What’s in a mechanism? Development of a key concept in realist evaluation

Background: The idea that underlying, generative mechanisms give rise to causal regularities has become a guiding principle across many social and natural science disciplines. A specific form of this enquiry, realist evaluation is gaining momentum in the evaluation of complex social interventions. It focuses on ‘what works, how, in which conditions and for whom’ using context, mechanism and outcome configurations as opposed to asking whether an intervention ‘works’. Realist evaluation can be difficult to codify and requires considerable researcher reflection and creativity. As such there is often confusion when operationalising the method in practice. This article aims to clarify and further develop the concept of mechanism in realist evaluation and in doing so aid the learning of those operationalising the methodology. Discussion: Using a social science illustration, we argue that disaggregating the concept of mechanism into its constituent parts helps to understand the difference between the resources offered by the intervention and the ways in which this changes the reasoning of participants. This in turn helps to distinguish between a context and mechanism. The notion of mechanisms ‘firing’ in social science research is explored, with discussions surrounding how this may stifle researchers’ realist thinking. We underline the importance of conceptualising mechanisms as operating on a continuum, rather than as an ‘on/off’ switch. Summary: The discussions in this article will hopefully progress and operationalise realist methods. This development is likely to occur due to the infancy of the methodology and its recent increased profile and use in social science research. The arguments we present have been tested and are explained throughout the article using a social science illustration, evidencing their usability and value

Understanding communication pathways to foster community engagement for health improvement in North West Pakistan

Background: This paper describes the community engagement process undertaken to ascertain the focus, development and implementation of an intervention to improve iodised salt consumption in rural communities in North West Pakistan. The Jirga is a traditional informal structure, which gathers men respected within their community and acts in a governing and decision making capacity in the Pukhtoon culture. The Jirga system had a dual purpose for the study; to access men from the community to discuss the importance of iodised salt, and as an engagement process for the intervention. Methods: A number of qualitative data collection activities were undertaken, with Jirga members and their wives, male and female outreach workers and two groups of women, under and over forty years old. The aim of these were to highlight the communication channels and levers of influence on health behaviour, which were multiple and complex and all needed to be taken into consideration in order to ensure successful and locally sensitive community engagement. Results: Communication channels are described within local families and the communities around them. The key influential role of the Jirga is highlighted as linked both to the standing of its members and the community cohesion ethos that it embodies. Engaging Jirga members in discussions about iodised salt was key in designing an intervention that would activate the most influential levers to decision making in the community. Gendered decision making-processes within the household have been highlighted as restricting women’s autonomy. Whilst in one respect our data confirm this, a more complex hierarchy of decisional power has been highlighted, whereby the concept of ‘wisdom’, an amalgamation of age, experience and education, presents important possibilities. Community members with the least autonomy are the youngest uneducated females, who rely on a web of socially and culturally determined ways to influence decision-making. Conclusions: The major lines of communication and influence in the local community described are placed within the wider literature on community engagement in health improvement. The process of maximisation of local cultural knowledge as part of a community engagement effort is one that has application well beyond the particular setting of this study

Protocol for a realist review of complex interventions to prevent adolescents from engaging in multiple risk behaviours

Objectives - Adolescent risk behaviours are a key health concern. The purpose of this research is to gain a deeper understanding of how, why, for whom, and in what circumstances complex adolescent risk behaviour prevention programmes are most successful. Methods and analysis - To understand how adolescent risk behaviour prevention programmes work in a real life context, a realist synthesis will be undertaken, operationalised in four phases. Phase one - Developing a framework to map the theoretical and conceptual landscape of adolescent risk behaviour prevention. Guided by stakeholder consultation. Phase two - Formulating initial programme theories through exploration of the literature, along with primary data from professional stakeholder interviews. Phase three - Refining programme theories through more purposeful, in depth screening of the literature, along with primary qualitative data, from young people and professionals. Data will be collected through semi structured focus groups, to explore specific elements of the emerging programme theories. Phase four - Testing programme theories through interviews with youth workers, following consultation with young people, using vignettes to explore the relationship between specific programme theories. This relatively novel method of primary and secondary data integration within a realist synthesis will provide deeper insight in to young peoples lived experience of risk behaviour prevention programmes, while maintaining transparency in the process of programme theory development. Methods and analysis Data analysis - A realist logic of analysis will be used to align data from each phase with context mechanism outcome configurations or specific elements thereof. Substantive theory will then be sought to understand and explain the findings. Ethics and dissemination - This study has been approved by the Ethics committee at Northumbria University, UK. Findings will be disseminated through knowledge exchange with stakeholders, publications in peer-reviewed journals, conference presentations, and formal and informal reports

