Realist review as a methodology for using evidence in health policies: an integrative review

Yonekura, Tatiana; Quintans, Jeane Roza; Soares, Cassia Baldini; Negri Filho, Armando Antonio De

doi:10.1590/S1980-220X2018037703515

Tatiana Yonekura

Hospital do Coração, São Paulo, SP, Brazil.

https://orcid.org/0000-0001-8271-6691

Jeane Roza Quintans

Universidade de São Paulo, Escola de Enfermagem, Departamento de Orientação Profissional, São Paulo, SP, Brazil.

https://orcid.org/0000-0003-0076-9242

Cassia Baldini Soares Corresponding author: Cassia Baldini Soares, Av. Dr. Enéas de Carvalho Aguiar, 419, Cerqueira César CEP 05403-000 – São Paulo, SP, Brazil cassiaso@usp.br

Universidade de São Paulo, Escola de Enfermagem, Departamento Enfermagem em Saúde Coletiva, São Paulo, SP, Brazil.

https://orcid.org/0000-0002-8457-3775

Armando Antonio De Negri Filho

Rede Brasileira de Cooperação em Emergências, São Paulo, SP, Brazil.

https://orcid.org/0000-0001-7749-9864

Corresponding author: Cassia Baldini Soares, Av. Dr. Enéas de Carvalho Aguiar, 419, Cerqueira César CEP 05403-000 – São Paulo, SP, Brazil cassiaso@usp.br

Data source	Search strategy	Identified references
PubMed	Realist review [Title/Abstract]	216
LILACS	Realist [Palavras] and review [Palavras]	1
COCHRANE Library	realist:ti,ab,kw and review:ti,ab,kw (Word variations have been searched)	21
SCOPUS	TITLE-ABS-KEY (“Realist review”)	257
EVIPNet	ti:(realist) AND ti:(review)	3
Health Systems Evidence	“Realist review”	20
Rx for change	“Realist review”	3
PDQ-Evidence	“Realist review”	12
SciELO	Revisão [Resumo] and Realista [Resumo]	6
Teses CAPES	“Revisão realista”	2
Google Scholar	“Realist review”	85

Author(s)/Year/Country of affiliation of the main author/Knowledge area of the first author	Definitions and purposes of the realist review
Pawson (2001)⁽¹⁸⁾ United Kingdom Sociology and Social Policy	Aims to obtain information about what works, for whom and in under what circumstances, applicable to contexts, aspects and subjects in specific situations.
Pawson (2002)⁽¹⁰⁾ United Kingdom Sociology and Social Policy	Favors constructing program theories to satisfy the needs in diverse social situations based on existing evidence.
Pawson et al. (2005)⁽⁶⁾ United Kingdom Sociology and Social Policy	Synthesis of research with explanatory focus that aims to unpack the mechanisms of how complex programs work (or why they fail), in specific contexts and configurations. The search for understanding what works in social interventions involves the attempt to establish causal relationships, and it is necessary to understand the underlying mechanism that connects them, as well as the context in which the relationship occurred.
Dixon-Woods et al. (2005)⁽³⁰⁾ United Kingdom Social Sciences and Health	Acknowledges the theories behind a particular program or intervention. It seeks evidence in different types of texts: qualitative and quantitative formal study reports, case studies, media reports, among other sources, and integrates them as evidence proof or to refute the theory.
Mays et al. (2005)⁽³¹⁾ United Kingdom Public Health	Develops theory to explain why interventions or programs work (or not) for specific groups in characteristic contexts.
Tractenberg et al. (2011)⁽⁸⁾ Brazil Administration	Seeks the theoretical understanding of the mechanisms underlying the interventions to provide an explanation of how and why the intervention works (or not) in a given context.
Wong (2012)⁽¹⁹⁾ United Kingdom Policy and Innovation in Health	Understands complex interventions and does not aim to prove that an intervention works, but to explain how, why, to whom, under what circumstances and to what extent it works. Context influences which mechanism will be triggered to produce specific results.
Kirst et al. (2012)⁽²⁷⁾ Canada Public Health	Recognizes that the effects of interventions such as programs and policies crucially depend on context and implementation. It does not adhere to a strict hierarchy of evidence in which randomized clinical trials are considered the best type of study.
Rycroft-Malone et al. (2012)⁽³²⁾ United Kingdom Health Sciences	Approach to reveal implicit theories by examining the interactions between mechanism, context and outcome, and to identify strategies and interventions to enable healthcare informed by evidence.
Saul et al. (2013)⁽²⁹⁾ Canada Research Center	Structured method to respond to local policy needs. The Rapid Realist Review is a tool used to apply realist precepts to the knowledge synthesis process in order to build a product that is relevant to local policy makers, in the decisions and necessary responses.
Tractenberg (2013)⁽²⁶⁾ Brazil Administration/Management	Qualitative research synthesis with an interpretative and explanatory purpose, used to understand the processes or mechanisms inherent in complex social interventions.
Jagosh et al. (2013)⁽³³⁾ Canada Medicine	A theory-oriented interpretive approach to configuring contextual factors and outcome-related change mechanisms.
Gough (2013)⁽³⁴⁾ United Kingdom Social Sciences	Revisions of mixed methods with three overlapping principal components: 1) unpack explicit and implicit assumptions of context, mechanism and outcome; 2) iterative aggregative test of the empirical data in particular CMO configurations; 3) explore and explain findings in different contexts from CMO interaction.
Wong et al. (2013)⁽²⁰⁾ United Kingdom Social Sciences	Relates to a single research question or set of questions, which can be summarized as what works, for whom, under what circumstances, how and why. The reviewers seek the contextual influences that supposedly triggered the relevant mechanism(s) for each idea to generate the outcome(s) of interest.
Wong et al. (2013)⁽²¹⁾ United Kingdom Primary Care	A theory-based approach to synthesize existing evidence. It is emphasized that theories are basic units of analysis.
Fawcett (2013)⁽³⁵⁾ United States Nursing	It enables researchers to better understand why an assessment, intervention or policy tool is effective or not for use with specific individuals in a given environment.
Edgley, Stickley, Timmons (2016)⁽²⁸⁾ United Kingdom Social Sciences and Mental Health	Critical realist review includes factors related to interventions and social justice. It tries to evaluate the logic of a study design about a certain phenomenon.
Wong et al. (2014)⁽²²⁾ United Kingdom Primary Care	Systematic, theory-oriented interpretive techniques which have been developed to make sense of heterogeneous evidence on complex interventions applied in various contexts to subsidize policy.
Tricco et al. (2016)⁽³⁶⁾ United Kingdom Institute of Knowledge	Data collection involves the process of interrogating the evidence to refine the medium-range theory using a set of instruments that can evolve as the review progresses.
Pawson, Greenhalgh, Brennan (2017)⁽²³⁾ United Kingdom Sociology and Social Policy	Locates the primary studies to explore the form and direction of the continuous theory refinement process in order to understand in what circumstances and by what processes these system tensions are solved.
Wong (2018)⁽²⁴⁾ United Kingdom Primary Care	Establishes a realistic explanation of the links between context and outcome through mechanisms. It has a particular approach to the analysis, succinctly captured in the heuristic context + mechanism = outcome (or C + M = O).
Wong (2018)⁽³⁷⁾ United Kingdom Primary Care	A theory-oriented approach to evidence synthesis. Realist reviews and evaluations are best suited to make sense of complex interventions, where context influences outcomes, and to answer questions such as what works, who, in what contexts, to what extent, how and why.
Wong (2018)⁽²⁵⁾ United Kingdom Primary Care	Its central point is to develop the initial program theory, which is confirmed, refuted or refined through data collection. It deals with complex interventions and their many components, which interact in a linear or non-linear way with context-sensitive results.

