Understanding the Institutional Logics of China's Community-Based Intervention for Older People

Community-based policies have gained global popularity, signaling a paradigm shift from individual responsibility for healthy aging to an approach involving community-based intervention. Learning from Western experience, China has also experimented with this form of intervention. It has policy interventions aimed at providing community-based facilities and services that enable older people to age in place. However, the institutional foundations of Chinese communities differ greatly from those in Western countries. Implementing a critical realist case study focusing on a community-based program in Beijing, this study aims to examine the institutional logics that contribute toward a contextually appropriate community-based policy intervention in China. We identified three institutional logics. First, the Confucian moral obligation of benevolence requires authorities to provide social welfare for vulnerable citizens. Second, China's community-based interventions are state-led territorialized provisions prioritizing communities rather than individuals. Third, community-based social policies are subordinate to economic growth objectives. This study contributes to the understanding of contextually appropriate community-based policy interventions in China.

A protocol for a critical realist synthesis of school mindfulness interventions designed to promote pupils' mental wellbeing

Introduction

The review described in this protocol will be the first critical realist review of the literature reporting on the impact of school-based mindfulness interventions on the mental wellbeing of pupils. Mindfulness interventions are increasingly being introduced into schools to promote children's (and teachers') wellbeing. Findings from impact evaluations, including systematic reviews and metanalysis, suggest that school-based mindfulness interventions promote pupils' wellbeing. However, there is a need for further evidence on the underlying causal mechanisms and contexts that explain program outcomes, to provide insight into how mindfulness programs can be successfully implemented in other contexts.

Methods and analysis

A critical realist review methodology will be used to provide a causal interdisciplinary understanding of how school-based mindfulness interventions promote the mental wellbeing of pupils. This will be done through a systematic literature review and extrapolating context, agency, intervention, mechanisms, and outcome configurations. This will enable an understanding of how, in certain contexts, pupils can use the resources offered by a mindfulness intervention knowingly or unknowingly to trigger mechanisms that promote their mental wellbeing and what mechanisms in the context support, restrict or prevent change. We will then use retrodiction and retroduction to develop the most plausible interdisciplinary middle-range theory to explain the findings.

Discussion

The review findings will inform a critical realist evaluation of a mindfulness intervention in schools. The findings from the review will also enable us to inform policymakers and other stakeholders about what conditions need to be in place for mindfulness interventions to promote pupils' mental wellbeing. We will publish the findings from the review in academic and professional publications, policy briefs, workshops, conferences, and social media.PROSPERO registration number: CRD42023410484.

British mental healthcare responses to adult homosexuality and gender non-conforming children at the turn of the twenty-first century

The roots of the recent controversy about how mental health professionals should respond to gender non-conforming children are traced. To make historical sense, this paper distinguishes between epistemological (discursive) and ontological (non-discursive) aspects and describes their features, since 1970. This helps to clarify some of the confusions at the centre of the still heated debate about sexuality and gender identity today. In the concluding discussion, the philosophical resource of critical realism is used to interpret the historical narrative provided. It cautions against the anachronistic tendency to amalgamate the short-lived, and now defunct, experiment of aversion therapy for homosexuality with more recent defences of exploratory psychotherapy. The latter have challenged a different form of experimentation: the bio-medicalisation of gender non-conforming children.

The different facets of 'experiential knowledge' in Swedish women's claims about systemic side effects of the copper intrauterine device

'Experiential knowledge' has been identified as a key epistemic resource used by lay people to contest medical authorities and build new knowledge related to health. The Internet has created unprecedented opportunities for such experience-based epistemic projects. This article contributes to understandings of the as yet under-theorised concept of experiential knowledge by analysing accounts of a group of Swedish women who claim that their use of contraceptive copper IUDs has led to systemic side effects not recognised by health care providers. Based on digital group interviews and written essays, we distinguish between three components or stages of experiential knowledge at work in the women's use of experience as an epistemic resource: somatic knowing, collective validation and self-experimentation. Drawing on a critical realist framework, we defend a notion of experiential knowledge as crucially, while only partially, based on a bodily and practical access to aspects of reality organised by extra-discursive principles. By providing theoretical complexity to the notion of experiential knowledge, we contribute resources for discriminating between and evaluating various experience-based claims, something that is particularly needed in the current 'post-truth' era where experience-based knowledge claims pointing in divergent directions flourish.

Seven key insights from critical realism and their implications for ecological thinking and action in community psychology

This article explores some of the possible links between community psychology and critical realism, a relatively new approach to the philosophy of science that has received little attention from community psychologists. Critical realism is presented in relation to seven key insights that can be linked to fundamental tenets of the ecological approach in community psychology. These insights are: (1) A complex reality exists independently of our ideas about it, and this reality is knowable, although imperfectly. (2) Reality is composed of a complex and stratified hierarchy of open systems. (3) Causality is best understood in terms of causal processes that may or may not be directly observable or generalizable; these processes involve complex interactions among generative mechanisms and contextual conditions. (4) Theory and theorizing about causal processes are central to both scientific explanation and practical action. (5) Theory exists at multiple levels of abstraction, ranging from models to metatheory. (6) A diversity of methods can provide evidence in the search for causal processes operating in context. (7) As social scientists, we have an obligation to use social science knowledge to promote human flourishing. Although these insights may be familiar to many community psychologists who adopt an ecological approach to their work, we suggest that clearly articulating these principles can provide more solid foundations for inquiry in the field. We conclude the article by highlighting how critical realism may help to bridge the research-practice gap in community psychology and similar social sciences.

