Building Realist Program Theory for Large Complex and Messy Interventions

Abstract

Program theory, that is, the specific idea about how a program causes the intended or observed outcomes, should be the central aspect of any realist evaluation or synthesis. The methods used for explicating or building initial rough program theories (IRPTs) in realist research are varied and arguably often underreported. In addition, preexisting psychological and sociological theories, at a higher level of abstraction, could be used to a greater extent to inform their development. This article illustrates a method for building IRPTs for use in realist research evaluation and synthesis. This illustration involves showing how the IRPTs were developed in a realist evaluation concerning sexual health services for young people. In this evaluation, a broad framework of abstract theories was constructed early in the process to support IRPT building and frame more specific program theories as they were developed. These abstract theories were selected to support theorizing at macro-, meso-, and microlevels of social structure. This article discusses the benefits of using this method to build initial theories for particular types of interventions that are large, complex, and messy. It also addresses challenges relating to the selection of suitable theories.Keywords realist, program theory, sexual health, young people, middle-range theory, adolescents, organizational change, conceptual framework What Is Already Known?Methods for developing initial theories in realist research are varied and underreported. Additionally, existing abstract theories are often used to substantiate rather than inform program theory development. What This Paper Adds?This paper provides an account of program theory development in a realist evaluation of positive comprehensive youth sexual health services. It offers a rationale for early development of a framework of abstract theories to improve coherence, quality, and transparency in realist research and a set of criteria for selecting abstract theories.

Can sexual health interventions make community-based health systems more responsive to adolescents? A realist informed study in rural Zambia

“…Although some respondents in our study seemed to suggest a linear relationship between the mechanisms, with one leading into another, the development of the individual and collective mechanisms are more likely to be affected by individual demographics, interpersonal relationships and structural factors, such as political and socio-economic structures [35,40]. For example, sociocultural norms have been shown to negatively affect the type of SRHR information given and consequently adoption of SRHR interventions, especially if they include promoting discussions related to sexual matters between parents and unmarried adolescents [36].…”

“…The second programme theory presents an alternative theory of what would happen if the conditions in which actors interacted with the interventions were inhibiting. Following the stages of realist evaluation [28,35], the initial programme theories developed in this phase need to be tested and refined.…”

“…Further, implementing the intervention in line with existing school and health policies could be seen as a way of strengthening existing policies and laws, thus fulfilling all the requirements of SRHR approaches that work [23]. Our programme theory can therefore be used to inform comparable interventionswhich are interventions that aim to achieve similar outcomes [35].…”

Exposing the impact of intensive advice services on health: A realist evaluation

“…The figure provides an explanatory framework, which accounts for the different levels through which CA improve people's mental health (which may therefore impact physical health); client capabilities representing the micro, the meso being the trusting relationship between the client and the CA advisor, and the macro being the buffering role CA form between clients and the state. Previous realist research has drawn on substantive theories focused at macro, meso, and micro levels at the outset of the research in order to support the development of more specific program theories (Shearn et al, ). By contrast, our research built theory in the opposite direction, from programme theories anchored in the data to the construction of an abstract explanatory framework operating at these different layers.…”

“…Qualitative data were transcribed verbatim, imported into NVivo and analysed using a realist CMO lens. During the data collection and analysis, we moved iteratively between analysis of particular examples, refinement of programme theory, and application of abstract theory (Emmel, 2013;Shearn, Allmark, Piercy, & Hirst, 2017;Wong et al, 2015).…”