1. Formation of realist review team ⁽ ⁶ ^, ¹⁹ ^, ²⁷ ^, ³³ ^, ³⁹ ⁾

2. Panorama of the theme and locate possible theories ⁽ ¹⁹ ^, ²⁵ ⁾

3. Title ⁽ ²⁰ ⁾

4. Abstract ⁽ ²⁰ ⁾

5. Introduction

5.1. Rationale for review and identification of the research question⁽⁶^,²⁰^–²¹⁾

6. Review objectives and focus ⁽ ²⁰ ⁾

7. Methods

7.1. Rationale for using a realist review⁽⁶^,²⁰⁾

7.2. Scope of the literature⁽⁶^,²⁰^,³²⁾

7.3. Description of the search process⁽²⁰^–²¹^,²⁵⁾

7.4. Description of the selection processes and evaluation of documents⁽⁶^,²⁰^–²¹⁾

7.5. Description of the data extraction process⁽⁶^,²⁰^,³²⁾

7.6. Description of the analysis and synthesis process⁽⁶^,²⁰^–²¹⁾

7.7. Changes in the review process⁽²⁰⁾

8. Results

8.1. Selection and inclusion flow diagram⁽²⁰^,²⁵⁾

8.2. Evaluation of the included studies⁽⁶⁾

8.3. Description of the characteristics of the documents⁽²⁰^,²⁵⁾

8.4. Extraction, analysis and synthesis of the findings⁽⁶^,²⁰^–²¹^,²⁵⁾

8.5 Theory test⁽⁶^,²⁰^–²¹^,²⁵⁾

8.6. Review of the results⁽³²⁾

8.7. Construction of a hierarchical theoretical framework⁽⁶^,²⁰⁾

9. Discussion

9.1. Summary of the findings⁽²⁰⁾

9.2. Strengths, limitations and future directions of research⁽²⁰⁾

9.3. Comparison with existing literature⁽²⁰⁾

10. Conclusion and recommendations ⁽ ⁶ ^, ²⁰ ⁾

11. Financing and conflict of interest ⁽ ²⁰ ⁾

12. Dissemination ⁽ ⁶ ^, ³² ⁾

Realist review as a methodology for using evidence in health policies: an integrative review

ABSTRACT