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[Message from Soo Downe <[log in to unmask]> posted by me as there was a technical glitch]
Ah, I totally agree Justin - and maybe this is where realist approaches overlap with complexity approaches (again) in that some of the 'key causal' elements you mention might also be constructed as 'initial conditions' in a complexity theory sense...?
All the best
Soo
On 7 November 2015 at 18:32, Jagosh, Justin <[log in to unmask]> wrote:
Carter,
I would agree with what you’ve said – and again it’s shifting away from the idea that interventions cause things to happen . And especially Ray’s comment that the idea of ‘core components’ is likely a mirage is quite interesting. Being informed by a realist perspective, perhaps we should think of core components of socially contingent interventions as being things like trust, perceived safety, and other motivating relationship elements among various actors, coming into states of self-empowerment etc. And that such core components are influenced by both background (contextual) causal forces as well as new resources provided in terms of what we commonly would refer to as ‘intervention components’.
So to re-iterate, in that shifted frame, we would understand ‘core components’ as supported or hindered by key causal elements within the implementation context as well as deliberately enacted changes which are basically resources provided within the rubric of ‘the intervention’. Then the CMO configuration as an ‘aide-mémoire’ (as Ray puts it) and through its evolving transmogrifications can help in developing and evaluating such interventions. I hope I’m being clear…
Justin
Justin Jagosh, Ph.D
Senior Research Fellow
Director, Centre for Advancement in Realist Evaluation and Synthesis (CARES)
University of Liverpool, UK
From: Realist and Meta-narrative Evidence Synthesis: Evolving Standards [mailto:[log in to unmask]] On Behalf Of Carter
Sent: November 6, 2015 7:35 PM
To: [log in to unmask]
Subject: Re: Qualitative interviewing/CR--Active Ingredients
Realisters,
After reviewing this string, I noticed that no one actually addressed Caroline's question about the usefulness of the idea of "active ingredients" for clinicians. I brought a related question up a while ago when I asked fellow realisters what they thought of the notion of "core components," which has gotten a great deal of play in the USA.
Specifically, there was a very recent report from the Institute of Medicine on Psychosocial Interventions(1) that tries to develop what they call an "elements," approach, where they identify common critical features across a range of different psychotherapeutic models or labels. They distinguish between specific and "non-specific" elements.
I had asked the question about core elements, but I have also found that core elements, core components, and active ingredients all have been used somewhat interchangeably here. My quick and dirty explanation for this is that these ideas are related to a model of evidence-based program implementation that stresses fidelity as a means of ensuring quality control and good outcomes. Fidelity is following procedure, i.e. reading the manual, using the same examples, same dosing, etc. Of course, in reality, program replication and implementation are complex. Populations differ, implementers differ, geography, etc., and stakeholders who want to implement a program want to get good outcomes the first time out. They will often want to "adapt" a program to their situation. And that is where the active ingredients, core components metaphors come into play. (Active ingredients has a strong pharmacological association with it, which makes it rhetorically attractive.) The idea of a core is intuitively appealing, but identifying what is and is not core is difficult, especially when clinicians, or any practitioners think of programs in terms of concrete activities, and not as instantiations of mechanisms. How does someone determine which features of a program are core and which are not without doing a full range of implementations in which each different section or idea is dropped?
Ray Pawson commented to me that the idea of core components is likely a "mirage." In the end, he said that ideas of core components would refer to ideas, i.e. theories, about what is happening. I had suspected as much, but I was trying to find some wedge which I could use to split the whole issue open and force researchers in the USA to embrace the question of theory. As an alternative however, I found myself thinking that if practitioners did was to "adapt" a program, then they would have to collaborate with the program developer who developed the program and the fidelity criteria so that programs
On a pragmatic level, the idea of core components or active ingredients represents a first step in an interrogation of the whole evidence-based practice/implementation science paradigm. Right now, it isn't clear when we will have that full blown discussion here in the states, but it appears to have started in the commonwealth.
