FR5073 Hills

The Effectiveness of Community Initiatives to Promote Health: A Realist Synthesis Approach: 

The Effectiveness of Community Initiatives to Promote Health: A Realist Synthesis Approach Marcia Hills, RN, PhD Co-Chair, Canadian Consortium for Health Promotion Research Simon Carroll, University of Victoria Sylvie Desjardins, Public Health Agency of Canada 6th IUHPE European Conference, Stockholm, Sweden June 3, 2005

Outline: 

Outline Context - the Effectiveness of Community Initiatives Project (ECIP) Realist Synthesis Approach Framework Conclusion

Context: 

Context What is the ECIP project? What are the goals of ECIP? Why are we doing it? Who is doing it? What is our biggest challenge? Which was the process around it? How will this new approach help? Where are we going with it?

Typical Strategies for Assessing Effectiveness…Systematic Reviews: 

Typical Strategies for Assessing Effectiveness…Systematic Reviews Numerical Meta- analysis Randomized Control Trials Quantitative Statistical notion of causality (probability) Narrative Review Multiple Methodologies (interpretative) Qualitative Ignores or rejects causal explanation Different philosophies, assumptions Paradigm 'wars'

Difficulties with both approaches…: 

Difficulties with both approaches… Accumulation of evidence in similar programs Beliefs about causality that are based on statistics or reactions to it Either context–free or over contextualized lessons

Realist synthesis approach (Pawson, 2004): 

Realist synthesis approach (Pawson, 2004) Based on philosophy of science that argues that it is possible to have a logic of comparison that is not statistical Causal powers of an intervention (program) lie in its underlying mechanism/s - its basic theory about how program resources will affect participants’ actions in certain contexts NOT …does the program work ? …BUT what are the conditions (context) under which the resources the program offers have an impact on participant’s actions

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Mechanisms, Contexts, Outcomes: 

Mechanisms, Contexts, Outcomes Want to discover those contexts (C) that interact with specific mechanisms (M) that have produced solid and successful outcomes (O) FROM…those contexts that induce failure M-C-O configurations All cases are important …successful policy depends as much on avoiding previous errors as by 'imitating' successes

Causality…: 

Causality… The language of causality is crucial because it refers to the elements of a programme that make them work…or not work. Improving the priority setting of funders and improving the quality of practice in health promotion demands attention to what causes positive and negative outcomes We need to move beyond the either/or of relying on probabilistic reasoning or retreating into the defensive position of denying the capability of causal assertions We need to conceptualize our phenomena into discernable structures, objects and relations, rather than a obsessive focus on producing data for statistical modeling.

Causality and Anti-positivism: 

Causality and Anti-positivism The reaction to positivism within health promotion circles has often been to avoid the language of causality altogether However, this rejection of ‘causality’ as appropriate for evaluating health promotion has uncritically accepted the positivist interpretation of causal relations The result has been a retreat to the margins of the debate, where the accumulation of narrative or qualitative data is meant to substitute for a logic of comparative analysis

Causality and Realism: 

Causality and Realism Realists question the fundamental philosophical basis of empiricist-positivism For realists, causal relations are not dependent on the constant conjunction of events Causal relations are embedded in the ‘causal powers’ of structures, objects and mechanisms. These causal powers hold, whether or not they are observed empirically, or whether they are even ‘activated’ given other contextual factors For example, an airplane has the causal ability to fly, due to its structural design and other causal mechanisms (i.e. the skills of a pilot), not due to the empirical fact of it flying

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Individual, Community andamp; Systems Change Framework for Assessing the Effectiveness of Community Initiatives That Promote Health Improvements in Population Health Outcomes While Reducing Health Inequity Impact on Determinants of Health Individual Change Community Change Systems Change Community Organization andamp; Action Collaborative Planning Transformational Change Social Economic Political Environment Gender Cultural Contexts

Component 1 Mechanisms: Collaborative Planning: 

Component 1 Mechanisms: Collaborative Planning 1) Meaningful participation of all relevant stakeholders 2) Critical dialogue 3) Shared power 4) Project action planning and evaluation

Component 2: Community Organization and Action: 

Component 2: Community Organization and Action 1) Ongoing education and training opportunities 2) Evolving leadership 3) Sustained mobilization of resources 4) Critical reflection and systematic monitoring

Component 4: Transformational Change: 

Component 4: Transformational Change 1) Develop and attract champions 2) Generate publicity of project successes 3) Influence Public Policy and Decision-making Bodies 4) Work with relevant social movements and provincial and/or national advocacy groups

Conclusion: A Realist Synthesis Approach to Assessing Effectiveness…: 

Conclusion: A Realist Synthesis Approach to Assessing Effectiveness… Allows us to learn from past successes and failures Focuses our attention on the issues so important to community practitioners Uncovers what is often undervalued and discounted Builds credibility for community initiatives by using a theory of causation based on a realist philosophy of science

A Snapshot of the NARO Effectiveness WebsiteURL <http://dynosite.romulin.com/web/uofvic>: 

A Snapshot of the NARO Effectiveness Website URL andlt;http://dynosite.romulin.com/web/uofvicandgt;

Key References: 

Key References McQueen, D. V. (2001). Strengthening the evidence base for health promotion. Health Promotion International 16(3), 261-268. Pawson, R. (2002a). Evidence-based policy: In search of a method. Evaluation 8(2),157-181. Pawson, R. (2002b). Evidence-based policy: The Promise of 'Realist Synthesis Evaluation 8(3), 340-358. Pawson, R., Greenhalgh, T., Harvey, G., andamp; Walshe, K. (2004). Realist synthesis: An introduction - ESRC Research Methods Programme Working Paper Series: University of Manchester. Email addresses: mhills@uvic.ca scarroll@uvic.ca

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