Realist reviews

ramses2There’s a not-so-new kid on the systematic review block that seeks to cogently and comprehensive look at if, why (or why not) an intervention ‘package’ works in practice. They are ‘realist reviews‘ which, in brief, take a slightly different idea to how things work than the standard medical researchers might.

The reviews aim to unpick the relationships between a programme of intervention (e.g. approaches to substance misusing parents of younger children), the mechanisms of action (e.g. how people think, act and believe stuff when they are approached by programme elements, the choices made), how they are contextual (e.g alter if you’re in or out of a house you can stay in), and the outcomes (e.g. school attendance, child growth, police involvement). They undertake this by following a structure similar to many systematic reviews; they define a clear question, seek widely for appropriate evidence, weigh the potential strengths and weaknesses of the evidence, synthesise it into an understanding of stuff and provide messages for using the research. The synthesis comes from a stated theory, often rough-cut, about how the intervention might work; what the mechanisms may be and how contexts may alter that.

A relevant example to us in paediatrics is a realist review of how intervention programmes for children of substance abusing parents work, using this method to see what programmatic elements seem to work (and why), and we in paeds can use this order to think how best to suggest programmes in our locality may be structured to get good outcomes.

The output of their work gives concrete examples of what bits seems to be the cogs that make the machine roll, but additionally provides a ‘middle level theory’ that may be transportable to similar types of programme: you need to provide supported opportunities for positive child/parent interaction, peer:peer support, educational elements to improve knowledge and outreach for folk who find accessing such things difficult that are sensitive to socio-economic needs. (By transportable, I’m meaning that you might take these four ‘top tips’ and think about how they may be relevant to children of parents with severe mental health needs, or children who are carers, for example.)

Such reviews seem like a really good idea to help us think about how to make research outputs work in wards and clinics – and I’d love to see more of them showing us how to make paeds more effective and reducing the re-inventions of the wheel.

– Archi

(There’s a really readable explanation of how the whole system works, what the terms mean, and a structure for appraisal, in the appendix of the HTA report.)



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