Being, Knowing, and Doing: Importing Theoretical Toolboxes for Autism Studies

The aim of this article was to think with and elaborate on theories developed outside of autism research and the autistic community, and through this support the production of new autistic-led theories: theories and concepts based on autistic people's own embodied experiences and the social worlds we inhabit. The article consists of three different sections all of part of the overall umbrella, Being, knowing, and doing: Importing theoretical toolboxes for autism studies. In each section, we import useful concepts from elsewhere and tailor them to autism studies. Throughout, we mingle our own autoethnographic accounts and shared discourse in relation to research accounts and theories. Illustrating being, we explore and discuss the possibilities of critical realism in autism studies. Illustrating knowing, we explore and discuss the possibilities of standpoint theory in autism studies. Finally, illustrating doing, we explore and discuss the possibilities of neurocosmopolitics including epistemic (in)justice in autism studies. Our proposal here is for an epistemic shift toward neurodiverse collaboration. We are inviting nonautistic people to work with, not on, us, aiming at to make autism research more ethical, breaking down bureaucratic structures, and questioning poor theory and shoddy methodology. Acknowledging intersecting axes of oppression in which an individual seeks to renegotiate and reimagine what it means to belong also means to understand what needs changing in society, as it is and how we might do things differently.

Women, alcohol consumption and health promotion: the value of a critical realist approach

Research on women's drinking occurs in largely disparate disciplines-including public health, health promotion, psychology, sociology, and cultural studies-and draws on differing philosophical understandings and theoretical frameworks. Tensions between the aims and paradigmatic underpinnings of this research (across and within disciplines) have meant that knowledge and insight can be frequently disciplinary-specific and somewhat siloed. However, in line with the social and economic determinants of the health model, alcohol research needs approaches that can explore how multiple gender-related factors-biological, psycho-social, material, and socio-cultural-combine to produce certain drinking behaviours, pleasures and potential harms. We argue that critical realism as a philosophical underpinning to research can accommodate this broader conceptualization, enabling researchers to draw on multiple perspectives to better understand women's drinking. We illustrate the benefit of this approach by presenting a critical realist theoretical framework for understanding women's drinking that outlines interrelationships between the psychoactive properties of alcohol, the role of embodied individual characteristics and the material, institutional and socio-cultural contexts in which women live. This approach can underpin and foster inter-disciplinary research collaboration to inform more nuanced health promotion practices and policies to reduce alcohol-related harm in a wide range of women across societies.

Introduction to the special issue on critical realism

This special issue explores how philosophy of science matters for both research and social action in community psychology. It explores the complex issue of what might be appropriate philosophical bases for community psychology theory, research, and practice. In particular, it focuses on critical realism, a relatively new approach to the philosophy of science. In this introductory article, we start by discussing the importance of philosophy of science for community psychologists. We then situate our subject by exploring the history of paradigms in community psychology. We next offer a brief description of critical realism by describing its assumptions on ontology (nature of the world), epistemology (theory of knowledge), axiology (theory of values), and methodology (theory of action).

Critical realism methodology as a guiding framework for interdisciplinary theory enrichment: Reflections on a study of empowerment

Philosophy of science and ontological assumptions underpin our work as scholars, explicitly, or implicitly. In this paper, we develop empowerment theory with a critical realism (CR) lens. Through the example of a study of empowerment, we examine how can it be used as a guiding paradigm for research in community psychology (CP). We sought to increase theoretical rigor by using a CR approach to interdisciplinarity. We put empowerment into conversation with Social Reproduction Theory and Black, Indigenous, People of Color feminisms, because both represent situated knowledge that address experiences with oppression and focus on dismantling systems of oppression. We illustrate how a CR approach shaped our understanding of empowerment, and in turn, provided an analysis that was (a) more nuanced and actionable, (b) more aligned with CP values and definitions of social justice, and (c) more likely to contribute to the field by developing an intersectional anticapitalist and feminist intervention into empowerment literature. This paper highlights how, aligned with an interdisciplinary CR approach, we questioned assumptions about empowerment theory, which influenced our empirical work so that we could provide a more focused critique of unjust social arrangements, and with it, the possibility to act upon those arrangements.

