953 essay express a causal realist stance; and (3) Friedman and Schwartz’s work on US monetary history presupposes causal realism. These arguments are contestable. First, there are important differences between Marshall’s and Friedman’s methodology. Second, key passages in the 1953 essay are prima facie incompatible with a causal realist stance. Third, Friedman and Schwartz’s ‘transmission mechanism’, appended to their monetary history, is arguably instrumentalist in character. The article concludes with some brief reflections on how Friedman’s approach to economics, including his 1953 essay, could be read as strategically malleable, rather than being an ‘objectively’ prescriptive methodology.

Planetary health in the tropics: how community health-care doubles as a conservation tool

Abstract Background The Indonesian non-profit organisation Alam Sehat Lestari (ASRI), with support from the US non-profit organisation Health In Harmony, was created in 2007 to protect biodiverse rainforest in Gunung Palung National Park (GPNP) in Borneo, Indonesia, and to improve the lives of the communities surrounding the park. ASRI used a process of radical listening to identify the drivers of deforestation within the park and to help the community design and execute solutions. Methods Based on community design, multiple strategies relating to health service provision and alternative livelihoods training were implemented. To understand the health and conservation changes in the project communities, we did three quantitative surveys of 25 villages surrounding GPNP: one in 2007 (baseline), one in 2012 (5 years), and one in 2017 (10 years). Pairs of trained nurses systematically interviewed 1300 households out of 60 000 in the region. Additionally, to assess how the project was working, a qualitative study using realist methodology was selected to help determine whether there were aspects of ASRI's multipronged approach that the communities saw as effective in motivating conservation behaviour, and under what circumstances the model might be replicable in other areas of high-conservation value under threat by local communities. 70 interviews were conducted among loggers, patients, government officials, and random community members. Findings The quantitative results demonstrated that positive changes were being achieved, with a 68% drop by 2012 and a 89% drop by 2017 in households practising illegal logging (a decrease from an estimated 1350 logging households to 150 logging households currently) and a concomitant stabilisation of primary forest loss. By 2012, infant mortality decreased from 3·2 per 100 households to 1·1 per 100 households (70% decrease). The qualitative survey indicated that social capital and female empowerment played an important part in the positive community responses to the project's conservation messaging. Interpretation Health In Harmony and the ASRI clinic have improved the health of the people and of the forest in the GPNP region in Borneo. This comprehensive approach to conservation and health care provides innovative solutions to conserving the environment while empowering individuals to improve the health of their communities. Funding None.

Realism and Pragmatism in a mixed methods study.

A discussion of how adopting a Realist rather than Pragmatist methodology affects the conduct of mixed methods research. Mixed methods approaches are now extensively employed in nursing and other healthcare research. At the same time, realist methodology is increasingly used as philosophical underpinning of research in these areas. However, the standard philosophical underpinning of mixed methods research is Pragmatism, which is generally considered incompatible or at least at odds with Realism. This paper argues that Realism can be used as the basis of mixed methods research and that doing so carries advantages over using Pragmatism. A mixed method study into patient handover reports is used to illustrate how Realism affected its design and how it would have differed had a Pragmatist approach been taken. Discussion Paper. Philosophers Index; Google Scholar. Those undertaking mixed methods research should consider the use of Realist methodology with the addition of some insights from Pragmatism to do with the start and end points of enquiry. Realism is a plausible alternative methodology for those undertaking mixed methods studies.

A Protocol for Concretizing and Contextualizing a Critical Realist “Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHD)”, Sydney Australia

