critical realist literature review

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Knowledge syntheses: systematic & scoping reviews, and other review types.

• Before you start
• Getting Started
• Different Types of Knowledge Syntheses
• Assemble a Team
• Develop your Protocol
• Eligibility Criteria
• Screening for articles
• Data Extraction
• Critical appraisal
• What are Systematic Reviews?
• What is a Meta-Analysis?
• What are Scoping Reviews?
• What are Rapid Reviews?

When is a Realist Review methodology appropriate?

Elements of a realist review, methods & guidance.

• What are Mapping Reviews?
• What are Integrative Reviews?
• What are Umbrella Reviews?
• Standards and Guidelines
• Supplementary Resources for All Review Types
• Resources for Qualitative Synthesis
• Resources for Quantitative Synthesis
• Resources for Mixed Methods Synthesis
• Bibliography
• More Questions?
• Common Mistakes in Systematic Reviews, scoping reviews, and other review types

According to  Pawson et al. (2005) , a realist review, or a realist synthesis, is a method for studying complex interventions in response to the perceived limitations of conventional systematic review methodology. It involves identification of Contexts, Mechanisms and Outcomes for individual programs to explain differences, intended or unintended, between them.   Pawson et al. (2005) add that "t raditional 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" (p. 21).

When to Use It:  As stated by Wong (2019) , realist reviews are used when needing to answer the question “what works, for whom, under what circumstances?”  Rycroft-Malone et al. (2012)   state that realist reviews are "particularly appropriate for unpacking the impact of complex interventions because it works on the premise that one needs to understand how interventions work in different contexts, and why" (p. 9).  Wong (2019) confirms that realist reviews are steadily on the rise. 

The following characteristics, strengths, and challenges of conducting realist reviews are derived from  Rycroft-Malone et al. (2012)  and  Pawson et al. (2005) .

Characteristics: 

Rycroft-Malone et al. (2012)  describe that "a realist synthesis follows similar stages to a traditional systematic review, but with some notable differences" which include:

The focus of the synthesis is derived from a negotiation between stakeholders and reviewers and therefore the extent of stakeholder involvement throughout the process is high.

The search and appraisal of evidence is purposive and theoretically driven with the aim of refining theory.

Multiple types of information and evidence can be included., the process is iterative..

The findings from the synthesis focus on explaining to the reader why (or not) the intervention works and in what ways, to enable informed choices about further use and/or research.

Strengths:  

The innate  theory-driven approach  in conducting realist reviews allows for coherent sense-making of complex interventions. 

According to  Pawson et al. (2005) , realist reviews have "an exploratory rather than judgmental focus" (p. 21), adding that they "seek to unpack the mechanism of  how  complex programmes work (or  why  they fail) in particular contexts and settings" (p. 21).

According to  Pawson et al. (2005) ,  realist reviews have "the potential to maximize learning across policy, disciplinary and organizational boundaries", mainly due to the programme theory approach it takes (p. 32). 

​ Challenges:  

Finding balance: According to  Rycroft-Malone et al. (2012) , "the challenge of developing a framework for a realist synthesis is in finding a level of abstraction that allows reviewers to stand back from the detail and variation in the evidence, but that is also specific enough to meet the purpose of the review" (p. 3).

Rycroft-Malone et al. (2012)  state that conducting a realist review "is not an easy option. Realist review[s] demands much of the reviewer, including an ability to think flexibly and deal with complexity" (p. 9).

Pawson et al. (2005)  also state that realist reviews can't be applied in a wide variety of contexts, explaining that "realist review[s] cannot be used as a formulaic, protocol-driven approach. Realist review[s] [are] more about principles that guide than rules that regularize" (p. 32).

Pawson et al. (2005)  also add that realist reviews are "not standarizable or reproducible the same sense as a conventional Cochrane review" (p. 32) and that realist reviews often only lead to, at the most, tentative recommendations. As well, it is important to note that realist reviews require considerable skill to complete and to date have not been published as much as other review types. 

The following resource provides further support on conducting a realist review:

METHODS & CONDUCT

Marchal, B., Belle, S. V., & Westhorp, G. (2018, April 18). Realist Evaluation . Retrieved from https://www.betterevaluation.org/en/approach/realist_evaluation

Westhorp, G. (2015, February 27). Realist impact evaluation: an introduction . Retrieved from https://www.betterevaluation.org/resources/realist-impact-evaluation-introduction

Wong, G., MacPhee, M., Merrett, K., Miller, K., Taylor, S., & Pawliuk, C. (2020, March 10). The Realist Review Process Workshop [Presentation]. doi:http://dx.doi.org/10.14288/1.0390457

REPORTING STANDARDS

Wong, G., Westhorp, G., Manzano, A., Greenhalgh, J., Jagosh, J., & Greenhalgh, T. (2016). RAMESES II reporting standards for realist evaluations .  BMC Medicine ,  14 (1). doi: 10.1186/s12916-016-0643-1

SUPPLEMENTARY RESOURCES

Check out the  supplementary resources page  for additional information, including articles, on realist reviews.

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Understanding Realist Reviews for Medical Education

Rola ajjawi.

Rola Ajjawi, PhD, is Associate Professor in Educational Research, Centre for Research in Assessment and Digital Learning (CRADLE), Deakin University, Geelong, Victoria, Australia

Fiona Kent, PhD, is Director, Collaborative Care and Work Integrated Learning, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia

The Aim of a Realist Review

A realist review is a theory-driven approach to literature synthesis that seeks to evaluate the effectiveness of interventions in a contextualized way. Realist research, which includes review and program evaluation, is a relatively recent development. Pioneered by Pawson, 1 - 3 this approach has proliferated in health services because realist research acknowledges that program interventions are complex, and context is fundamental to understanding how outcomes are mediated. The foundational premise of realism is that interventions work differently in different contexts and for different people. In medical education, realist reviews have been conducted to understand internet-based medical education, 4 balancing health professional education and patient care, 5 productive research environments, 6 clinical reasoning, 7 and interprofessional programs. 8 (See the Box for a case example of an interprofessional education realist review.)

Box The Case of Dr. Smith 10

Dr. Smith, a program director, has been tasked to develop an interprofessional education (IPE) experience for the residency. Dr. Smith decides that conducting a literature review would be a savvy way to examine the existing evidence and generate a publication useful to others. Dr. Smith decides they need to know how IPE works and that a realist literature review may help to answer the question: How and under what circumstances does participation in interprofessional education work for medical interns?

The initial search might explore IPE broadly or a specific area, such as interprofessional simulation, and underlying theory, before determining the focus of the formal literature search. Although interns are the focus of the query, the formal search might include what is known about IPE for senior medical students as more educational research has been conducted in this group. Initial program theories might be drawn from formal education theories, theories of workplace learning, or critical theories of power and hierarchy. The retrieved papers would be assessed to determine their relevance and rigor, to contribute to theory development of how IPE works. Context-mechanism-outcome (CMO) configurations within each article would be coded and extracted, and common configurations further explored both inductively and deductively. The initial program theory would be tested against the extracted CMO configurations, to both respond to the research question and justify the evolving theory.

The purpose of a realist review is to build theory and new understandings of causal mechanisms from existing research by focusing on the relationship between context and outcomes. A critical feature of complex interventions is that “as they are delivered, they are embedded in social systems. It is through the workings of entire systems of social relationships that any changes in behaviours, events and social conditions are effected.” 3 Complex interventions include multiple interrelated components, which occur over time, in intricate environments, with multiple stakeholders. In a realist review, context is more than a setting or a community; it includes individual, institution, practice, social, technical, and other layers, as described by Bates and Ellaway. 9

The key realist research question is typically: What intervention works, for whom, how, and in what circumstances?