Understanding Causation in Healthcare: An Introduction to Critical Realism

Both healthcare providers and researchers in the health sciences are well rehearsed in asking the question 'What could be causing this'? and examining beyond the surface of observable symptoms or obvious factors to understand what is really occurring with patients and health services. Critical realism is a philosophical framework that can help in this inquiry as we attempt to make sense of the observable world. The aim of this article is to introduce critical realism and explore how it can help both healthcare providers and health science researchers to better understand causation through the mechanisms that generate events, despite those mechanisms often being unseen. The article reviews foundational concepts and examples framed in the healthcare setting to make the key principles, strengths and limitations of critical realism accessible for those who are just beginning their journey with this approach.

A comparison of formal and informal help in the context of mental health recovery

BACKGROUND

People in recovery from anxiety, depressive or bipolar disorders can receive both formal (from practitioners) and informal help (from family and friends). These two types of helping relationships have often been studied separately as either therapeutic relationships or social support. Yet, the mechanisms of these two forms of help have not been empirically compared in the context of mental health recovery.

AIMS

The purpose of this study is to compare the mechanisms of informal help and formal help in recovery by combining the perspectives of individuals in recovery, their informal helper and their practitioner.

METHOD

Individual interviews were conducted with 15 triads (N = 45 participants) comprising a person in recovery, their most significant informal helper and their most significant practitioner to compare the two forms of help through a mixed method approach. Based on the paradigm of critical realism, the research puts the emphasis on the triangulation of data sources and types.

RESULTS

The informal and formal helping relationships serve multiple functions some can be found in both, often in different ways (communication, presence and availability). Informal helpers tend to serve a broader array of functions than practitioners do. Regarding differences, formal help is characterised by scheduling, time limitations and professional competencies. Informal help is characterised by emotional closeness, companionship and reciprocity. Also, people in recovery are active when it comes to determining the role that their helpers play (agency).

CONCLUSIONS

Social support from family members and friends, as well as help from professionals can contribute to recovery in different ways. Attesting to the agency of people in recovery, the two forms of help are not only perceived as complementary, they are deliberately kept so.

'A troublesome girl is pushed through': Morality, biological determinism, resistance, resilience, and the Canadian child migration schemes, 1883-1939

This article critically analyses correspondence and decisions regarding children/young people who were included in the Canadian child migration schemes that ran between 1883 and 1939, and those who were deemed 'undeserving' and outside the scope of the schemes. Drawing on critical realist ontology, a metatheory that centralises the causal non-linear dynamics and generative mechanisms in the individual, the cultural sphere, and wider society, the research starts from the premise that the principle of 'less or more eligibility' lies at the heart of the British welfare system, both now and historically. Through analysing case files and correspondence relating to children sent to Canada via the Waifs and Strays Society and Fegan Homes, I shed light on the complex interplay between morality, biological determinism, resistance, and resilience in decisions around which children should be included or excluded. I argue that it was the complex interplay and nuance between the moral/immoral, desirable/undesirable, degenerate, and capable/incapable child that guided practice with vulnerable children in the late 1800s. In judgements around 'deservedness', related stigmas around poverty and 'bad' behaviour were rife. Within this, the child was punished for his/her 'immoral tendencies' and 'inherited traits', with little regard for the underlying reasons (e.g. abuse and neglect) for their (abnormal) behaviour and 'mental deficiencies'.

Legal, geographic and organizational contexts that shape knowledge sharing in the hospital discharge process for people experiencing homelessness in Toronto, Canada

People experiencing homelessness use acute healthcare at higher rates than the general population, yet hospitals frequently discharge them to the streets or emergency shelters. Available literature on the hospital discharge process for people experiencing homelessness identifies knowledge sharing as an important and challenging part of the discharge process; however, it does little to explain what generates these challenges or what might support knowledge sharing. In this study, we explain under which contexts certain mechanisms are triggered to facilitate knowledge sharing between hospitals and shelters during the discharge process. Between September 2018 and April 2019, we interviewed 33 participants: hospital workers on general medicine wards across three hospitals; shelter workers; researchers, policy advisors or advocates working at the intersection of homelessness and healthcare in Toronto. We find that within the legal context of health information protection, the concept of "circle of care" has created barriers to knowledge sharing between hospitals and shelters by excluding shelter workers from discharge planning. We note, however, that the degree to which hospital workers have navigated these barriers and brought shelter workers into the discharge process varies across hospitals. We explore this variation and find that certain geographic and organisational contexts have activated the development of institutional- and individual-level relationships between hospitals and shelters or their workers, respectively. We suggest that these relationships generate increased trust and communication and have led to knowledge sharing between hospitals and shelters. These findings are applicable in most urban centres with hospitals and where people experiencing homelessness live. Understanding the role of context is imperative for developing appropriate and effective interventions to improve hospital discharge processes. The development and implementation of more effective discharge processes can contribute to improved post-discharge care and recovery for this patient population and contribute to addressing health equity.