‘The book’s a conversation starter’: a realist exploration of the salutogenic potential of reading for pleasure

\ua9 Author(s) (or their employer(s)) 2024.Reading for Wellbeing (RfW) is a pilot initiative, aimed at improving mental health and well-being through supporting access and increasing opportunities to read for pleasure. RfW was implemented across six North-East local authorities in England and employed Community Reading Workers to support access to books and reading for targeted populations. The current study used realist methodology to understand context, potential mechanisms of action, acceptability and reported outcomes. Data generation and analysis were conducted iteratively, using focus groups, interviews and observations. The analysis of the collated data highlighted that a positive attitude towards reading and a desire for social connections were significant motivators for engagement with RfW. This paper postulates eight programme theories relating to that context, which describe key mechanisms within RfW linked to engagement with reading, well-being, connections and practice. The paper concludes that previous notions of positivity associated with reading for pleasure enable participants to experience RfW as a positive social encounter. This positive social encounter enhances participants’ multiple resistance resources such as increased sense of self-efficacy and connectedness that could impact on their sense of well-being

British South Asian and Muslim Community’s Perceptions and Experiences of Addiction and Traditional Drug and Alcohol Treatment Services

\ua9 2024 by the authors.Within traditional drug and alcohol (D&A) treatment services, the majority of those accessing support are of white ethnicity, with only a small percentage of people from the British South Asian (BSA) and Muslim community engaging in treatment services. This paper aims to explore perceived barriers to accessing traditional D&A services within the British South Asian and Muslim communities, based on qualitative data from interviews with family members and a practitioner. Qualitative data were obtained via 11 semi-structured interviews involving a practitioner (n = 1), and family and friends (n = 10) of those with historic and current D&A use in the community. Reflexive thematic analysis revealed four themes: (1) awareness of drug and alcohol use in the community, (2) drug and alcohol use as a taboo topic and the impact of admitting use, (3) knowledge of services for treatment, (4) how to increase awareness and accessibility of treatment. There was an increasing awareness of D&A use in the BSA and Muslim community. Despite this, limited conversations and misconceptions around D&A use and recovery led to those using D&A and their family members feeling stigmatised within their community and unable to seek support. This paper concludes by recommending increased communication between the BSA and Muslim communities and D&A treatment services to ensure accessibility of treatment by improving cultural competency

Exploring community perceptions in preparation for a randomised controlled trial of biofortified flour in Pakistan

Background: Biofortification of staple food crops may be a cost-effective and sustainable approach to reducing micronutrient deficiencies in resource-poor settings with low dietary diversity. However, its success depends on uptake by the local population. This paper presents formative research conducted in a remote, rural community in North West Pakistan, prior to commencing a randomised controlled trial to test the effectiveness of consuming zinc-biofortified wheat flour for alleviating zinc deficiency. It explored local community members’ knowledge, understanding and attitudes towards biofortification and views on members of their community taking part in the trial. Methods: Four focus group discussions were conducted with male and female community members (separately for cultural reasons) and four in-depth interviews were conducted with Jirga members—respected male elders. Participation was limited to households that were ineligible for the trial so that we could explore the perspectives of community members who were not influenced by the incentives of the trial. Focus group participants were selected at community events for transparency. Data collection took place at the local school and homes of Jirga members. Thematic analysis was undertaken, using a combination of deductive and inductive approaches to identify key themes. Results: A total of 47 men and women participated in this study. Participants reported clear motivation to access and consume more nutritious flour, believing this would bring health benefits, particularly to women and children. Trusted members of the local community, including Jirga members and female health workers, should be involved in providing information on biofortified flour (and the trial) to increase levels of awareness and acceptance. Without their involvement, there is a risk that biofortified flour would be mistrusted. The cost of flour is the main factor affecting purchasing decisions, and biofortified flour will need to be cost-competitive to achieve widespread uptake in marginalised, rural communities. Conclusion: This formative study generated rich, qualitative data from a range of community stakeholders to improve the understanding of important barriers and facilitators to the widespread acceptability and adoption of biofortified wheat. Implementation research such as this will inform future decision-making in relation to scaling up biofortified wheat in Pakistan

