Realist review - a new method of systematic review designed for complex policy interventions

2005 ◽  
Vol 10 (1_suppl) ◽  
pp. 21-34 ◽  
Author(s):  
Ray Pawson ◽  
Trisha Greenhalgh ◽  
Gill Harvey ◽  
Kieran Walshe
Keyword(s):  
Empirical Evidence ◽  
Public Services ◽  
Local Level ◽  
Social Systems ◽  
Realist Review ◽  
Policy And Practice ◽  
Programme Theory ◽  
Theoretical Understanding ◽  
Social Interventions ◽  
Policy Interventions

Evidence-based policy is a dominant theme in contemporary public services but the practical realities and challenges involved in using evidence in policy-making are formidable. Part of the problem is one of complexity. In health services and other public services, we are dealing with complex social interventions which act on complex social systems-things like league tables, performance measures, regulation and inspection, or funding reforms. These are not ‘magic bullets‘ which will always hit their target, but programmes whose effects are crucially dependent on context and implementation. Traditional methods of review focus on measuring and reporting on programme effectiveness, often find that the evidence is mixed or conflicting, and provide little or no clue as to why the intervention worked or did not work when applied in different contexts or circumstances, deployed by different stakeholders, or used for different purposes. This paper offers a model of research synthesis which is designed to work with complex social interventions or programmes, and which is based on the emerging ‘realist’ approach to evaluation. It provides an explanatory analysis aimed at discerning what works for whom, in what circumstances, in what respects and how. The first step is to make explicit the programme theory (or theories) - the underlying assumptions about how an intervention is meant to work and what impacts it is expected to have. We then look for empirical evidence to populate this theoretical framework, supporting, contradicting or modifying the programme theories as it goes. The results of the review combine theoretical understanding and empirical evidence, and focus on explaining the relationship between the context in which the intervention is applied, the mechanisms by which it works and the outcomes which are produced. The aim is to enable decision-makers to reach a deeper understanding of the intervention and how it can be made to work most effectively. Realist review does not provide simple answers to complex questions. It will not tell policy-makers or managers whether something works or not, but will provide the policy and practice community with the kind of rich, detailed and highly practical understanding of complex social interventions which is likely to be of much more use to them when planning and implementing programmes at a national, regional or local level.

scholarly journals Why do some inter-organisational collaborations in healthcare work when others do not? A realist review

2021 ◽  
Author(s):  
Justin Avery Aunger ◽  
Ross Millar ◽  
Joanne Greenhalgh ◽  
Russell Mannion ◽  
Anne Marie Rafferty ◽  
...  
Keyword(s):  
Case Studies ◽  
Resource Sharing ◽  
Realist Review ◽  
Primary Data ◽  
Refined Theory ◽  
Policy And Practice ◽  
Programme Theory ◽  
Healthcare Improvement ◽  
Healthcare Work ◽  
Partnership Synergy

Abstract Background Inter-organisational collaboration is increasingly prominent within contemporary healthcare systems. A range of collaboration types such as alliances, networks, and mergers have been proposed as a means to turnaround organisations, by reducing duplication of effort, enabling resource sharing, and promoting innovations. However, in practice, due to the complexity of the process, such efforts are often rife with difficulty. Notable contributions have sought to make sense of this area, however further understanding is needed in order to gain a better understanding of why some inter-organisational collaborations work when others do not, to be able to more effectively implement collaborations in the future. Methods Realist review methodology was used with the intention of formulating context-mechanism-outcome configurations (CMOCs) to explain how inter-organisational collaborations work and why., combining systematic and purposive literature search techniques . The systematic review encompassed searches for reviews, commentaries, opinion pieces and case studies on HMIC, Medline, PsycINFO, and Social Policy and Practice databases and further searches were conducted using Google Scholar. Data were extracted from included studies according to relevance to the realist review. Results Fifty-three papers were included, informing the development of programme theories of how, why, and when inter-organisational collaborations in healthcare work. Formulation of our programme theories incorporated the concepts of Partnership Synergy and Collaborative Inertia and found that it was essential to consider mechanisms underlying partnership functioning, such as building trust and faith in the collaboration to maximise synergy and thus collaborative performance. More integrative or mandated collaboration may lean more heavily on contract to drive collaborative behaviour. Conclusion As the first realist review of inter-organisational collaborations in healthcare as an intervention for improvement, this review provides actionable evidence for policymakers and implementers, enhancing understanding of mechanisms underlying the functioning and performing of inter-organisational collaborations, as well as how to configure the context to aid success. Next steps in this research will test the results against further case studies and primary data to produce a further refined theory. Review registration This review is registered at PROSPERO with ID CRD42019149009. Keywords Collaboration, partnership working, integration, healthcare, improvement, realist review, realist synthesis, context, programme theory, implementation

