Realist inquiry

Text by Marjolein Dieleman and Sumit Kane
Development, Policy and Practice. Royal Tropical Institute

Public health interventions are complex interventions located within complex and open health and social systems. They are sets of activities meant to achieve change, these activities occur within the context of the health system and the larger social settings. Most current research and evaluation methods in public health do not sufficiently take into account this complexity and tend to look at outcomes of the interventions alone, trying to answer whether interventions work. They are not enough to assist policy makers and planners to choose appropriate interventions, and are also insufficient to respond to the key concerns of practitioners and policy makers: “Will this work in my context”. Public health researchers need to respond to this need of practitioners and policy makers, we need to have credible evidence which takes into account the complexities of real life and of the myriad contexts within which public health interventions are implemented. We need to come up with nuanced, context informed bodies of evidence which explain the context in which interventions succeed or fail, and which are able to reveal when and how a particular intervention is likely to work in what conditions. Knowing how different (or similar) interventions will produce varying impacts in different circumstances, will help the policy maker and practitioner, to decide what policies to implement in what conditions.

Realist inquiry
Realist inquiry is an approach that can help answer the question: “what is it about this program that works for whom in what circumstances” (Pawson, 2005: 22), in other words: which mechanisms cause which outcome under which circumstances. Realist inquiry has an explanatory focus and aims to unravel mechanisms of change. Traditional experimental evaluations tell us ‘what works” and implicitly mean that because it works here, it will work elsewhere too. This ‘constant conjunction’ account of causality renders the findings of traditional evaluations insufficient to practitioners and policy makers. The realist approach aims to reveal the underlying mechanisms which lead to certain outcomes. These underlying mechanisms may either be explicit or tacit. Central to the realist approach is the acknowledgement and cognizance of the important role the context plays in determining the outcome(s) of a particular intervention.

According to the realists, the interaction of an intervention with a specific context triggers reactions (mechanisms) which cause certain outcomes to occur. These interactions are called “Context-Mechanism-Outcome” configurations. Contexts are the circumstances within which public health interventions are implemented and include the organizational, socio-economic, cultural and political conditions, but also the stakeholders involved, their interests and convictions regarding change and the process of implementation. Mechanisms are reactions of the target group, triggered by the intervention within a certain context, which lead to a certain outcomes (or to change from the status quo). Realist inquiry is concerned with understanding these causal mechanisms and the conditions under which they are activated to produce specific outcomes.

A realist approach is a theory based approach, and evidence building using a realist approach implies researching CMO-configurations by:

• Making the program theory that underlies the choice of a certain intervention, explicit; i.e. making explicit the assumptions regarding expected outcome of an intervention and how - through which mechanisms or reactions - this will be achieved. A theory-surfacing or theory-revealing exercise.
• Conducting research on implemented interventions to collect evidence about this program theory, in order to refine this theory. Research based on a realist perspective can use both qualitative and quantitative data collection techniques.