Introduction: This research protocol has been developed as part of an integrated care initiative for vulnerable families in Sydney, Australia. The aim is to develop “whole-of-government” interventions that break intergenerational cycles of disadvantage and poor life outcomes. A realist methodology will be described for the translation of empirically ‘data derived’ causal middle-range theories of social mechanisms, into health and social programme theories, whose theoretical propositions can be operationalized and studied in concrete situations using collective theory driven approaches. Theory/Methods: The research settings are in metropolitan Sydney, Australia. The design will be a longitudinal, multi-level, mixed method realist evaluation of applied programme interventions that seek to break the intergenerational cycle of social disadvantage and poor child health and developmental outcomes. The programme of research will consist of three components: 1) Operationalization of the theory and designing of programme initiatives for implementation; 2) Evaluation of the translated programme and implementation theory using Theory of Change and Realistic Evaluation; and 3) Theory Testing of realist hypotheses using both intensive and extensive critical realist research methods including realist structural modelling. Results: No applicable Discussion: The proposed programme of research will assist in translating empirical explanatory theory building to theory driven interventions. The research will be situated in socially disadvantaged regions of Sydney where the local child and family interagencies will collaborate to design and implement new initiatives that address significant disparities in early childhood development and adolescent outcomes attributed to neighbourhood circumstances, family stress and intergenerational cycles of disadvantage and poor mental health. Conclusions: Central to this protocol is the development of programme theory. Much of the theory driven and realist evaluation literature begins with existing interventions. The first task in those situations is to identify the underlying programme theory. In preparing this programme of work we were faced with the translation of causal theory to programme and implementation theory. We have proposed as a first step in this protocol the formal translation of the middle-range ‘causal’ theory into a middle-range ‘programme theory’ followed by an intervention design process based on Theory of Change approaches. Lessons learned: In preparing the protocol we have identified extensive debate concern the nature of implementation theory and programme theory. There is also on-going critical analysis of the nature of context (c), mechanisms (M) and outcomes (o) and how these might be defined and measured. Limitations: The application of realist methodologies to population health interventions is relatively new and there is little extant literature on the translational process from causal theory to programme theory. The study protocol is thus breaking new ground and it is anticipated that the approaches described will require modification. Suggestions for future research: The protocol development identified a need for further clarification of the nature of causal mechanism and programme mechanisms among the integrated care and evaluation research communities.

“Each is in different circumstances anyway”: A realist multilevel situational analysis of maternal depression

Introduction: We present here the findings of a realist multilevel situational analysis of maternal depression. We use situational analysis to identify the interaction of mothers with social structures and the possible causal influence of those social structures on her wellbeing. The analysis moves from an emergent empirical approach toward the more reflexive and abductive approach of situational analysis thus better informing our abductive reasoning and the generation of theory. The purpose is to understand the social determinants of health affecting families in stressful situations. Theory/Methods: Critical realism and symbolic interactionism provide the methodological underpinning for the study. Interviews of mothers and practitioners were analysed using open coding to enable maximum emergence. Situational analysis was then undertaken using situational and social worlds/arena maps. Results: Home and neighbourhood situational analysis mapping and analysis of relations identified the following concepts: a) expectations and dreams; b) marginalisation and being alone; c) loss or absence of power and control; and d) support and nurturing. The neighbourhood and macro-arena situational analysis mapping and analysis of relations identified the following concepts: a) social support networks, social cohesion and social capital; b) services planning and delivery and social policy; and c) global economy, business and media. Discussion: The use of qualitative methods for emergent theory building was suited to the aim and objectives of this study which was to explain the mechanisms by which circumstances influence developmental and life course outcomes with a focus on perinatal depression. Emergent theory building methods such as those used here are also consistent with accepted critical realist methodologies (i.e. grounded theory). We were not able to identify where situation analysis had been previously used for critical realist theory building but, as a symbolic interactionist methodology, its use within a critical realist epistemology is appropriate. Conclusions: Emerging was the centrality of being alone and expectations lost as possible triggers of stress and depression within circumstances where media portrays expectations of motherhood that are shattered by reality and social marginalisation. We further observe that powerful global economic and political forces are having an impact on the local situations. The challenge for policy and practice is to support mothers and their families within this adverse regional and global-economic context. Lessons learned: Situational analysis is a grounded theory method that can be usefully used to visually map the local neighbourhood setting. The findings proved useful for the designing of local integrated care initiatives. Limitations: The study undertaken utilised data from three focus groups and 8 key informant interviews. Further interviews and focus groups would have enabled exploration of emerging themes related to cultural diversity and the impact acculturation. Suggestions for future research: We propose that future research using situational analysis take a mixed method approach with, for example, concept mapping and social network analysis.