1. IOM (Institute of Medicine). 2015. Psychosocial interventions for mental and substance
use disorders: A framework for establishing evidence-based standards. Washington, DC: The National
Academies Press.
> Date: Fri, 6 Nov 2015 23:35:46 +1030
> From: [log in to unmask]
> Subject: Re: Qualitative interviewing/CR
> To: [log in to unmask]
>
> Hi Andy -
>
> I'd like the paper too please, if I may?
>
> One of the other things that was discussed briefly (or perhaps only in my
> small group! - my memory fails me) at this week's conference was using
> 'stories' within the interview rather than direct questions about theory.
>
> So something along the lines of "There's a whole bunch of different ideas
> about how this works and we're pretty sure it works differently for
> different people, or at different times. So here's one idea (brief
> explanation of one bit of program theory). Have there been any times it's
> worked anything like that for you? (Get answer and tease out response with
> follow up questions as appropriate). Have there been other times when it
> didn't work like that for you? (Tease out again). So it sounds like the
> times when it works like that are ... and the times when it doesn't are ...
> (framing revised theory back to them for their further refinement).
>
> Of course when interviewing service providers one changes "times for you" to
> "participants for whom"; when interviewing managers it might be about
> "workers who adopted the practice" and "who didn't" or "times you enforce
> the policy and times you don't"... etc ad infinitum.
>
> Cheers
> Gill
>
>
> -----Original Message-----
> From: Realist and Meta-narrative Evidence Synthesis: Evolving Standards
> [mailto:[log in to unmask]] On Behalf Of Andrew Harding
> Sent: Friday, 6 November 2015 10:37 PM
> To: [log in to unmask]
> Subject: Re: Qualitative interviewing/CR
>
> Thanks Vanessa. I can send the paper separately if you wish?
>
> It sounds like there's a study in itself about why, how, for whom and in
> what context the realist interview works best, and what participant groups
> it might be pertinent to tweak it etc :)
>
> Andy
>
> Doctoral researcher
> Bournemouth University - Faculty of Health & Social Sciences Bournemouth
> House, B112a
> 19 Christchurch Road
> Bournemouth
> BH1 3LH
>
> @AndrewJEHarding
> Office - 01202 963025
> Mobile - 07808794141
> ________________________________________
> From: Vanessa Abrahamson <[log in to unmask]>
> Sent: 06 November 2015 11:54
> To: Realist and Meta-narrative Evidence Synthesis: Evolving Standards;
> Andrew Harding
> Subject: Re: Qualitative interviewing/CR
>
> Hi Andy,
>
> Thanks for your post and suggested reading which looks very helpful. I am in
> a similar boat interviewing older people post-stroke some of whom will have
> communication &/or cognitive difficulties, and staff who may be reluctant to
> criticise the status quo. I think my topic guide would be criticised for a
> lack of CR orientation but equally I don't have 'theory' as such, more
> 'theoretical propositions) (Yin, 2014). Yin (2014, p90) talks about levels
> of questions, with Level 1 being those asked of individuals, up to Level 5
> normative questions about policy/recommendations beyond scope of study. So
> what we ask relates to theory but is not necessarily phrased in such a way.
> I'm not sure that helps or I have explained...
>
> Bw,
> Vanessa.
>
> Yin, 2014, Case Study Research. Sage
> ________________________________________
> From: Realist and Meta-narrative Evidence Synthesis: Evolving Standards
> <[log in to unmask]> on behalf of Andrew Harding
> <[log in to unmask]>
> Sent: 06 November 2015 10:50
> To: [log in to unmask]
> Subject: Re: Qualitative interviewing for mechanisms & 'active ingredient'
> terminology
>
> Hi all,
>
>
> Would just like to reopen this interesting discussion if I may, particularly
> around style of interview questions.
>
>
> Just as a bit of context, participants in my PhD are older people who have
> engaged with an information and advice service on their housing situation...