Community Asset Mapping: Promoting Inclusion and Equity and Countering Stigma in Applied Substance Use Research

\ua9 2025 by the authors.People Who Use Substances (PWUS) are among the most stigmatised groups in society. Stigma associated with substance use is known to be detrimental to the individual’s wellbeing, and substance use is often used as a mechanism by policy makers and services to legitimise exclusion. PWUS often do not benefit from the drug and alcohol services that are available to them. Community Asset Mapping (CAM) is a strengths-based approach involving the re-engagement of communities through active involvement in research. There are criticisms and concerns about equity and the burden on participants involved in CAM projects; however, the broad aim of CAM is to identify and document the strengths and pre-existing resources that exist within a community. In the following study, we utilised CAM processes and principles in a large city in the Northeast of England to enable people with lived experience of substance use and practitioners working in drug treatment services to come together and identify resources in the form of services and groups that support recovery. In the process, we were concerned with identifying, engaging with, and involving groups that were known to the recovery community but also were not part of an existing recovery network. Qualitative data were obtained from semi-structured interviews (n = 13) and focus groups (n = 2). A reflexive thematic analysis approach was used to analyse the transcriptions, and from this we generated four themes: (1) community visibility, (2) ownership of the recovery agenda, (3) the impact of stigma and shame, and (4) the benefits of involvement. Our findings revealed a partly fragmented but also well-established, connectedand resourced local recovery community in the city. We were also able to identify a number of recovery groups and services that had previously not been known to the existing recovery community. Additionally, we identified that public and societal substance-related stigma continued to be a barrier that inhibited individuals and recovery groups from making themselves more visible and available to others

The impact of precarious employment on the health and wellbeing of immigrants: a systematic review

Abstract Background Migration and precarious employment are social determinants associated with adverse health outcomes. In the United Kingdom, migration policy and labour market characteristics mean that migrants are often engaged in precarious work. We synthesise evidence on the experiences of migrants and explore the effects of precarious employment on their health and wellbeing. Methods Electronic databases were searched for peer-reviewed qualitative studies describing the experiences of United Kingdom migrants in precarious employment. Title and abstracts were screened, followed by full text screening using pre-specified inclusion and exclusion criteria. Data on employment experiences and effects of working conditions on physical and mental health and perceived wellbeing were extracted. The Centre for Reviews and Dissemination (2009) framework was used to conduct a narrative synthesis. Results Out of 1577 unique citations, 5 met our inclusion criteria. All included studies reported negative outcomes on physical and mental health. 2 reported positive or negative outcomes for perceived wellbeing depending on pre-migration experience. Musculoskeletal pain, exhaustion, anxiety and depression were commonly reported effects of precarious employment. Communication difficulties and over qualification were identified as migrant specific factors influencing health outcomes. Conclusions Stress response theories and risk factors associated with occupational injury explain how employment specific factors influence health. Extrinsic factors such as immigration policies, pre-migration experience, responsibilities in home country and acculturation mediate precarious employment effect on health. Key messages Migrants feel isolated in precarious employment and are vulnerable to negative mental and physical health impacts. Broader migration related policies impact on experiences of employment and health. </jats:sec