"From the World of Falsehood to the World of Truth": Recovery and reflexivity in Clubs of Families with Alcohol-related Problems in Crete

The potential for a critical realist community psychology in the Greek context is not yet apparent. In this article, we present the results of a qualitative study that adheres to critical realism and community psychology principles. The study's focus is the lives of members of the 12 Clubs of Families with Alcohol-related Problems (CFAP) that operate on Crete. The empirical material was derived from fieldwork notes, minutes from CFAP weekly meetings, and interviews provided by 13 CFAP members. Participants conceptualized the path from alcohol addiction to sobriety as a transition from a world of falsehood and deceit ("fractured reflexivity") to a world of truth and communalism ("communicative reflexivity"). The article argues that CFAP's "regime of truth" prioritizes communicative reflexivity as the desirable mode of reflexivity, while at the same time contributing to an ambivalent political stance towards the oppressive structural arrangements that promote addiction.

Critical realism, community psychology, and the curious case of autism: A philosophy and practice of science with social justice in mind

Community psychology (CP) is a transformative subdiscipline of psychology which aims to address inequality and social injustice and to attend to wellbeing. It has been argued that CP lacks an underpinning philosophy of science. Philosophies of science provide road maps for values, methods, and objectives, thus ultimately framing all research. This study will highlight how traditional philosophies of science such as positivism, interpretivism, and social constructivism fail to support the complexity of CP and often essentialise complex phenomena, such as autism, to the detriment of stakeholders. Critical realism will then be introduced as a promising philosophy of science for CP, which can reinvigorate CPs push for impactful research and social change. The study will highlight how CP provides a platform for appreciating the complexity of autism and for transforming structures of inequality experienced by autistic people, together with autistic people.

Interactions between healthcare personnel and family caregivers of people with dementia from minority ethnic backgrounds in home-based care-An explorative qualitative study

AIMS

To explore how healthcare personnel in home-based care perceive interactions with family caregivers of people with dementia from minority ethnic backgrounds.

BACKGROUND

Research shows that the organization of home-based care rarely allows opportunities to provide support to family caregivers in practice. However, how these organizational structures influence the way in which healthcare personnel perceive their interactions with family caregivers of people with dementia from minority ethnic backgrounds remains an unexplored area.

DESIGN

An explorative qualitative study inspired by a critical realist approach using Pierre Bourdieu's theoretical concepts of field, habitus and capital.

METHODS

Data were collected through individual semi-structured interviews with six nurses and four auxiliary nurses employed in home-based care in Norway. The data were analysed using a thematic analysis approach. The participants were recruited in September and October 2020.

FINDINGS

'Family caregivers perceived as facilitators of or barriers to collaborative care' was identified as an overarching theme, supported by two main themes: 'Preconditions for successful collaboration' and 'Challenges for collaborative relationships'. The findings revealed that the participants mainly focused their attention on the dementia patients from minority ethnic backgrounds, while they felt that the family caregivers influenced the way in which they provided healthcare.

CONCLUSIONS

The findings demonstrate that timesaving strategies have a major influence on healthcare personnel's perceptions of family caregivers from minority ethnic backgrounds. Attention towards the needs of the family caregivers was often replaced by evaluations of their usefulness in the provision of healthcare to the dementia patients.

IMPACT

This study raises concerns about home-based care as a rigid and inflexible system. It therefore provides opportunities to raise questions on status quo, stimulate debate and encourage fresh thinking with regards to the support and inclusion of family caregivers in the home-based care system for people with dementia from minority ethnic backgrounds.

Caregiver Support in Mental Health Recovery: A Critical Realist Qualitative Research

Support from caregivers is an important element of mental health recovery. However, the mechanisms by which social support influences the recovery of persons with depressive, anxiety, or bipolar disorders are less understood. In this study, we describe the social support mechanisms that influence mental health recovery. A cross-sectional qualitative study was undertaken in Québec (Canada) with 15 persons in recovery and 15 caregivers-those having played the most significant role in their recovery. A deductive thematic analysis allowed for the identification and description of different mechanisms through a triangulation of perspectives from different actors. Regarding classic social support functions, several of the support mechanisms for mental health recovery were identified (emotional support, companionship, instrumental support, and validation). However, informational support was not mentioned. New mechanisms were also identified: presence, communication, and influence. Social support mechanisms evoke a model containing a hierarchy as well as links among them.

Transgender debates and healthcare: A critical realist account

The meta-theoretical resource of critical realism (CR) is deployed in order to examine transgender and healthcare. CR treads a middle way between positivism and postmodernism, within post-Popperian discussions of the philosophy of natural and social science. It focuses on the conditions of possibility for the emergence of a phenomenon under investigation. In this case, the focus is on the emergence of debates about transgenderism in healthcare. These have been technological (about the prospect of biomedical solutions to personal problems) and ideological, with the enlarged salience of identity politics and our currently unresolved "culture wars." Identity politics have brought a focus on epistemological privilege or "lived experience" and on rights to healthcare being driven by consumer choice. The current contestation and its history are discussed in relation to our four planar social being (nature, relationality, socio-economic structures, and our particular personalities) and future scenarios are rehearsed.