Origins and Points of Difference

Realist reviews differ from other reviews in approach to causality and attention to mechanisms of change and human action. Given that interventions are embedded within social systems, causality is understood as dependent on the whole context of an intervention. 11 How an intervention or program causes an outcome is not simple, linear, or deterministic. Programs will have multiple mechanisms that lead to different outcomes, both positive and negative.

Understanding mechanisms is the crux of understanding realist reviews. While there is no consensus on a single definition, broadly speaking, mechanisms cause things to happen . Mechanisms can be defined as the “underlying entities, processes, or structures which operate in particular contexts to generate outcomes of interest.” 12 A mechanism may cause changes in individual beliefs, values, or reasoning or may change the social structures and resources available to individuals. 13 Mechanisms are not necessarily visible but can mediate effects in certain contexts. For example, trust might be a mechanism by which feedback could lead a trainee to change their behavior in the context of a supervisory relationship. Motivation might be another mechanism for how feedback interventions work. It is not difficult to accept that both can operate in any single feedback intervention, which is why multiple mechanisms may be identified in a single review.

Realist reviews seek to unpack mechanisms that mediate outcomes within specific contexts. These context-mechanism-outcome (CMO) configurations may occur in regular patterns, also called demi-regularities , which is another defining feature of realist reviews. The term demi-regularity is used to indicate that these patterns of human choice and agency manifest in a semipredictable manner. 3 While the role of context is essential, generalizable abstractions are also required to implement changes that may work in other contexts. Therefore, if researchers can identify abstract mechanisms that work within and possibly across contexts, then policy makers can develop interventions and policies for real world effects (see the Table ).

Example of Context-Mechanism-Outcome From a Realist Review of Feedback for Written Tasks 14

CMO configurations should help to explain why particular interventions succeed or fail, and how they influence outcomes. These theoretical explanations of influence are referred to as middle-range theories, that is, ones which involve abstraction yet remain close to the observed data. 15 Such theoretical explanations connect empirical evidence, the rationale for practice, and contextual issues through a review of the literature. According to Pawson, 1 there are 3 characteristics of middle-range theories: (1) sufficient abstraction advancing beyond descriptions or empirical generalizations; (2) logical derivation, that is, making transparent connections to empirical evidence; and (3) adaptive, cumulative explanations, which means accepting that theory will evolve and change with circumstances and new evidence.

When designing an education program, educators consider what the program will achieve and how, but may not base decisions on formal educational theories such as constructivism. Realist researchers seeking to understand how an intervention or program works start by articulating underlying explanations for how the interventions (feedback for example) are expected to work. These are referred to as preliminary explanatory theories , initial program theory, or initial rough theory . Researchers then interrogate the existing evidence to adjudicate between initial theories and ascertain whether they are relevant in understanding mechanisms and observed outcomes. Hence, primary research is examined for its contribution to the developing theory. 16

For example, in a recent realist review undertaken by the authors, 14 we sought to explain how feedback programs and interventions might lead to changes in behavior in learners. Our preliminary program theory took account of 3 theories for their potential explanatory powers: self-regulated learning (SRL), 17 the educational alliance, 18 and self-determination theory (SDT). 19 All 3 theories have been used to explain feedback processes and tend to focus on what the trainee does. They also fit with our assumption that feedback is not solely due to the input of teachers, but how it is interpreted also influences learning. SRL might help us understand how feedback could support trainee goal construction, monitoring of performance, information seeking, and closing the gap. The educational alliance might offer different mechanisms for how feedback might influence some trainees within a certain context (eg, through relationship, dialogue, and co-construction). SDT as a theory of motivation might attune us to the conditions that promote trainees' internal motivations to engage with feedback processes. As you can see, all 3, at face value, offer a way to understand how feedback might work, for whom, and under what circumstances. The job of the realist reviewer is to test and refine these initial theories, by seeking evidence in the literature, understanding the relationships between different components based on existing research, and extending program theory in relation to the phenomenon under study.

Philosophical Basis

Realism as advanced by Pawson and Tilley 2 is the underlying philosophy of realist research. Pawson 1 translates Bhaskar's critical realism to a more pragmatic and operational perspective that enables empirical research into how a program works. According to Pawson, 3 realism occupies a midpoint between constructivism and post-positivism. Pawson holds that there is a concrete view of reality—a material reality. In other words, reality exists but can only be imperfectly known as processed through human senses, brains, language, and culture. Realism holds that “while our knowledge will always be partial and imperfect, it can accrue over time.” 20

Process Considerations

Pawson and colleagues 21 describe the key steps for undertaking a realist review. Like other qualitative literature syntheses, a realist review is not a technical process that follows a set protocol, rather, judgements are made about the relevance and robustness of specific data for the purposes of answering the research question. 20

The initial phase of scoping the literature is iterative and non-linear. It can include grey literature or advance along different pathways. An important aspect of scoping is developing the program theory—an explanation for why and how a program works. Initial program theories might be developed through brainstorming, speaking with experts in the field, familiarity with the literature, and initial scoping of literature. These are then tested and refined through the analysis process.

Searching the literature can be iterative and subsets of educational programs might be reviewed. Questions may be narrow or broad. For example, a review of effective research environments might include searches of specific interventions such as building research capacity, mentoring, or protected time. Resources, time, funding, etc will limit the breadth of the search; therefore, it is necessary to contain or focus the review by deciding on priorities for the lines of investigation. Issues of scale that might need to be managed include time frames, cultures, and countries. As with other reviews, snowballing (ie, identification of references from included papers) forms part of the search strategy. Librarian input is advised to guide researchers through the multitude of databases and the development of a parsimonious search strategy.

Relevance and rigor are 2 commonly used criteria for appraising the literature. Relevance is a determination of whether the paper contributes to theory building. Rigor refers to the quality and robustness of the methods. Authors may use holistic appraisal of relevance and rigor or specific analytical tools such as the Critical Appraisal Skills Programme checklists ( https://casp-uk.net/casp-tools-checklists/ ). Software such as Covidence can make this step more manageable across a research team.

Extracting Data

This step focuses on identifying CMO configurations. Realist analysis involves applying a realist philosophical lens to the data. This may be done in an Excel spreadsheet, comments in a PDF, or with software such as NVivo or Covidence. Data extraction is often qualitative and can be inductive and deductive.

A researcher will seek out the CMO configurations in each paper, then seek to identify CMO configurations across the data set. As mentioned, there may be a series of mechanisms required to achieve outcomes. As you can imagine, this leads to multiple circular conversations about what constitutes the CMO configuration. Returning to our feedback example, if trust (M) exists between a supervisor and trainee (C), then feedback (intervention) leads to improved performance (O). Further, CMO configurations are not linear. For example, having feedback conversations can lead to increased trust and motivation. Therefore, we also can think of these causal links as reciprocal. 22

Data Synthesis and Narrative Development

This stage relates to articulating an explanation of the patterns of CMO configurations identified in the previous stage. At issue is whether the identified CMO configuration can be used to justify, refute, or extend the program theory.

When a particular explanatory program theory fails to explain the data, new ones are sought. In keeping with the example above in relation to feedback, an overwhelming number of demi-regularities supported SDT as an explanatory theory. Given that the context of this review was undergraduate-level, open-ended, written tasks, it is possible that a realist review of trainee feedback in clinical environments might lead to a different refined program theory.