Including health in environmental impact assessments of three mega transport projects in Sydney, Australia: A critical, institutional, analysis

This article details how health impacts came to be assessed in three mega, billion dollar, transport infrastructure projects, two road tunnels and one light rail, in Sydney Australia. The known health impacts of transport decisions include environmental, behavioural and social factors. EIA practice prioritises environmental risks, and there has been scant attention to understanding why this is persistently the case. Here we provide a critical theory lens, using critical realist methodology, to analyse empirical data collected through interviews and documents for the three cases. Our analysis focusses on EIA practice within its institutional context, building on ‘new institutional’ approaches to policy analysis that emphasise actors (the stakeholders involved in the EIA), structures (the ‘rules of the game’ that influence practice in systems), and power. We find that the various actors engaged in the EIAs principally to address particular goals that were pre-determined by the system in which they worked or belonged. Structurally, each EIA was undertaken as a compliance process relatively late in the planning process. Considering project options was not part of the EIA's purpose. Resources to undertake the EIAs were provided by those funding the projects (“the proponents”) and determined the types of issues to be considered. The full range of links between transport and health were not identified. Concerning power, health impacts were considered through inter-professional technical negotiation. The inability to engage in the fundamental options driving projects meant impacted communities questioned the validity of the EIA, and the health assessment within this. Our institutional analysis provides important knowledge about how the EIAs preferenced a focus on specific health risks to the detriment of the known broader determinants that shape the health impacts of transport.

Creating ‘healthy built environment’ legislation in Australia; a policy analysis

Influencing healthy public policy through health advocacy remains challenging. This policy analysis research uses theories of agenda setting to understand how health came to be considered for specific mention in legislation arising from land-use planning system reform in New South Wales, Australia. This qualitative study follows critical realist methodology to conduct a policy analysis of the case. We collected data from purposively sampled in-depth interviews (n = 9), a focus group and documentary analysis. We used three classic policy process (agenda setting) theories to develop an analytic framework for explaining the empirical data: Multiple Streams; Punctuated Equilibrium Theory and Advocacy Coalition Framework. The reform process presented a window of opportunity that opened incrementally over a 2 year period. The opportunity was grasped by individual policy entrepreneurs who subsequently formed a coalition of healthy planning advocates focused on strategically positioning 'health' as legislative objective for the new system. The actual point of influence seemed to appear suddenly when challenges to a perceived economic development agenda within the reforms peaked, and the health objective, see as non-threatening by all stakeholders, was taken up. Our analysis demonstrates how this particular point of influence followed sustained long-term activity by health advocates prior to and during the reform process. We demonstrate a theory-driven policy analysis of health advocacy efforts to influence an instance of major land-use planning reform. The application of multiple policy process theories enables deep understanding of what is required to effectively advocate for healthy public policy.

A realist review of shared medical appointments: How, for whom, and under what circumstances do they work?

BackgroundShared medical appointments (SMAs) are doctor-patient visits in which groups of patients are seen by one or more health care providers in a concurrent session. There is a growing interest in understanding the potential benefits of SMAs in various contexts to improve clinical outcomes and reduce healthcare costs. This study builds upon the existing evidence base that suggests SMAs are indeed effective. In this study, we explored how they are effective in terms of the underlying mechanisms of action and under what circumstances.MethodsRealist review methodology was used to synthesize the literature on SMAs, which included a broad search of 800+ published articles. 71 high quality primary research articles were retained to build a conceptual model of SMAs and 20 of those were selected for an in depth analysis using realist methodology (i.e.,middle-range theories and and context-mechanism-outcome configurations).ResultsNine main mechanisms that serve to explain how SMAs work were theorized from the data immersion process and configured in a series of context-mechanism-outcome configurations (CMOs). These are: (1) Group exposure in SMAs combats isolation, which in turn helps to remove doubts about one’s ability to manage illness; (2) Patients learn about disease self-management vicariously by witnessing others’ illness experiences; (3) Patients feel inspired by seeing others who are coping well; (4) Group dynamics lead patients and providers to developing more equitable relationships; (5) Providers feel increased appreciation and rapport toward colleagues leading to increased efficiency; (6) Providers learn from the patients how better to meet their patients’ needs; (7) Adequate time allotment of the SMA leads patients to feel supported; (8) Patients receive professional expertise from the provider in combination with first-hand information from peers, resulting in more robust health knowledge; and (9) Patients have the opportunity to see how the physicians interact with fellow patients, which allows them to get to know the physician and better determine their level of trust.ConclusionsNine overarching mechanisms were configured in CMO configurations and discussed as a set of complementary middle-range programme theories to explain how SMAs work. It is anticipated that this innovative work in theorizing SMAs using realist review methodology will provide policy makers and SMA program planners adequate conceptual grounding to design contextually sensitive SMA programs in a wide variety of settings and advance an SMA research agenda for varied contexts.