Understanding community violence: A critical realist framework for community psychology

Critical realism can unsettle a number of orthodoxies that surround the study of community violence within community psychology. This is to say, because critical realism is embraced so rarely by community psychologists, it can institute a parallax shift within the discipline, whereby we are granted alternative ways of perceiving violence within community contexts. Drawing on transdisciplinary thought, we offer in this article a retroductive framework for studying community violence. This framework, we argue, can facilitate an understanding of structurally violent causal mechanisms through interrogating how direct-or observable-violence intersects with epistemic violence (i.e., harmful and inaccurate representation). Demonstrating the efficacy of this framework, we provide an example from our work, where participants from a low-income South African community produced and screened a documentary film on community violence and collective resistance. Reflecting on the ways by which this film engaged xenophobic violence in particular, we examine how community members used the film to trouble perceptions of community violence and advance a multifaceted antiviolence agenda. By way of conclusion, we consider how our framework can be used to inform a critical realist community psychology, wherein violent social structures are analyzed against the agentic community-driven initiatives which oppose these structures.

Psychomotor Predictive Processing

Psychomotor experience can be based on what people predict they will experience, rather than on sensory inputs. It has been argued that disconnects between human experience and sensory inputs can be addressed better through further development of predictive processing theory. In this paper, the scope of predictive processing theory is extended through three developments. First, by going beyond previous studies that have encompassed embodied cognition but have not addressed some fundamental aspects of psychomotor functioning. Second, by proposing a scientific basis for explaining predictive processing that spans objective neuroscience and subjective experience. Third, by providing an explanation of predictive processing that can be incorporated into the planning and operation of systems involving robots and other new technologies. This is necessary because such systems are becoming increasingly common and move us farther away from the hunter-gatherer lifestyles within which our psychomotor functioning evolved. For example, beliefs that workplace robots are threatening can generate anxiety, while wearing hardware, such as augmented reality headsets and exoskeletons, can impede the natural functioning of psychomotor systems. The primary contribution of the paper is the introduction of a new formulation of hierarchical predictive processing that is focused on psychomotor functioning.

Participation as means for adaptation in dementia: a conceptual model

OBJECTIVES

There are a number of conceptual models of dementia, capturing a range of biopsychosocial factors. Few integrate the lived experience of dementia. The aim of this study was to develop a conceptualisation grounded in the first-hand accounts of living with the condition and reflecting its complexity.

METHOD

The study was conducted within an explanatory, critical realist paradigm. An overarching narrative approach, informed by a previously completed systematic review and metasynthesis of research on the lived experience of dementia and the assumptions of complexity theory, was used to guide data collection and analysis. Data were contributed by 31 adults, including 12 people living with dementia and 19 family caregivers.

RESULTS

The experience of living with dementia was conceptualised as a process of adaptation through participation, emerging from ongoing, dynamic and nonlinear interactions between the adaptive capacity of a person with dementia and the adaptive capacity within the environment. The proposed conceptual model describes contexts and mechanisms which shape this capacity. It identifies a range of potential outcomes in dementia. These outcomes reflect interactions and the degree of match between the adaptive capacity of a person and the adaptive capacity within the environment.

CONCLUSION

By recognising and exploring the potential for adaptation and enduring participation in dementia, findings of this research can support practitioners in facilitating positive outcomes for people affected by the condition.

Care Coordination for Vulnerable Families in the Sydney Local Health District: What Works for Whom, under What Circumstances, and Why?

Introduction:

Healthy Homes and Neighbourhoods (HHAN), an integrated care programme in the Sydney Local Health District (SLHD), seeks to address the needs of disadvantaged families through care coordination, as one of its components. This research aims to determine for whom, when and why the care coordination component of HHAN works, and establish the reported outcomes for clients, service-providers and partner organisations.

Methods:

Critical realist methodology was utilised to undertake a qualitative evaluation of the impact of care coordination. Purposive sampling was used to select a total of 37 participants for interview, including consumers, service-providers and key stakeholders. Thematic analysis was undertaken to derive the major modes of intervention of HHAN, and data representing these elements was coded and summarised under contexts, mechanisms and outcomes.

Results:

Analysis indicates that care coordination has a positive impact on clients’ sense of independence, self-awareness and outlook on life. Trust and favourable interpersonal relations were identified as major underlying mechanisms for a successful client-provider working relationship. The identified modes of intervention facilitating positive consumer outcomes included accessibility, flexibility and service navigation. Persistent siloes in health and systemic resistance to collaboration was seen to hinder effective care delivery.

Conclusions:

This study suggests that a care coordination model may be effective in engaging disadvantaged families in healthcare, assist them in navigating the health system and can lead to beneficial health and social outcomes. Successful implementation of care coordination requires flexible programme design and experienced and skilful clinicians to fulfil the care coordinator role. There is a need to appreciate the negative impact that the complex and siloed health system can have on disadvantaged families.