scholarly journals Carers, Choice and Personalisation: What Do We Know?

2015 ◽  
Vol 15 (2) ◽  
pp. 189-205 ◽  
Author(s):  
Mary Larkin ◽  
Wendy Mitchell
Keyword(s):  
Social Work ◽  
Empirical Evidence ◽  
Public Services ◽  
Future Research ◽  
Family Carers ◽  
Policy And Practice ◽  
And Control ◽  
Social Work Policy ◽  
The Relationship

Despite the long-term strategic shift to personalisation, with its emphasis on choice and control for those who use public services, there has been relatively little policy consideration of family carers’ choice within personalisation. The relationship between carers and personalisation also remains under-researched. This article is based on a review of existing knowledge around personalisation. It shows that carer choice is highly complex, not least because of the multifaceted and paradoxical nature of the concept of choice itself. The review demonstrates that choice for carers within personalisation is no less complex and is subject to new and overlapping variables which do not necessarily lead to improved choice for carers. In light of the limited empirical evidence about carers, choice and personalisation, the introduction of the Care Act 2014, and the importance of frontline practice in securing choice for carers, recommendations are made for future research and social work policy and practice.

OP63 Clinical Videoconferencing - Critical-realist Review As Evidence?

2019 ◽  
Vol 35 (S1) ◽  
pp. 15-16
Author(s):  
Anne Ekeland
Keyword(s):  
Critical Review ◽  
Digital Health ◽  
Local Level ◽  
Real Life ◽  
Realist Review ◽  
Health Interventions ◽  
Decision Makers ◽  
Social Interventions ◽  
Critical Realist ◽  
What Works

IntroductionIt is not clear yet whether new digital health interventions can and should be assessed by using ‘conventional’ health technology assessment (HTA) methodology. In response to the question about how much and which type of evidence is needed for decisions on new digital health interventions, this presentation discusses complimentary evidence as generated through a critical-realist review and a qualitative meta-synthesis. This work follows from earlier work by AG Ekeland, AH Hansen and TS Bergmo.MethodsA realist review addresses complex social interventions investigated in real life settings. The review was conducted with the purpose of generating knowledge on what works, for whom and under which circumstances. The aim was to enable decision-makers to reach a deeper understanding of how the intervention can be made to work most effectively. A critical review goes beyond mere description of identified articles and includes analysis and conceptual innovation. An effective critical review synthesizes material from diverse sources, provides an opportunity to ‘take stock’ and evaluate what is of value related to a previous body of work.ResultsUser patterns of clinical videoconferencing turned out to be dependent on contextual factors like clinical condition, motivation, technological skills, professional and organizational arrangements, trust and the perceived value they add compared with “services as usual”. The pattern of what works, for whom and under which circumstances was heterogeneous and dynamic. The review types helped identify and conceptualize new user categories, and understand the complex patterns of use.ConclusionsThe in-depth accounts of different clinical use resulting from such a review provide decision makers with a highly practical understanding of complex social interventions which is likely to be of use when planning and implementing programs at a national, regional or local level. A critical-realist review of digital services can complement controlled studies and evidence summaries in HTA.

scholarly journals Upskilling health and care workers with augmented and virtual reality: protocol for a realist review to develop an evidence-informed programme theory