>
>
> The teacher-learner cycle approach mentioned below I assume to be the
> realist interview approach as advocated by Pawson and Tilley in Realistic
> Evaluation?
>
>
> The issue I have with this is that considering the dynamics in my study -
> older people (65+) who are often 'grateful' for being given I&A on their
> housing - I'm unsure as to whether participants will be receptive to being
> imparted with theories to engage with (and actually think it may alienate in
> some cases), and that direct questions will merely serve to shape and bias
> their responses.
>
>
> I'm not solely advocating open constructivist/narrative style questioning
> (doesn't philosophically align...), but I think more indirect queries have a
> place in realist research interviews, and then following up with more direct
> questions - particularly considering my study dynamic. 'Critical Realism and
> Interviewing Subjects' by Elger and Smith - a working paper (2012) and book
> chapter (2014) - suggest this when discussing P&Ts realist interview
> approach... (will send separately if people want these).
>
>
> Just wonder if anyone else has grappled with these issues?
>
>
> I hope the Leeds conference was good. It certainly looked it from twitter!
>
>
> Best wishes,
>
>
> Andy
>
>
> Doctoral researcher
> Bournemouth University - Faculty of Health & Social Sciences Bournemouth
> House, B112a
> 19 Christchurch Road
> Bournemouth
> BH1 3LH
>
> @AndrewJEHarding
> Office - 01202 963025
> Mobile - 07808794141
> ________________________________
> From: Realist and Meta-narrative Evidence Synthesis: Evolving Standards
> <[log in to unmask]> on behalf of Caroline Stretton
> <[log in to unmask]>
> Sent: 04 November 2015 22:03
> To: [log in to unmask]
> Subject: Re: Qualitative interviewing for mechanisms & 'active ingredient'
> terminology
>
> Excellent. Great advice. Thank you Rebecca -Thanks also for the reminder
> about that paper. I came across it a couple of years ago and dismissed it as
> being too hard to understand. Time to revisit it I think!
> Cheers
> Caroline
>
> From: Realist and Meta-narrative Evidence Synthesis: Evolving Standards
> [mailto:[log in to unmask]] On Behalf Of Rebecca Randell
> Sent: Tuesday, 3 November 2015 4:23 a.m.
> To: [log in to unmask]
> Subject: Re: Qualitative interviewing for mechanisms & 'active ingredient'
> terminology
>
> Hi Caroline
>
> Another article that I would recommend to help with your thinking about the
> active ingredients question is one that I came across thanks to this list:
>
> Clark A. What are the components of complex interventions in healthcare?
> Theorizing approaches to parts, powers and the whole intervention. Social
> Science & Medicine 93 (2013) 185-193
>
> Regarding the interviews, we have used the teacher-learner cycle approach
> which I have found really helpful in drawing out people's reasoning -
> similar to Avril's comment about giving people examples from other
> interviews, presenting the theories we found in the literature gave the
> interviewees something to engage with, test their ideas against, and I think
> provided us with much richer data than if we'd taken a more standard
> semi-structured interview approach.
>
> Best wishes
>
> Rebecca
>
> Dr Rebecca Randell
> Lecturer
> School of Healthcare
> Baines Wing
> University of Leeds
> Leeds LS2 9UT
> Email: [log in to unmask]" target="_blank"> [log in to unmask]<mailto:[log in to unmask]>
>
> [250 Great Minds website - apply for Academic Fellowships at the University
> of
> Leeds]<http://250greatminds.leeds.ac.uk/?utm_source=emailmessage&utm_medium=
> email&utm_campaign=thrive2>
>
> From: Realist and Meta-narrative Evidence Synthesis: Evolving Standards
> [mailto:[log in to unmask]] On Behalf Of Avril Nicoll
> Sent: 02 November 2015 09:36
> To: [log in to unmask]" target="_blank"> [log in to unmask]<mailto:[log in to unmask]>
> Subject: Re: Qualitative interviewing for mechanisms & 'active ingredient'
> terminology
>
>
> Hi Caroline,
>
> Would it be worth your RA trying out a less structured approach? Being asked
> questions about reasoning can be quite confronting, particularly where there
> are power differentials, so there's a case for just getting people talking
> about their stroke, about their everyday activities and being ready to pick
> up on anything that seems to be relevant to your research questions,
> particularly if there are signs of heightened emotion. I also think examples
> from other interviews can be really helpful in allowing participants to see
> that other people have a range of experiences, and it's fairly natural to
> compare these with their own. Your longitudinal design also allows similar
> discussion around changes in their accounts over time. There are some
> interesting papers around interviewing people with learning disabilities and
> children with speech, language and communication needs that might give you
> other ideas. I'm on a train to the Realism Leeds conference, but could send
> you links off list when I get home on Friday if you like.