Refining Program Theory for a Place-Based Integrated Care Initiative in Sydney, Australia

Introduction

The Healthy Homes and Neighbourhoods (HHAN) Integrated Care Program seeks to enhance vulnerable family engagement with health and social services through a care coordination model. Besides servicing families in Sydney, HHAN has also established place-based initiatives (PBIs) in areas of disadvantage such as Redfern. The Redfern PBI co-locates HHAN with housing, drug and alcohol services, and financial and legal services. This integration aims to facilitate service access and multi-agency support for vulnerable families in Redfern. Hence, this study aims to evaluate for whom, when and why HHAN's PBI at Redfern works, or not, and what are its outcomes.

Methods

The project utilises critical realist methodology to undertake a qualitative evaluation of the impact of the PBI on clients, services and the community. Purposive sampling was used to identify 21 participants including HHAN clients, HHAN staff and stakeholders (HHAN partners). In-depth, semi-structured interviews were audio-recorded, transcribed, coded and analysed using a context (C), intervention (I), mechanism (M) outcome (O) (CIMO) approach to abductive analysis.

Results

Five key CIMO configurations of the Redfern PBI emerged - whole-of-family involvement, flexibility, trust, building connections and co-location. Whilst each theory had specific outcomes, overall client outcomes included improved access to services, better outlook, empowerment and engagement with services. Service outcomes included increased collaboration and foundation for integration between HHAN and other services. Negative outcomes included lack of full integration, the risk associated with integration and difficulty evaluating impact.

Conclusion

This study successfully refined the program theory for subsequent use in later implementation of critical realist evaluation studies.

The development of the new assistant practitioner role in the English National Health Service: a critical realist perspective

Adopting a critical realist perspective, this article examines the emergence of a relatively new non-professional healthcare role, the assistant practitioner (AP). The role is presented as a malleable construct cascading through and sensitive to structure-agency interaction at different levels of NHS England: the sector, organisation and department. At the core of the analysis is the permissiveness of structures established at the respective levels of the NHS, facilitating or restricting agency as the role progresses through the healthcare system. A permissive regulatory framework at the sector level is reflected in the different choices made by two case study NHS acute hospital trusts, in their engagement with the AP role. These different choices have consequences for how the AP impacts at the departmental level.

The rural determinants of health: using critical realism as a theoretical framework

Rural health needs to be based on robust theory that guides efforts in practice, teaching and research. This could make the sets of assumptions that are inevitably brought to bear on prioritization and decision-making more explicit. It has not yet been described in theoretical terms because to insiders such as health practitioners it seems to be more of a practical endeavour than an academic one. The rural determinants of health, as a more specific expression of the social determinants of health, include issues of geography and topography in addition to the social, economic and political factors that result in the persistent disadvantage in health access and outcomes of rural populations. The philosophical approach of critical realism provides a theoretical framework that is inclusive of subjective, objective and abstract realities. Using a case study from South Africa to illustrate these notions, a conceptual model is proposed that displays the geographical and historical foundations of rural health alongside the political, economic, social and health system factors influencing patterns of disease and wellness in rural areas.

Implementation, Mechanisms of Effect and Context of an Integrated Care Intervention for Vulnerable Families in Central Sydney Australia: A Research and Evaluation Protocol

Introduction:

In March 2014, the New South Wales (NSW) Government (Australia) announced the NSW Integrated Care Strategy. In response, a family-centred, population-based, integrated care initiative for vulnerable families and their children in Sydney, Australia was developed. The initiative was called Healthy Homes and Neighbourhoods. A realist translational social epidemiology programme of research and collaborative design is at the foundation of its evaluation.

Theory and Method:

The UK Medical Research Council (MRC) Framework for evaluating complex health interventions was adapted. This has four components, namely 1) development, 2) feasibility/piloting, 3) evaluation and 4) implementation. We adapted the Framework to include: critical realist, theory driven, and continuous improvement approaches. The modified Framework underpins this research and evaluation protocol for Healthy Homes and Neighbourhoods.

Discussion:

The NSW Health Monitoring and Evaluation Framework did not make provisions for assessment of the programme layers of context, or the effect of programme mechanism at each level. We therefore developed a multilevel approach that uses mixed-method research to examine not only outcomes, but also what is working for whom and why.

A Critical Realist Translational Social Epidemiology Protocol for Concretising and Contextualising a "Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD)", Sydney Australia

Background:

We will describe here a translational social epidemiology protocol for confirming a critical realist “Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD). The approach will include the concretising and contextualising of the above causal theory into programme theories for child and adolescent interventions that aim to break intergenerational cycles of disadvantage and poor life outcomes. In undertaking this work we seek to advance realist translational methodology within the discipline of applied perinatal and paediatric social epidemiology.

Theory and Methods:

The research settings are in metropolitan Sydney. The design will be a longitudinal, multi-level, mixed method realist evaluation of applied programme interventions that seek to break the intergeneration cycle of social disadvantage and poor child health and developmental outcomes. The programme of research will consist of three components: 1) Operationalisation of the theory and designing of programme initiatives for implementation; 2) Evaluation of the translated programme and implementation theory using Theory of Change and critical realist evaluation; and 3) Theory Testing of realist hypotheses using both intensive and extensive critical realist research methods including realist structural modelling.