BMJ Open ◽  
2021 ◽  
Vol 11 (7) ◽  
pp. e050033
Author(s):  
Norina Gasteiger ◽  
Sabine N van der Veer ◽  
Paul Wilson ◽  
Dawn Dowding
Keyword(s):  
Virtual Reality ◽  
Grey Literature ◽  
Healthcare Providers ◽  
Realist Review ◽  
Relevant Information ◽  
Care Providers ◽  
Programme Theory ◽  
Clinical Educators ◽  
Continued Learning ◽  
Search Quality

IntroductionAugmented reality (AR) and virtual reality (VR) are increasingly used to upskill health and care providers, including in surgical, nursing and acute care settings. Many studies have used AR/VR to deliver training, providing mixed evidence on their effectiveness and limited evidence regarding contextual factors that influence effectiveness and implementation. This review will develop, test and refine an evidence-informed programme theory on what facilitates or constrains the implementation of AR or VR programmes in health and care settings and understand how, for whom and to what extent they ‘work’.Methods and analysisThis realist review adheres to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) standards and will be conducted in three steps: theory elicitation, theory testing and theory refinement. First, a search will identify practitioner, academic and learning and technology adoption theories from databases (MEDLINE, Scopus, CINAHL, Embase, Education Resources Information Center, PsycINFO and Web of Science), practitioner journals, snowballing and grey literature. Information regarding contexts, mechanisms and outcomes will be extracted. A narrative synthesis will determine overlapping configurations and form an initial theory. Second, the theory will be tested using empirical evidence located from the above databases and identified from the first search. Quality will be assessed using the Mixed Methods Appraisal Tool (MMAT), and relevant information will be extracted into a coding sheet. Third, the extracted information will be compared with the initial programme theory, with differences helping to make refinements. Findings will be presented as a narrative summary, and the MMAT will determine our confidence in each configuration.Ethics and disseminationEthics approval is not required. This review will develop an evidence-informed programme theory. The results will inform and support AR/VR interventions from clinical educators, healthcare providers and software developers. Upskilling through AR/VR learning interventions may improve quality of care and promote evidence-based practice and continued learning. Findings will be disseminated through conference presentations and peer-reviewed journal articles.

scholarly journals Contexts and mechanisms that promote access to healthcare for populations experiencing homelessness: a realist review

BMJ Open ◽  
2021 ◽  
Vol 11 (4) ◽  
pp. e043091
Author(s):  
Rikke Siersbaek ◽  
John Alexander Ford ◽  
Sara Burke ◽  
Clíona Ní Cheallaigh ◽  
Steve Thomas
Keyword(s):  
Health System ◽  
Healthcare Access ◽  
Grey Literature ◽  
Realist Review ◽  
Access To Healthcare ◽  
Staff Retention ◽  
Programme Theory ◽  
Eligibility Criteria ◽  
Ovid Medline ◽  
High Level

ObjectiveThe objective of this study was to identify and understand the health system contexts and mechanisms that allow for homeless populations to access appropriate healthcare when needed.DesignA realist review.Data sourcesOvid MEDLINE, embase.com, CINAHL, ASSIA and grey literature until April 2019.Eligibility criteria for selecting studiesThe purpose of the review was to identify health system patterns which enable access to healthcare for people who experience homelessness. Peer-reviewed articles were identified through a systematic search, grey literature search, citation tracking and expert recommendations. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded to identify data relating to contexts, mechanisms and/or outcomes.AnalysisInductive and deductive coding was used to generate context–mechanism–outcome configurations, which were refined and then used to build several iterations of the overarching programme theory.ResultsSystematic searching identified 330 review articles, of which 24 were included. An additional 11 grey literature and primary sources were identified through citation tracking and expert recommendation. Additional purposive searching of grey literature yielded 50 records, of which 12 were included, for a total of 47 included sources. The analysis found that healthcare access for populations experiencing homelessness is improved when services are coordinated and delivered in a way that is organised around the person with a high degree of flexibility and a culture that rejects stigma, generating trusting relationships between patients and staff/practitioners. Health systems should provide long-term, dependable funding for services to ensure sustainability and staff retention.ConclusionsWith homelessness on the rise internationally, healthcare systems should focus on high-level factors such as funding stability, building inclusive cultures and setting goals which encourage and support staff to provide flexible, timely and connected services to improve access.