Publication standards have been established for the dissemination of realist reviews. 15 A guideline priority is the need for transparency of process and reasoning, which can be shown through document flow diagrams such as PRISMA, 15 tables, quotations, or diagrams showing the preliminary and refined program theories.

Strengths and Limitations

The strength of realist reviews is clear: their ability to build and refine middle-range theory to explain how a program works and why it might not. Realist reviews enable the drawing of connections across different contexts.

Working with qualitative and quantitative source papers is both a strength and a challenge. Together they strengthen theory development, which brings richness to the analysis. However, researchers need to be able to judge the quality of both approaches and to interpret findings in relation to the review research question. Quantitative studies can identify effects of a program on outcomes but not necessarily elucidate the mechanisms that mediate the effect. Alternatively, by their nature qualitative studies might highlight context and mechanisms, but not quantitative outcome measures.

There are multiple limitations to consider when undertaking a realist review. Initial program theories are drawn from multiple sources. The breadth and depth of the researchers' knowledge of theory will affect the direction of the review. In addition, the data analysis and synthesis stage of a realist review is particularly time consuming, as is the challenge of identifying CMO configurations.

Realist inquiry seeks to unpack the patterns of context-mechanism-outcome relationships which might explain why particular interventions succeed or fail, and how they influence outcomes in complex, open, adaptive systems. Put simply, realist inquiry asks what it is about the program or intervention that generates change. Thus, realist synthesis plays a key role in advancing theoretical explanations of interventions in medical education.

Critical Realist Considerations for Literature Reviews

26 Pages Posted: 8 Dec 2015

Chitu Okoli

SKEMA Business School

Date Written: December 8, 2015

This article adopts a critical realist approach to conducting literature reviews, an approach which attempts to discern the latent theoretical concepts underlying apparently disparate empirical investigations to synthesize diverse yet commensurable primary studies. Following the general model of a systematic review, it makes various comments with a specific goal of developing theory from a critical realist perspective.

Keywords: Theory development, theory building, theory testing, literature reviews, critical realism, information systems research

Suggested Citation: Suggested Citation

Chitu Okoli (Contact Author)

Skema business school ( email ).

Grand Paris Campus 5 quai Marcel Dassault, Suresnes Paris, 92150 France

HOME PAGE: http://chitu.okoli.org/pro

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The Guide to Literature Reviews

• What is a Literature Review?
• The Purpose of Literature Reviews
• Guidelines for Writing a Literature Review
• How to Organize a Literature Review?
• Software for Literature Reviews
• Using Artificial Intelligence for Literature Reviews
• How to Conduct a Literature Review?
• Common Mistakes and Pitfalls in a Literature Review
• Methods for Literature Reviews
• What is a Systematic Literature Review?
• What is a Narrative Literature Review?
• What is a Descriptive Literature Review?
• What is a Scoping Literature Review?

When to conduct a realist review?

How are realist reviews different from other reviews, how to conduct a realist review.

• What is a Critical Literature Review?
• Meta Analysis vs. Literature Review
• What is an Umbrella Literature Review?
• Differences Between Annotated Bibliographies and Literature Reviews
• Literature Review vs. Theoretical Framework
• How to Write a Literature Review?
• How to Structure a Literature Review?
• How to Make a Cover Page for a Literature Review?
• How to Write an Abstract for a Literature Review?
• How to Write a Literature Review Introduction?
• How to Write the Body of a Literature Review?
• How to Write a Literature Review Conclusion?
• How to Make a Literature Review Bibliography?
• How to Format a Literature Review?
• How Long Should a Literature Review Be?
• Examples of Literature Reviews
• How to Present a Literature Review?
• How to Publish a Literature Review?

What is a Realist Literature Review?

Understanding how, why, and under what circumstances complex interventions work is crucial for making informed decisions and policies. Realist reviews offer a robust methodology to achieve this by focusing on the mechanisms, contexts, and outcomes of interventions. They delve deeper to explore the intricate dynamics that contribute to an intervention's success or failure.

Realist reviews, also known as realist syntheses, are a type of literature review that aims to explain how and why interventions, such as complex policy interventions, work in specific contexts. They focus on the underlying mechanisms of action, the contexts in which these mechanisms operate, and the outcomes they produce. The primary purpose of a realist review is to provide a nuanced understanding of the complex interactions between interventions and their contexts. Realist reviews seek to answer questions such as: What works for whom, in what contexts, and why? How do specific contexts influence the effectiveness of interventions? What are the key mechanisms that drive outcomes? It is rooted in realist philosophy, which emphasizes the importance of understanding the mechanisms through which interventions bring about outcomes and the contextual factors that influence these mechanisms.

These reviews help policymakers, practitioners, and researchers determine the effectiveness of an intervention and understand the conditions under which it can be most effective. Realist review methodology is designed to develop and refine program theories that explain the observed outcomes. These program theories explain how an intervention works in different contexts, and researchers can explore the particular mechanisms that generate outcomes while considering the influence of contextual factors.

Realist reviews are grounded in theories that explain how interventions are supposed to work. These theories are tested and refined throughout the review process. A central element of realist reviews is the identification of Context-Mechanism-Outcome configurations (Pawson and Tilley 1997). These configurations help explain how certain contexts trigger specific mechanisms, leading to particular outcomes. The review process is iterative, involving constant refinement of theories and conclusions as new evidence is analyzed. Realist reviews emphasize understanding causal relationships rather than merely identifying correlations between interventions and outcomes.

Conducting a realist review is particularly advantageous when dealing with complex interventions involving multiple components and interactions. These interventions often do not yield straightforward results, and a realist synthesis can uncover the underlying mechanisms driving outcomes. This approach is especially useful in fields like healthcare, education, and social policy, where numerous factors interplay. When interventions are applied across diverse contexts, a realist review helps explain how different settings influence outcomes. If an intervention works well in one context but not in another, a realist synthesis can identify the contextual factors that affect its success or failure.

Realist reviews are also appropriate when there is a need to develop or refine theoretical frameworks explaining how interventions work. This theory-driven inquiry is beneficial in building a robust understanding of the underlying principles guiding effective interventions. When stakeholders need practical insights for program implementation or policy development, a realist review provides detailed explanations of what works, for whom, and under what circumstances. This type of review is valuable for policymakers, program developers, and practitioners requiring actionable knowledge. Lastly, in situations with limited or fragmented evidence, a realist review can synthesize available data to provide a coherent understanding of intervention mechanisms and contexts.

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A realist review or realist synthesis, differs notably from conventional review methodologies , such as those used in systematic reviews and meta-analyses . A systematic review designed to assess the effectiveness of interventions primarily uses quantitative methods to aggregate findings across studies. This approach focuses on producing a summary of evidence to determine if an intervention works. In contrast, realist syntheses aim to uncover the underlying mechanisms and contextual factors influencing outcomes. Unlike systematic reviews , which often provide little or no clue about how or why an intervention works, realist reviews explore these dynamics in-depth, offering a richer understanding of the intervention's impact within specific settings.

In the health sciences, where the complexity of interventions is often high, realist syntheses offer a unique advantage. While systematic reviews provide valuable insights into the overall effectiveness of interventions, they do not delve into the intricacies of programme theory. Realist reviews, guided by realist program theory, examine the interactions between context, mechanism, and outcome, offering a comprehensive view of how interventions work. This approach contrasts with the conventional review methodology, which may overlook these critical factors. By focusing on the realist program theory, realist syntheses provide practical insights that can inform the design and implementation of interventions, particularly in complex fields like health sciences.