Discussion:

The proposed programme of research will assist in translating empirical explanatory theory building to theory driven interventions. The research will be situated in socially disadvantaged regions of Sydney where the local child and family inter-agencies will collaborate to design and implement new initiatives that address significant disparities in childhood development and adolescent outcomes attributed to neighbourhood circumstances, family stress and intergenerational cycles of disadvantage and poor mental health.

Designing Initiatives for Vulnerable Families: From Theory to Design in Sydney, Australia

Introduction:

Intergenerational cycles of poverty, violence and crime, poor education and employment opportunities, psychopathology, and poor lifestyle and health behaviours require innovative models of health care delivery to break them. We describe a programme of research informed service development targeting vulnerable families in inner metropolitan Sydney, Australia that is designed to build and confirm a “Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD)”. We describe the development of an intervention design and business case that drew on earlier realist causal and programme theoretical work.

Methods:

Realist causal and programme theory were used to inform the collaborative design of initiatives for vulnerable families. The collaborative design process included: identification of desirable and undesirable outcomes and contextual factors, consultation forums, interagency planning, and development of a service proposal.

Results:

The design elements included: perinatal coordination, sustained home visiting, integrated service model development, two place-based hubs, health promotion and strengthened research and analysis capability.

Conclusions:

We demonstrate here the design of interventions for vulnerable families in Sydney utilising translational research from previous realist causal and program theory building to operational service design. We have identified the importance of our earlier analysis of underlying causal mechanisms and related programme mechanisms for identifying the elements for the full intervention design. The application of theory added rigour to the design of the integrated care initiatives. In applying the theory to the local situation the analysis took into account: the role of the local agencies; evidence of program effectiveness; determinants and outcomes for local children and their families; the current deployment of service resources; and insights from front-line staff and interagency partners.

Research paradigms and the politics of nursing knowledge: A reflective discussion

A standard view would suggest that research is a neutral apolitical activity. It neutralizes external pressures by its fidelity to robust scientific methods. However, politics is an inevitable part of human knowledge. Our knowledge of the world is always mediated by human priorities. What matters is therefore a contested and political debate rather a neutral accumulation of factual data. How researchers manage this varies. Research paradigms are one way in which research engages with knowledge. They frame knowledge within epistemological and ontological philosophies. In this paper, I will explore this view in relation to neo-positivism, qualitative research, Foucault and critical realism. I will argue that if nursing knowledge is to be effective it needs to acknowledge the political, particularly in the context of neoliberalism. Healthcare systems are having to cope with a social world increasingly dominated by market fundamentalism, extreme levels of inequality and a rise in xenophobia. These forces are undermining the provision of ethically sound health care, misdirecting research practice and contributing to a discourse of dehumanization. These forces need to be challenged politically and I will argue that epistemologically diverse approaches, alongside a realist ontology can provide a way forward for nursing research.

Therapy the Natural Way: A Realist Exploration of the Wilderness Therapy Treatment Process in Adolescent Mental Health Care in Norway

Wilderness therapy has the potential to meet the specific needs of the current adolescent population by providing a rather unique outdoor group treatment. Wilderness therapy is not a new approach to mental health treatment, but its theoretical basis is not yet clearly delineated, in part because of the diversity found across programs and contexts. This article presents a critical realist exploration of a wilderness therapy program that was recently implemented as part of adolescent mental health services in Southern Norway. In this study, we combine fieldwork and interviews for an in-depth investigation of the treatment process, where the objective was to acquire a deeper understanding of the opportunities that arise in the wilderness therapy setting. The therapeutic mechanisms and influential contextual premises found across the ecological, physical, and psychosocial factors of this multidimensional approach to treatment are presented, and their underlying conditions are briefly discussed.

Presenting Critical Realist Discourse Analysis as a Tool for Making Sense of Service Users' Accounts of Their Mental Health Problems

Making sense of service users' accounts of their mental health problems requires a method able to deal with complexity. Yet the different underlying epistemological and ontological positions of the methods researchers use, based, for example, on biomedicine or social constructionism, produce highly partial analyses. Addressing this problem, this article offers a method of Critical Realist Discourse Analysis (CRDA) that employs a synthesized discourse analysis, informed by critical realism, to examine the discursive, material, embodied, and institutional factors that might inform how mental health service users make sense of their mental health problems and associated service use. The article describes the epistemological/ontological underpinnings of CRDA and its three-phase methodology, before showcasing the method using, as examples, two data sets from care leavers and mothers. With our CRDA, we demonstrate a method for analyzing the complexity of interacting factors informing service users' understanding of their mental health problems.