The transcendent influence of spirituality on ethical action in organizations

In recent times, there has been a shift in the management literature toward embracing spirituality in the workplace. Much of this literature promulgates the idea that spiritual individuals are moral and therefore, valuable ethical assets to any organization. However, there is negligible research validating this claim. As part of a larger study, this research investigated how spirituality influenced ethical behavior in a variety of work contexts. This was based on a critical realist methodology, semi-structured interviews with 31 highly spiritual cases and a thematic analysis of 80 ethical incidents. It found participants’ spirituality was manifested through an awareness of others that guided and enabled them to act in authentically ethical ways that transcended organizational conditions. When participants reported doing this, they felt increased well-being; when they were unable to enact their spirituality, they suffered a variety of negative feelings. The paper concludes by discussing the implications of these findings.

Austerity Resistant Social Policies to Protect Employment.

During the worse phase of the economic downturn, few social policies resisted to the austerity measures imposed to Italy by the European Union. Among them, the most important is the Wage Supplementation Fund, to protect workers and entrepreneurs from bankruptcy and unemployment. Adopting a realist methodology we studied the social mechanisms which are the roots of some political and administrative choices in that period; the public policy decision making approach gave us a theoretical base. Some main mechanisms have been discovered: technical and economic mechanisms overcame politics, social attitudes pushed political choices, the fear of political and social instability drove all parties.

Provision of positive sexual health services for young people: a realist evaluation

BackgroundEnglish and international policy calls for positive, comprehensive youth sexual health services (PCYSHS) that support young people to achieve sexual wellbeing. In practice, youth sexual health services are often oriented solely towards reducing unwanted conceptions and preventing sexually transmitted infections. This study aimed to develop theory and recommendations for practitioners to support delivery of PCYSHS. MethodsA realist evaluation was undertaken to uncover what works, for whom, and under what conditions, to deliver PCYSHS. We developed concepts and initial theories, in which we combined existing substantive theory with a logic model based on stakeholder's tacit knowledge, observational visits, and data that were relevant to underlying causal processes, extracted from academic and policy literature (27 sources). Academic sources were identified via a systematic search of four electronic databases. Search terms were “sexual health”, combined with “sex positive”, “young people”, “service”, and synonyms (“reproductive health”, “sexual subjectivity”, “sexual rights”, “holistic”, “integrated”, “reproductive rights”, “preventative”, “comprehensive”, “young”, “youth” “teen*”, “adolescen*”, “intervention*”, “framework*”, “paradigm*”, “programme*”, “model*”, “trial*”, “pilot*”) with no date restrictions. We selected papers relating to whole system transformation to PCYSHS in developed countries, written in English. Papers that considered only education settings, one-off interventions, or information resources were excluded. Papers were appraised by rigour and relevance in accordance with realist methodology guidelines. Evidence was then gathered from case studies of three services in England that had attempted implementation of PCYSHS. Data were derived via stakeholder interviews (n=24), social and print media (15), service specifications (5), and evaluation and consultation documentation (5). Analysis of these data (Nvivo, version 10) was directed at substantiating, refining, or refuting the initial theories. Ethics approval was given by Sheffield Hallam University Research Ethics Committee. Findings76 sources contributed to the development and testing of programme theories. The theories articulated how local buy-in to PCYSHS could be led by the following factors: clarity of both the concept and individual role; conviction in the approach to bring about positive change for young people; and coherence with local and national priorities. The theories suggested the mechanisms by which these factors work and showed the ways in which outcomes are contextually dependent. InterpretationThis study explains some of the challenges of translating the policy ambition of PCYSHS into practice. The realist inquiry found theoretical mechanisms that might affect delivery of PCYSHS and the contextual conditions that could hinder or enable them. These theories can help inform the development and evaluation of PCYSHS initiatives. FundingSheffield Hallam University Faculty PhD scholarship.