scholarly journals A Multi-scale Approach to Interculturalism: From Globalised Politics to Localised Policy and Practice

2021 ◽  
Author(s):  
Ricard Zapata-Barrero ◽  
Fethi Mansouri
Keyword(s):  
International Relations ◽  
United Nations ◽  
Local Level ◽  
The European Union ◽  
Council Of Europe ◽  
Policy And Practice ◽  
United Nations Educational ◽  
Multi Scale ◽  
Cultural Organization ◽  
Global Agenda

AbstractInterculturalism (IC) is presently discussed as a foundational basis for local public policy aimed at managing migration-related diversity within ethno-culturally plural societies, especially at the local level. Despite its increased saliency over the last decade, IC is neither theoretically new nor was it always intended for mere application in strictly city contexts of diversity. Rather, it has a global origin as a political basis for international relations and negotiations. In discussing these origins, this article has two main interrelated aims. Firstly, it provides an overview of the multi-scale approach of IC, with the purpose of disentangling analytically the different empirical bases where it can frame the diversity agenda. Secondly, it explores whether a lack of appreciation and awareness of this multi-scale orientation may affect IC’s capacity to address the challenges of diversity governance at the local level. Methodologically, the article will undertake a textual analysis of a select number of leading documents framing its practice within the broader policy literature produced by the four main institutions that have advocated the intercultural approach within a global agenda. These are the United Nations Educational, Scientific and Cultural Organization (UNESCO) and United Nations University, on one hand, and the European Union and the Council of Europe on the other. The main findings show us the importance of a multi-scale thinking in diversity and IC studies, to avoid contributing to greater confusion in its applications.

scholarly journals Conversations about FGM in primary care: a realist review on how, why and under what circumstances FGM is discussed in general practice consultations

BMJ Open ◽  
2021 ◽  
Vol 11 (3) ◽  
pp. e039809
Author(s):  
Sharon Dixon ◽  
Claire Duddy ◽  
Gabrielle Harrison ◽  
Chrysanthi Papoutsi ◽  
Sue Ziebland ◽  
...  
Keyword(s):  
Primary Care ◽  
Grey Literature ◽  
Relevant Literature ◽  
Theory Development ◽  
Realist Review ◽  
Primary Outcome Measure ◽  
Mandatory Reporting ◽  
Programme Theory ◽  
Genital Mutilation ◽  
The Impact

ObjectivesLittle is known about the management of female genital mutilation (FGM) in primary care. There have been significant recent statutory changes relevant to general practitioners (GPs) in England, including a mandatory reporting duty. We undertook a realist synthesis to explore what influences how and when GPs discuss FGM with their patients.SettingPrimary care in England.Data sourcesRealist literature synthesis searching 10 databases with terms: GPs, primary care, obstetrics, gynaecology, midwifery and FGM (UK and worldwide). Citation chasing was used, and relevant grey literature was included, including searching FGM advocacy organisation websites for relevant data. Other potentially relevant literature fields were searched for evidence to inform programme theory development. We included all study designs and papers that presented evidence about factors potentially relevant to considering how, why and in what circumstances GPs feel able to discuss FGM with their patients.Primary outcome measureThis realist review developed programme theory, tested against existing evidence, on what influences GPs actions and reactions to FGM in primary care consultations and where, when and why these influences are activated.Results124 documents were included in the synthesis. Our analysis found that GPs need knowledge and training to help them support their patients with FGM, including who may be affected, what needs they may have and how to talk sensitively about FGM. Access to specialist services and guidance may help them with this role. Reporting requirements may complicate these conversations.ConclusionsThere is a pressing need to develop (and evaluate) training to help GPs meet FGM-affected communities’ health needs and to promote the accessibility of primary care. Education and resources should be developed in partnership with community members. The impact of the mandatory reporting requirement and the Enhanced Dataset on healthcare interactions in primary care warrants evaluation.PROSPERO registration numberCRD42018091996.