Conducting a realist review involves several key steps to ensure a thorough and systematic approach to understanding complex interventions. Here are the main steps:

Formulate the review question : Define the review question, objectives, and scope. This question should incorporate elements of context, mechanism, and outcome (CMO)(Pawson and Tilley 1997). The review focus should be on theory development and refining theory through empirical evidence and qualitative data .

Search for evidence : Conduct an iterative and flexible search process to gather a wide range of evidence. This includes primary studies and meta-narrative evidence syntheses that can provide insights into how the intervention works in different settings.

Appraise and extract data : Evaluate the relevance and rigour of the research evidence . Focus on extracting data that illuminate the mechanisms, contexts, and outcomes related to the intervention. Use inclusion and exclusion criteria to ensure the evidence is relevant to the review scope.

Synthesize evidence : Develop and refine theories about how the intervention works by identifying patterns across the studies. This involves constructing CMO configurations (Pawson and Tilley 1997) that explain the observed outcomes. Data synthesis is a crucial part of this process.

Interpreting and reporting : Interpret the findings to provide actionable insights. The final report should include recommendations on how the intervention can be adapted or improved based on the understanding of its mechanisms and contexts. Stakeholder involvement in this phase can enhance the practical relevance of the findings.

Conducting realist reviews offers a powerful approach to understanding the complexities of interventions in real-world settings. A realist review provides valuable insights that go beyond simple effectiveness, focusing on the interplay between context, mechanism, and outcome. This method is particularly beneficial in healthcare, education, social policy, and environmental initiatives, where understanding the contexts, mechanisms, and outcomes is crucial.

Realist reviews help design and implement interventions that are both effective and context-sensitive. They delve into the why and how behind outcomes, making them essential for developing evidence-based policy grounded in a deep understanding of real-world complexities.

Realist reviews use diverse evidence and explain variability in outcomes, enhancing our understanding of interventions and improving their practical application in real-world settings. As a result, they serve as an indispensable method for designing and implementing effective, context-sensitive interventions. Employing realist reviews in your research can lead to more impactful and sustainable solutions across various fields.

• Pawson, R., & Tilley, N. (1997). Realistic Evaluation. SAGE Publications.

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The Palette of Literature Reviews Available for Critical Realists

• First Online: 28 September 2017

Cite this chapter

• Majbritt Rostgaard Evald 3  

1988 Accesses

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The chapter gives scholars insight into how different types of literature reviews can be conducted if you do research from a critical realist stance. Some researchers, because of their paradigmatic stances, have predetermined ideas about conducting a literature review. This makes sense if the researcher belongs to the positivist paradigm, where a researcher favours a meta-analysis review (systematically and empirically reviewing quantitative studies), whereas a researcher belonging to the interpretivist paradigm will prefer to conduct meta-synthesis reviews (reviewing qualitative studies and their interpretations). For a critical realist, more approaches are available, with the main proviso that the reviews undertaken are done in a systematic and transparent way. This chapter focuses on the critical realist options and provides researchers with an overview of different types of reviews to choose from. The chapter does not give an exhaustive account of all the reviews existing; rather, it gives scholars insight into the different review varieties that exist and thus prepares the scholar to take an active choice of what review to conduct in connection to its purpose and objectives.

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Evald, M.R. (2018). The Palette of Literature Reviews Available for Critical Realists. In: Freytag, P., Young, L. (eds) Collaborative Research Design. Springer, Singapore. https://doi.org/10.1007/978-981-10-5008-4_5

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Knowledge Syntheses: A How-To Guide

• Realist Review
• Before You Begin
• How can the Library Help You?
• Systematic Review
• Scoping Review
• Rapid Review
• Integrative Review
• Planning Your Review
• Searching & Documenting
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What is a Realist Review?

What is it.

• a method for studying complex interventions in response to the perceived limitations of conventional systematic review methodology
• Involves identification of Contexts, Mechanisms and Outcomes for individual programs to explain differences, intended or unintended, between them
• "t raditional methods of review focus on measuring and reporting on program 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" (p. 21)

Pawson et al. (2005)

Outline of Stages

• 1 to 6 months
• Answers complex questions in a manner that attempts to explain rather than pass judgement.
• Expect question focusing to be a time-consuming and ongoing task as you learn more about the topic over the course of the review

Sources and searches:

• These four steps can be a general outline on how to think about the searching process, but keep in mind that your process may be quite circuitous:
• A background search to see what's out there
• Focus the scope of the review by identifying "the administrative thinking, policy history, legislative background, key points of contention in respect of the intervention, and so on." ( Pawson et al., 2005)
• Formally search for primary studies to back up the theories (this search should be properly documented)
• One final search near the end of evidence compilation to find additional studies that add to the theories
• Since the method of searching is purposeful rather than comprehensive, compiling resources is more about actively seeking relevant materials rather than systematically gathering a large number of articles and excluding irrelevant ones
• Complex service interventions are influenced by other programs
• Policies are rarely adopted instantly in its entirety thereby defining a cut-off between control and intervention near impossible
• Realist reviews which favors judgement by the reviewer to appraise articles
• Involves taking the preliminary understanding of a theory and applying the evidence to refine the theory.
• A realist review tries to provide more explanation and detail to a theory or intervention

( Pawson et al., 2005)

Limitations

Finding balance: According to  Rycroft-Malone et al. (2012) , "the challenge of developing a framework for a realist synthesis is in finding a level of abstraction that allows reviewers to stand back from the detail and variation in the evidence, but that is also specific enough to meet the purpose of the review" (p. 3).

Rycroft-Malone et al. (2012)  state that conducting a realist review "is not an easy option. Realist review[s] demands much of the reviewer, including an ability to think flexibly and deal with complexity" (p. 9).

Pawson et al. (2005)  also state that realist reviews can't be applied in a wide variety of contexts, explaining that "realist review[s] cannot be used as a formulaic, protocol-driven approach. Realist review[s] [are] more about principles that guide than rules that regularize" (p. 32).

Pawson et al. (2005)  also add that realist reviews are "not standarizable or reproducible the same sense as a conventional Cochrane review" (p. 32) and that realist reviews often only lead to, at the most, tentative recommendations. As well, it is important to note that realist reviews require considerable skill to complete and to date have not been published as much as other review types. 

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• Unpacking the design, implementation and uptake of community-integrated health care services: a critical realist synthesis
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• http://orcid.org/0000-0003-1441-2172 Ferdinand C Mukumbang 1 , 2 ,
• Denise De Souza 3 ,
• Hueiming Liu 3 , 4 ,
• Gabriela Uribe 4 , 5 ,
• Corey Moore 2 ,
• http://orcid.org/0000-0003-1853-8194 Penelope Fotheringham 5 ,
• John G Eastwood 2 , 4
• 1 Department of Global Health , University of Washington , Seattle , Washington , USA
• 2 Ingham Institute , Liverpool , New South Wales , Australia
• 3 Torrens University Australia , Adelaide , South Australia , Australia
• 4 Sydney Local Health District , Camperdown , New South Wales , Australia
• 5 The University of Newcastle , Callaghan , New South Wales , Australia
• Correspondence to Dr Ferdinand C Mukumbang; mukumbang{at}gmail.com

Introduction Community-integrated care initiatives are increasingly being used for social and health service delivery and show promising outcomes. Nevertheless, it is unclear what structures and underlining causal agents (generative mechanisms) are responsible for explaining how and why they work or not.