>
> Re 'active ingredients', metaphors that resonate are worth capitalising on.
> Could you adapt it in terms of context by also talking about 'the kitchen'??
> You may already have come across Penelope Hawe but, if not, she writes very
> well on context and complex interventions - see eg 'Lessons from complex
> interventions to improve health' Annu. Rev. Public Health 2015 36:307-23.
> Point 6 in her summary seems especially relevant: 'Theory and evaluation of
> complex interventions have moved away from viewing an intervention as a
> program, technology, or set of products to represent interventions as
> routines, relationships, resources, power structures, symbols, forms of
> talk, "powerful ideas," and sets of values.'
>
> Looking forward to hearing more about your study in due course.
>
> Avril
>
> (PhD student, NMAHP Research Unit, University of Stirling)
>
> Sent from my Sony XperiaT smartphone
>
>
> ---- Caroline Stretton wrote ----
> Hello fellow realists,
> I have two questions I would welcome any thoughts on:
> My project is am trying to build and refine a treatment ( programme theory)
> on how to promote sustained behaviour change in people with stroke.
> I have developed an intervention based on my programme theory and am doing
> small a case study impact evaluation on the recipients of the programme.
> I have a research assistant completing semi-structured qualitative
> interviews at mid programme, post programme and at 3 months follow up. I
> want to understand the causal change mechanisms that are hopefully being
> activated by the innovative programme.
>
> I have just listened to some of the mid-programme interviews and the post
> programme interviews are due to be completed later this week. There is some
> interesting information coming through but I am struggling to know how to
> guide my RA to ask questions that can really get to the heart of the
> participants reasoning. One of the main reasons I think is the
> characteristics of my population. My participants come from a low socio
> economic area, many have English as a second language, the majority have
> delayed information processing ( cognitive problems) following their stroke,
> and are not used to being particularly self-reflective or dealing with
> abstract issues. Does anyone have any helpful suggestions for how to phrase
> questions that might help me get some more in-depth data at the next
> interview point ?
>
> My second questions relates to the use of the phrase 'active ingredients'
> and whether it is helpful. I am hoping that my programme theory will be of
> practical use for clinicians. From my professional background- theory based
> approaches are very uncommon and viewed as largely irrelevant to practice.
> However the metaphor of 'active ingredients' taken from a pharmacological
> model seems to resonate clinicians. Using the concept of 'active
> ingredients' and defining it as being the rehabilitation component that can
> 'activate' the causal change mechanism on one level would make sense to
> clinicians. However this runs the risk of ignoring the very significant
> contextual issues that affect firing or perhaps the fact that it is likely
> it is interacting ingredients that are part of complex interventions like
> rehabilitation. What are your thoughts about the phrase 'active ingredients'
> from a realist perspective
>
> Thank you in anticipation
> Caroline Stretton
>
>
>
>
>
> Caroline Stretton
> Doctoral Student
> School of Clinical Sciences
> Auckland University of Technology
>
>
> P 09 921 9999 ext 7697 E
> [log in to unmask]" target="_blank"> [log in to unmask]<mailto:[log in to unmask]> W
> aut.ac.nz<https://www.aut.ac.nz>
>
>
>
>
>
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