scholarly journals Wetlands in Ethiopia: Lessons From 20 years of Research, Policy and Practice

Wetlands ◽  
2021 ◽  
Vol 41 (2) ◽  
Author(s):  
Alan Dixon ◽  
Adrian Wood ◽  
Afework Hailu
Keyword(s):  
Research Policy ◽  
Wetland Management ◽  
Local Level ◽  
National Policy ◽  
Research Programme ◽  
Sub Saharan Africa ◽  
Policy And Practice ◽  
Policy Goals ◽  
Sub Saharan ◽  
Wetland Use

AbstractThroughout sub-Saharan Africa wetlands provide ecosystem services that are critical to the development needs of many people. Local wetland use, however, is often at odds with broader national policy goals in which narratives of conservation and protection dominate, hence a recurring challenge is how to reconcile these tensions through the development of policies and field practice that deliver sustainable development. In this paper we examine the extent to which this challenge has been achieved in Ethiopia, charting the changes in wetlands policy and discourse over the last twenty years while reviewing the contribution of the multidisciplinary Ethiopian Wetlands Research Programme (EWRP) (1997–2000). Our analysis suggests that despite EWRP having a significant legacy in developing national interest in wetlands among research, government and non-governmental organisations, its more holistic social-ecological interpretation of wetland management remains neglected within a policy arena dominated by specific sectoral interests and little recognition of the needs of local people. In exploring the impacts at the local level, recent investigations with communities in Ilu Aba Bora Zone highlight adjustments in wetland use that famers attribute to environmental, economic and social change, but which also evidence the adaptive nature of wetland-based livelihoods.

scholarly journals Sustaining organizational culture change in health systems

2016 ◽  
Vol 30 (1) ◽  
pp. 2-30 ◽  
Author(s):  
Cameron David Willis ◽  
Jessie Saul ◽  
Helen Bevan ◽  
Mary Ann Scheirer ◽  
Allan Best ◽  
...  
Keyword(s):  
Organizational Culture ◽  
Cultural Change ◽  
Grey Literature ◽  
Realist Review ◽  
Policy And Practice ◽  
Content Type ◽  
Organizational Culture Change ◽  
Contextual Elements ◽  
Values And Beliefs ◽  
Guiding Principles

Purpose – The questions addressed by this review are: first, what are the guiding principles underlying efforts to stimulate sustained cultural change; second, what are the mechanisms by which these principles operate; and, finally, what are the contextual factors that influence the likelihood of these principles being effective? The paper aims to discuss these issues. Design/methodology/approach – The authors conducted a literature review informed by rapid realist review methodology that examined how interventions interact with contexts and mechanisms to influence the sustainability of cultural change. Reference and expert panelists assisted in refining the research questions, systematically searching published and grey literature, and helping to identify interactions between interventions, mechanisms and contexts. Findings – Six guiding principles were identified: align vision and action; make incremental changes within a comprehensive transformation strategy; foster distributed leadership; promote staff engagement; create collaborative relationships; and continuously assess and learn from change. These principles interact with contextual elements such as local power distributions, pre-existing values and beliefs and readiness to engage. Mechanisms influencing how these principles sustain cultural change include activation of a shared sense of urgency and fostering flexible levels of engagement. Practical implications – The principles identified in this review, along with the contexts and mechanisms that influence their effectiveness, are useful domains for policy and practice leaders to explore when grappling with cultural change. These principles are sufficiently broad to allow local flexibilities in adoption and application. Originality/value – This is the first study to adopt a realist approach for understanding how changes in organizational culture may be sustained. Through doing so, this review highlights the broad principles by which organizational action may be organized within enabling contextual settings.

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