Methods and analysis Critical realist synthesis, a theory-driven approach to reviewing and synthesising literature based on the critical realist philosophy of science, underpinned the study. Two lenses guided our evidence synthesis, the community health system and the patient-focused perspective of integrated care. The realist synthesis was conducted through the following steps: (1) concept mining and framework formulation, (2) searching for and scrutinising the evidence, (3) extracting and synthesising the evidence (4) developing the narratives from causal explanatory theories, and (5) disseminate, implement and evaluate.

Results Three programme theories, each aligning with three groups of stakeholders, were unearthed. At the systems level, three bundles of mechanisms were identified, that is, (1) commitment and motivation, (2) willingness to address integrated health concerns and (3) shared vision and goals. At the provider level, five bundles of mechanisms critical to the successful implementation of integrated care initiatives were abstracted, that is, (1) shared vision and buy-in, (2) shared learning and empowerment, (3) perceived usefulness, (4) trust and perceived support and (5) perceived role recognition and appreciation. At the user level, five bundles of mechanisms were identified, that is, (1) motivation, (2) perceived interpersonal trust, (3) user-empowerment, (4) perceived accessibility to required services and (5) self-efficacy and self-determination.

Conclusion We systematically captured mechanism-based explanatory models to inform practice communities on how and why community-integrated models work and under what health systems conditions.

PROSPERO registration number CRD42020210442.

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All data relevant to the study are included in the article or uploaded as online supplemental information.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjgh-2022-009129

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Community-integrated care initiatives are designed to better co-ordinate care around people’s needs.

Community-integrated care initiatives are increasingly being used for social and health service delivery and show promising outcomes.

WHAT THIS STUDY ADDS

Causality-based explanatory models constructed through the integration of community health systems and patient-centred lenses to capture the complexity around the design, implementation and uptake of community-integrated care initiatives.

Unpacks and causally links the existing structures, relevant context conditions, and generative mechanisms critical to the design, implementation, and uptake of community-based integrated initiatives.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

The generative mechanisms, relevant structures and influential contextual elements can provide guidance to the critical elements required for the successful design, implementation and uptake of community-integrated care initiatives.

Introduction

Integrated service delivery initiatives are increasingly being identified and adopted to address the multifactorial and dynamic causes of ill health and ill-being across the globe. Integrated care is the inclusion of a range of different care services to achieve better social and health outcomes. 1 In this perspective, integrated care is a coherent set of methods and models for funding, administrative, organisational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the care and cure sectors. 2 Goodwin defines it as ‘a broad and multicomponent set of ideas and principles that seek to better co-ordinate care around people’s needs’. 3

Integrated care approaches strive to overcome care fragmentation, especially in situations where fragmented service delivery adversely impacts clients’ care experiences and outcomes. 3 Community-based integrated care initiatives are those that are based primarily in the community and aim to engage clients with primary healthcare and community services while using hospital services in an appropriate manner. 4 Leutz 5 observed that community-based integrated care approaches may be best suited to people living with poor socioeconomic determinants of health with medically complex or long-term care needs. The level, type and combination of strategies used while designing a community-based integrated care initiative would depend on the characteristics of the patient population and the specific challenges they face to obtain appropriate quality care. 5

Owing to their multidimensional design and service provision structure, community-based integrated care delivery models provide more comprehensive services to improve the care of families with complex health and social needs. There is an increasing evidence indicating that community-based integrated care models reduce avoidable hospital admissions. 6 From a health and social systems perspective, community-based integrated care services can reduce costs accrued from delivering inappropriate and fragmented care, across hospital and primary care services. 7 In addition, integrated care including community-based initiatives strive to enhance quality and provide a better service experience—more sensitive to the personal circumstances and wishes of the individual client and their family. 2 The goal of adopting integrative approaches to service delivery is to enhance the quality of care and quality of life, consumer satisfaction and system efficiency for people by cutting across multiple services, providers and settings. 3

Combined medicosocial services close to home have shown to have the potential to close the significant service delivery gap and improve the uptake of healthcare services, which in turn improves population health. 8 Nevertheless, such service delivery initiatives face regulatory, organisational and technical challenges. First, highly context-dependent unpredictable treatments are caused by uncertainties and interruptions typical of knowledge-intensive work. Second, the heterogeneity of available services hinders the required exchange of semantic information. Third, coordination across multiple organisations and different roles are essential. In addition, combining healthcare and social care activities provided in a specific spatiotemporal context and relational proximity, integrated and centred on the needs of the inhabitants of a territory engenders generative mechanisms to improve the health outcomes of a targeted population. 9

Owing to their multidimensional, multicomponent and complex nature, community-integrated care programmes pose enormous challenges to evaluate. To this end, the ‘true’ or ‘real life’ impact of community-integrated care initiatives are difficult to determine, and the standard measures currently used to assess them do not directly assess their impact on service users and service providers. Billings et al 10 confirm that there is a mismatch between the ability to capture the somewhat ‘elusive’ impact of integrated care initiatives and what could be the most appropriate way to do so. Consequently, there is advocacy for patient experiences and outcomes to be captured as measures of integration. 11 Nevertheless, simply capturing patients’ experiences and outcomes will have a limited contribution to evidence-based practice that can inform the further design, implementation and uptake of community-integrated care initiatives to other relevant contexts. As such, theory-driven approaches to evaluation such as realist-informed methodologies have been proposed as suitable for the evaluation of integrated care initiatives. 12

A pragmatic evaluation of a community-integrated care initiative should inform decision-makers whether the intervention has the capacity and capability to maintain service delivery, sustain (or improve) health outcomes and client experiences while minimising daily costs. 13 Critical realist approaches have value in improving evidence-based practice as they can be used to study the intricacies around the design, implementation and uptake by identifying and highlighting causal claims concerning these details while retaining the notion of complexity that exists in their practical implementation. 14 The dynamic learning process that can arise in conducting a realist synthesis may generate new ideas for programme development and innovation apart from what can be achieved in reviews providing a summary of quantified evidence. 15

In this critical realist synthesis, we aimed to identify the causal mechanisms provided and triggered by community-integrated care initiatives within various contextual conditions in relation to hospital presentation behaviours among people with complex health and social care requirements. We sought to achieve this by gleaning and refining a priori initial programme theory on ‘how’ and ‘why’ community-integrated care initiatives improve (or not) hospital presentation behaviours among people with complex health and social care requirements. The purpose of undertaking the review is to use the reported or identified causal mechanisms—which may highlight flows and blockages in the various context conditions—to build transferable integrated theories that can inform the design, implementation, and uptake of integrated care initiatives. 16

Study design

We conducted a critical realist synthesis (also known as “realist review”), a theory-driven approach to reviewing and synthesising the literature rooted in the philosophy of critical realism. Critical realist-informed research seeks to unearth the causal mechanisms and circumstances by which programmes, policies and interventions work or do not work. 17 Critical realist synthesis as a method has been used to develop evidence-informed theories about the interactions between community-based integrated care mechanisms and their implementation contexts. 18

As community-integrated care models strive to modify the organisation of services, it is possible to suggest that such social programmes, introduced as interventions, tend to also involve structural, cultural, agential and relational mechanisms. 14 Critical realists argue for comprehensive explanations of the interactions of structure and agency, 19 which are sometimes excluded or conflated in the realist synthesis practice proposed by the Realist and Meta-Narrative Evidence Syntheses—Evolving Standards project. This conflation occurs because Pawson and Tilley 20 present mechanisms as a combination of reasoning and resources, which implies that they can be components of both structure and agency. This makes discerning the actual source of change challenging and may lead to ‘the intervention’ in general being designated as the main source. 17

The concept of mechanisms is central to the critical realist philosophy of science. Mechanisms are typically not directly observable and are considered the underlying entities that produce specific outcomes in specific contexts. The task of conducting a realist synthesis is to mine and make explicit the underlying mechanisms that produce the ‘phenomenon and to understand the interplay between them and how they shape the outcome’. 14 The elicitation of our programme theories was informed by the critical realist causality framework proposed by Sayer 21 ( figure 1 ).

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Critical realist-informed causal configuration.

Under certain contextual conditions, the existing mechanisms and those introduced by the community-integrated care initiatives can be activated to improve hospital attendance and the uptake of healthcare services. Therefore, the identification of generative mechanisms and counteracting mechanisms requires the consideration of context elements, conditions required to determine how a mechanism empirically manifests. 14 The context or condition with causal tendencies may consist of aspects of structure, culture, agency and relations (eg, individual, organisational and environmental characteristics) and historical elements that can potentially (de)activate existing or introduced mechanisms. 18 22 23

The design of this synthesis was based on the realist synthesis idea proposed by Hinds and Dickson 17 and steps developed by Rycroft-Malone et al . 24 The steps adopted were as follows: (1) concept mining and framework formulation, (2) searching for and scrutinising the evidence, (3) extracting and synthesising the evidence (4) developing the narratives from causal explanatory theories, and (5) disseminate, implement and evaluate. 24

In addition to specific guidance for realist reviews, this review also drew on the six cross-cutting principles of meta-narrative reviews: pragmatism, pluralism, historicity, contestation, reflexivity and peer review 25 ( figure 2 ).

Proposed iterative process for searching articles in the synthesis. 28

Our realist search and review process was iterative and not as linear or rigid as a traditional systematic review. 16 The following sections describe the five steps that were adopted in the review.

Step 1: clarify scope - concept mining and framework formulation

This step involved refining the review focus and purpose through initial informal searches, discussions and drawing on existing theoretical and empirical literature. We started by identifying what definition of integrated care will suit our review aims. Integrated care, which has more generalised definitions, has also been defined from four different perspectives, namely, (1) a health system-based perspective; (2) a manager’s perspective; (3) a social science perspective and (4) a patient’s perspective. After iterative discussions about the review aim and objectives, we adopted a people-centred integration care approach to the review. According to Goodwin, a people-centred integration care approach is ‘integrated care between providers and patients and other service users to engage and empower people through health education, shared decision-making, supported self-management and community engagement’(Goodwin 3 , p 2).

The ‘community’ is particularly relevant in integrated care given that it is their dwelling place. To explain the impact of community-integrated care initiatives using the people-centred integration care approach while maintaining the element of complexity, we incorporated two lenses to guide our evidence synthesis — (1) the community health system 26 and (2) the person-focused perspective of integrated care. Our adoption of these two lenses is informed by the fact that when used to describe a person-centred care model, integrated healthcare is synonymous with a more holistic and tailored approach to patient care, one which focuses on a patient as a ‘whole person’ and incorporates more complementary services in the process ( figure 3 ).

Integration of community health systems and patient-centred lenses.

We initiated this critical realist synthesis by identifying two peer-reviewed articles through our initial scoping search to elicit the initial theories. 27 The rationale for our selection was to allow us to capture the critical elements of community-based integrated care programmes that provide care to people that often have complex health and social care requirements (structures). We intended to search for those articles that could shed light on elements related to such structures, possible mechanisms and possible observed outcomes to allow us to formulate our initial programme theory through abductive thinking—a form of inventive and intuitive (‘hunch-driven’) thinking that allows a researcher to creatively imagine, for example, potential mechanisms to be investigated. 28 29

The first of the two papers report on the critical realist evaluation of a community-based integrated care project, Healthy Homes and Neighbourhoods (HHAN), for vulnerable families in Sydney, Australia. 30 HHAN Integrated Care Initiative was established in Sydney, Australia to improve the care of families with complex health and social needs who reside in Sydney Local Health District. HHAN was designed to provide long-term multidisciplinary care coordination to enhance capacity building and promote integrated care. 30 The authors found trust, perceived support, social and organisational relationships, and client empowerment as mechanisms underpinning how HHAN worked. 30 The authors also found that reluctance to engage with services was related to service (un)availability and client vulnerability; important context conditions with causal tendencies. 30 This paper provided us with important information related to possible mechanisms and other conditions with causal tendencies at work in the implementation of a community-based integrated care model in Australia.

The second paper that we found useful to inform our initial programme formulation was a systematic review designed to explore the effects of integrated care models globally. The paper was focused on systematically reviewing the literature on the effects of integration or coordination between healthcare services or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. 6 The authors found perceived improved quality of care, increased patient satisfaction and improved access to care as the outcomes of various integrated care models implemented globally. 6 This paper, therefore, provided us with information regarding the possible outcomes of community-based integrated care models.

With the information on the possible mechanisms and other conditions with causal tendencies at work in the implementation of a community-based integrated care model from Tennant et al 30 and information regarding the possible outcomes of community-integrated care models from Baxter et al , 6 we developed the following initial programme theory (Figure 4). Our initial theory was elicited based on the information obtained from these two sources through abductive thinking and retroductive theorising figure 4 . 15 This meant considering the outcomes of community-based integrated care interventions described in the two selected studies—presentations at hospitals and the uptake of healthcare services, and working backwards to think about the conditions of reality that are necessary for these outcomes to occur as influenced by the elements of the community-based integrated care models. 15 The elements obtained from the two studies were abductively developed into a conceptual diagram informed by Sayer’s conceptualisation of critical realist causality. 21 The theories were further abstracted following discussions within the author team.

An initial programme theory of community-integrated care approaches.

Figure 4 illustrates the initial programme theory of community-integrated care approaches. Our initial programme theory captures how the perceptions, feelings and experiences vis-à-vis the different components of the community-based integrated care influence their hospital attendance and healthcare services uptake behaviours. This enables the review to remain open to both positive and negative, intended and emergent, and ethical or other outcomes.

Step 2: search for evidence

Searches for realist reviews are usually less formulaic and are iterative, involving multiple search strategies and approaches. 31 We searched the following databases: MEDLINE, Embase, CINAHL Plus, PsycINFO and the EBM reviews including the Cochrane Database of Systematic Reviews. This involved using combinations of search terms such as “integrated community care”, “non-communicable disease”, “complex health and social care requirements”, prevention and more. The search was focused on one or more integrated care health and/or social care interventions that are based in a primary care/community care setting, rather than a hospital setting.

An initial search strategy using MeSH terms was conducted by two of the authors CM and PF. This process yielded 21 articles that met the inclusion criteria. Then, a second search was conducted by FCM, which was relatively narrow and targeted two Integrated care journals: Journal of Integrated Care (JICA) and The International Journal of Integrated Care (IJIC). We searched the titles and abstracts of all the 10 last volumes of JICA and IJIC from 2011 to 2021. Through the second search process, a further 18 articles were included for review. The search and screening processes are reported on a Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram ( figure 5 ).

PRISMA diagram illustrating the search and screening process of relevant articles. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Our goal for information gathering was to obtain explanations based on empirical data and also on information as to how the introduction of community-integrated initiatives interact with other systems and cultural ideas to engender change. 17 It is acknowledged that realist searches are likely to be iterative and responsive to emergent data. 31 To this end, our study selection was purposive, meaning that the goal was not to represent the existing evidence base in its entirety, but rather only include what the authors deemed relevant for expanding, refuting or refining the initial theories. 32 Initial screening of studies based on title, abstract and keywords took place simultaneously with the searches. We also considered grey literature reporting on impact evaluations, process evaluations, action research, documentary analysis, administrative records, surveys, legislative analysis, conceptual critique, personal testimony thought pieces and commentaries. The following inclusion criteria were considered:

Study design: All published study types were included.

Papers from all WHO defined regions and countries will be considered if an English language translation is available.

Publication date: Any, with priority given to more recent studies.

Document type: Any document type that informed the review, including commentaries and practice-based articles, if they come from peer-reviewed journals or reputable and relevant sources of grey literature.

Population: Multimorbidity clients enrolled in an integrated care programme that takes place in a community setting will be included. Clients can be both adults and children in the included studies.

Content: Community-integrated care initiatives that provide healthcare and social services to people that often have complex health and social care requirements.

Intervention: One or more community-integrated care initiatives.

Language: English.

Step 3: appraise studies and extract data

Data extraction and appraisal were carried out using a template that was developed and piloted specifically for this realist review, covering both any data relevant to inform the theory development and study characteristics needed for conducting a quality assessment of each study. The template and data extraction process were also informed by the realist approach to thematic analysis, which incorporates different forms of reasoning (inductive, deductive, abductive and retroductive) into the thematic analysis. 33 While the use of a data extraction template resembles a codebook approach to thematic analysis, the realist approach was used to consider both manifest semantic content, such as reported outcomes, latent context and potential mechanisms. 34 This enabled us to start eliciting theories already at the data extraction phase.

Further inclusions and exclusions of literature, and refinement of inclusion criteria, occurred at this point. This step of the process entailed the review team’s judgement of ‘fitness for purpose’ in relation to the review’s aims. Considerations of ‘fitness for purpose’ was be guided by the two key criteria of relevance (does the research address the review’s objectives and theories being developed?) and rigour (do the conclusions put forward by researchers or the review team hold about the data presented?). 28

Step 4: synthesise evidence and draw conclusions

The process of synthesising the evidence was guided by retroductive theorising—deliberately going back to unearth the generative mechanisms and other causal conditions necessary for the observed phenomenon to occur. 35 Analysis and synthesis of data extracted in the previous step were carried out through thematic analysis 34 with a particular focus on abductive thinking to elicit new theories and build on the initial programme theory. Abductive thinking guided the process of postulating what mechanisms are involved in generating specific outcomes. 35 First, the mechanisms were identified through clear causal linkages identified as triads (context-mechanism-outcomes) and dyads (mechanism-outcome, context-mechanism) and then as single constructs. Through retroduction, we linked the thematically obtained constructs to formulate mechanism-based explanatory models. 36 Second, the countervailing mechanism identified at each level and pertaining to the identified outcomes were used to confirm the causal mechanisms that trigger the intended outcome. This was achieved in the process of counterfactual thinking. 37 We, therefore, used feedback loop diagrams as an analytic strategy to synthesise material from the review of evidence to map out pathways of change in community-integrated care initiatives and to identify generative mechanisms. 17 Using causal loop diagrams helped us to identify and represent the relevant constructs (structures, contexts, mechanisms and outcomes) and to illustrate the links between these constructs to highlight the micro theories that make up the theoretical model. 36

To streamline our identified theories, we followed Layder’s conceptualisation: self—consumer, situated face to face—clinician-consumer, and intermediate level of social and service organisation, 38 which aligns with the microlevel (clinical), mesolevel (service delivery) and macrolevel (system) of a health system. For each of these levels, we have provided thematic constructs for each of the elements in our heuristic tool, with table 1 illustrating the different elements of the Structure-Context-Mechanism-Outcome heuristic framework. In addition to the illustrative tables, we constructed causality models using the corresponding elements identified in table 1 . Figures 6–8 illustrate the programme theories elicited at three levels.

• View inline

Thematic representation of the realist constructs

Systems-level SCMO configurational theory. The mechanisms at this level are related to the actors operating at the systems level such as managers, heads of departments and other high-level stakeholders. SCMO, structure–context–mechanism–outcome.

Provider level SCMO configurational theory. Organisational level relates to programme implementers and health and social care providers. SCMO, structure–context–mechanism–outcome.

User-level programme theory. Consumer-level mechanisms relate to service users and their social networks. C, context; M, mechanism; O, outcome; S, structure.

Step 5: disseminate, implement and evaluate

The output of this critical realist synthesis has practical applications in community-based integrated care programmes research, design, interventions and other health promotion efforts. For evaluation, stakeholders—persons involved with or affected by a course of action—consultations should be carried out in relation to specific integrated initiatives the form of discussions and realist interviews to refine the programme theories in a contextually meaningful way.

Patient and public involvement

It was not appropriate to involve patients or the public in the design, or conduct, or reporting or dissemination plans of our research.

In this critical realist review, we sought to unearth, based on the published literature, the critical generative mechanism and social structures required to explain how and why community-integrated care initiatives are designed, implemented and adopted by the targeted populations. To streamline our identified theories, we followed Layder’s conceptualisation: consumer level provider level, and systems or service level of social and health service organisation. 38

At the systems level, three bundles of mechanisms were identified as critical to the consideration and design of community-based integrated health initiatives, namely, (1) commitment and motivation, (2) willingness to address integrated health concerns and (3) shared vision and goals. Frieden 39 identified political commitment as one of the six critical elements necessary for effective public health programme design and implementation. He argued that effectively engaged political commitment leads to the provision of resources and support needed to design, coordinate, implement and sustain public health interventions, including policy change where needed. 39 Lezine and Reed 40 also identified political will as being essential for securing the resources for policy change. The critical role of shared vision and goals as core features for primary care transformation, which includes the design of relevant healthcare interventions was also discussed by Tamblyn et al . 41 In combination, our study suggests that these three bundles of mechanisms are triggered under various contexts in the existence of structures such as national and regional policies promoting integrated care initiatives, the prevalence of integrated health concerns and historical service delivery silos to inform the development of integrated care initiatives.

At the provider level, five bundles of mechanisms critical to the successful implementation of integrated care initiatives were abstracted, namely, (1) shared vision and buy-in, (2) shared learning and empowerment, (3) perceived usefulness, (4) trust and perceived support, and (5) perceived role recognition and appreciation. Buy-in is considered to be a personal and professional commitment to actively engage in a process, task or initiative. 42 Buy-in does not occur until the individual’s goals and core beliefs align with those of the organisation hence its association with shared vision. 42 Shared vision and buy-in across organisations and professions are therefore critical to innovation and change including the implementation of integrated care initiatives. 43 Empowerment relates to a process in which an individual understands their role, are given the knowledge and skills to perform a task and encourages their participation in an activity. Its connection to knowledge acquisition justifies its association with shared learning in our analysis. Generally, ideals of empowerment are used to draw attention to the capacities and abilities of individuals to promote power and participation. 44 Regarding perceived usefulness, according to Gajanayake et al , 45 healthcare professionals’ perception of the usefulness and their attitudes towards an intervention has significant effects on the overall acceptance of that intervention by users. Healthcare providers perceived support has been associated with increased participation in healthcare intervention delivery. 46 The extant literature on organisational psychology suggests that employee engagement, in general, is related to the perceived social support offered by their organisation. 47 Perceived support enhances trust—reliance on a trustee with confidence—which is also important in the functioning of the health system and delivery of health and social care services. 48 An employee’s satisfaction with their job affects their quality of work and productivity. According to the American Society of Clinical Oncology, 49 when employees are appreciated, feel needed and nurtured, they become motivated to do more. The mechanisms discussed herein are underpinned within the structures of (1) state of formalisation of integrated care, (2) goals of the involved agencies, (3) level and complexity of clients’ vulnerabilities, (4) existing leadership structures and (5) collaborative design of the integrated care initiatives.

At the user level, five bundles of mechanisms were unearthed: (1) user motivation, (2) perceived interpersonal trust, (3) user-empowerment, (4) perceived accessibility to required services and (5) self-efficacy and self-determination. Motivation is central to the adoption of any healthcare delivery interventions. Regarding the uptake of integrated service initiatives, both extrinsic and intrinsic motivations have roles to play. While intrinsic motivation is based on the physiological needs of the patient primarily, extrinsic motivation is more service delivery related. Motivation has been identified as being a key mechanism for patient engagement in care especially long-term engagement. 50 Perceived trust from the point of view of the patient is the cornerstone for the uptake of health and social care services. According to Rowe and Calnan, 51 the need for interpersonal trust relates to the vulnerability associated with illness, information asymmetries, and the uncertainty and element of risk regarding the competence and intentions of the service provider. Having positive expectations regarding the competence of the service provider and that they will work in the best interests of patients 51 is, therefore, a key mechanism driving the uptake of integrated care initiatives. Patient empowerment—a process through which people gain greater control over decisions and actions affecting their health—is effective and beneficial to populations with complex medical and social needs. 52 Individuals who have difficulty gaining access to healthcare may delay seeking such services. According to Shavers et al , 53 an individual’s perception of healthcare access is likely to influence their uptake of healthcare services when the need arises. Two key determinants of behaviour are self-efficacy and self-determination. Individuals who have higher self-determined motivation to engage with integrated healthcare services are more likely to develop health self-efficacy.

In addition to identifying the generative mechanism and relevant structures central to determining how and why community-integrated care initiatives are designed, implemented and used, we also captured relevant social and health systems contexts that trigger such generative mechanisms. The consideration of context-embedded evidence includes understanding the history and precedence of the observation—basically what has happened in the past in the context, plays a part in explaining how things came to be so and not otherwise. Therefore, to improve the explanatory power and consequently, the adaptability of evidence informing the implementation of a community-integrated care initiative, the evidence should be linked to the programmatic/organisational and historical contexts.

The implementation of an integrated care approach involves all the settings where the targeted population dwell and function (communities), but also requires a concerted action among microlevel (clinical), mesolevel (service delivery) and macrolevel (system). 54 The community is, therefore, of relevance as it represents where the actors reside and function. To this end, we used integrated-community health systems and patient-centred lenses to delineate our study boundaries and capture the complexity of how and why community-integrated care initiatives are designed, implemented and used. Although we formulated three programme theories relating to outcomes of design, implementation and uptake, these programme theories are intricately connected. What happens at one level, the programme design, for example, affects what happens at the other levels. For example, poor implementation outcomes of the community integrated care initiative at the provider level will affect the uptake or adoption of the intervention at the user level. This approach aligns with the complexity science approach, a theoretical approach to understanding interconnections among agents and how they give rise to emergent-level, dynamic-level, and systems-level behaviours. 55

Limitations

All but one of the studies from which the evidence was obtained came from high income countries with most of the studies conducted in Australia and the USA. Therefore, critical context element and relevant mechanisms that are unique to middle-income and low-income countries might have not been captured.

Outcome-based and process evaluation exercises have demonstrated that community integrated care initiatives integrating healthcare and social services improve the uptake of healthcare services and the health outcomes of the targeted populations. This critical realist review unearthed the generative mechanisms, relevant structures and influential contextual elements critical to the successful design, implementation and uptake of these initiatives. In our three programme theories, we systematically captured through retroductive thinking, explanatory models to provide feedback to intervention developers and implementation-relevant information to the practice communities.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

Formal ethics review is not required for the review itself, as it constitutes secondary research with the element of peer feedback from relevant researchers.

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Handling editor Stephanie M Topp

Contributors The project was conceived by FCM and JGE. FCM designed, conducted and wrote the first draft of the manuscript. DDS provided methodological guidance and contributed to writing these sections. HL, GU and JGE revised the manuscript critically for important intellectual content. All authors approved the version to be published.

Funding This study will be funded in part by Sydney Local Health District, Sydney, NSW Australia (Award No. 162 N/A), and the Australian National Health and Medical Research Council Grant (Award No. 163 APP1198477) Centre of Research Excellence for Integrated Health and Social Care (Award No. N/A).

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

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Posted on Sep 24, 2013 in Research publications

Critical Realist Guide to Developing Theory with Systematic Literature Reviews (Okoli 2012)

Okoli, Chitu, A Critical Realist Guide to Developing Theory with Systematic Literature Reviews (December 13, 2012). Available at SSRN: http://ssrn.com/abstract=2115818 or http://dx.doi.org/10.2139/ssrn.2115818

A literature review requires sifting through large amounts of reading

Keywords: Theory development, theory building, theory testing, systematic reviews, literature reviews, critical realism, information systems research

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Critical Realism: A Literature Review and Methodological Implications Paperback – July 19, 2017

• Print length 148 pages
• Language English
• Publication date July 19, 2017
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• Publisher ‏ : ‎ LAP LAMBERT Academic Publishing (July 19, 2017)
• Language ‏ : ‎ English
• Paperback ‏ : ‎ 148 pages
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A protocol for a critical realist systematic synthesis of interventions to promote pupils’ wellbeing by improving the school climate in Low- and Middle-Income Countries

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Introduction The review described in this protocol will be the first critical realist review of the literature reporting on the impact of interventions to promote pupils’ wellbeing by improving the school climate in Low- and Middle-Income Countries. The review is being carried out to inform the programme theory for a critical realist evaluation of a whole school mindfulness intervention in Ethiopia and Rwanda to improve pupils’ mental wellbeing. Our initial programme theory hypothesises that pupils’ (and teachers’) responses to the mindfulness intervention as well as changing the behaviour and attitudes of individual pupils and teachers, will change the ‘school climate’ in ways that have a positive impact on mental wellbeing. This literature review will facilitate the identification of mechanisms for change working at the level of the whole school climate, something which is only infrequently discussed in evaluations of mindfulness interventions.

Methods and analysis A critical realist review methodology will be used to provide a causal interdisciplinary understanding of how school climate can promote the wellbeing of pupils. This will be done through a systematic literature review and extrapolating context, agency, intervention, mechanisms, and outcome configurations and synthesising these to provide a conceptual understanding of the impact of interventions to improve school climate.

Discussion The review findings will inform a critical realist evaluation of a mindfulness intervention in schools that we will be carrying out. The findings from the review will enable us to focus more precisely and transparently on what policymakers and other stakeholders need to know about how school climate changes due to introducing mindfulness to the curriculum and how this impacts pupils’ wellbeing [and for which pupils]. We will publish the findings from the review in academic and professional publications, policy briefs, workshops, conferences, and social media.

PROSPERO registration number CRD42023417735

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

The research is funded by the National Institute for Health and Care Research (NIHR133712) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government. The funders did not and will not have a role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The protocol is for a literature review and ethics approve is not required. However, the project of which the literature forms a part has obtained ethics approval from the University of Aberdeen, Addis Ababa University and the University of Rwanda

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

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