Using critical realistic evaluation to support translation of research into clinical practice

A challenge that speech-language pathologists (SLPs) face is the translation of research into clinical practice. While randomised controlled trials (RCTs) are often touted as the "gold standard" of efficacy research, much valuable information is lost through the process; RCTs by nature are designed to wash out individual client factors and contexts that might influence the outcome in order to present the "true" impact of the intervention. However, in the area of behavioural interventions, the interaction of client factors and contexts with the treatment agent can substantially influence the outcome. This paper provides an overview of the theoretical background and methods involved in critical realistic evaluation (CRE) and discusses its current and potential application to speech-language pathology. CRE is based on the premise that a behavioural intervention cannot be evaluated without considering the context in which it was provided. While the ways in which contextual aspects and treatment mechanisms interact may seem endless, CRE methodology attempts to operationalise them into hypotheses to be empirically tested. Research based on these principles has the potential to support clinical translation of research outcomes and reduce the costs of unsuccessful treatment attempts for SLPs, clients and the service provider.

The assets-based approach: furthering a neoliberal agenda or rediscovering the old public health? A critical examination of practitioner discourses

The 'assets-based approach' to health and well-being has, on the one hand, been presented as a potentially empowering means to address the social determinants of health while, on the other, been criticised for obscuring structural drivers of inequality and encouraging individualisation and marketisation; in essence, for being a tool of neoliberalism. This study looks at how this apparent contestation plays out in practice through a critical realist-inspired examination of practitioner discourses, specifically of those working within communities to address social vulnerabilities that we know impact upon health. The study finds that practitioners interact with the assets-based policy discourse in interesting ways. Rather than unwitting tools of neoliberalism, they considered their work to be about mitigating the worst effects of poverty and social vulnerability in ways that enhance collectivism and solidarity, concepts that neoliberalism arguably seeks to disrupt. Furthermore, rather than a different, innovative, way of working, they consider the assets-based approach to simply be a re-labelling of what they have been doing anyway, for as long as they can remember. So, for practitioners, rather than a 'new' approach to public health, the assets-based public health movement seems to be a return to recognising and appreciating the role of community within public health policy and practice; ideals that predate neoliberalism by quite some considerable time.

Queer Genes: Realism, Sexuality and Science

What are 'gay genes' and are they real? This article looks at key research into these hypothesized gay genes, made possible, in part, by the Human Genome Project. I argue that the complexity of both genetics and human sexuality demands a truly critical approach: one that takes into account feminist epistemologies of science and queer approaches to the body, while putting into conversation resources from agential realism and critical realism. This approach is able to maintain the agential complexity of genetic materiality, while also critically challenging the seemingly stable relationships between sex, gender and sexuality.

Family therapy and fundamentalism: One family therapist's exploration of ethics and collaboration with religious fundamentalist families

What are the therapeutic limitations of systemic psychotherapy when working with families who hold religious fundamentalist beliefs? At a time of debate about religious fundamentalism, terrorism and radicalisation, where do family therapists position themselves when confronted by extreme beliefs in the therapy room? Research suggests that the increase in modernity within our society equates not just with an increase in secularisation, but rather an increase in pluralism. Contemporary models of family therapy pay explicit attention to issues of gender, culture, ethnicity, discrimination and societal contexts. The author, therefore, proposes that family therapists need to examine their position regarding religious fundamentalism in relation to the social constructionist relativist continuum and engage with uncomfortable questions about whether they believe that fundamentalism has essentially pathological roots. This article will explore whether the dualist position within some religious movements set against a more secular psychotherapeutic and psychiatric cultural milieu can invite a fundamentalised response from clinicians. The author draws on her own work with families who hold religious fundamentalist beliefs and enquires about ethics, transparency and collaboration within family therapy practice. This article invites complex ongoing challenging questions and debate.

Towards a Human Rights Culture in Social Work Education

A human rights perspective must be embedded in the institutions, organisations or agencies where social work students find themselves. This paper will focus on one particular strategy that could be helpful to the process of solidifying a commitment to human rights for our students. Using a pedagogical tool from a school of social work in the USA originally developed to combat the social injustice of racism, the example transcends the academic institution and offers a solid link in connecting human rights, social justice and social work. Using the construct of critical realism, we argue that, for social work programmes to take steps towards an explicit commitment to human rights, not only must human rights be infused throughout the curriculum, but educators must provide opportunities for making more overt the links between human rights principles, social justice and social work. By addressing behaviours, tendencies and attitudes, students then acquire not only the skills and deeper understanding, but they internalise the motivation and commitment to broaden their human rights frame. In the process of developing a more firm commitment to human rights, we must not be limited to the walls of the academy, but rather extend beyond to our field agencies, organisations and communities.

Transitions to End-of-Life Care for Patients With Chronic Critical Illness: A Meta-Synthesis

BACKGROUND

Adults with chronic critical illness (CCI) frequently experience a terminal trajectory but receive varying degrees of palliation and end-of-life care (EOLC) in intensive care units (ICUs). Why palliation (over curative treatment) is not augmented earlier for patients with CCI in ICU is not well understood.

PURPOSE

To identify the social structures that contribute to timely, context-dependent decisions for transition from acute care to EOLC for patients with CCI and their families.

METHODS

We conducted a meta-synthesis of qualitative and/or mixed-method studies that recruited adults with CCI, their families or close friends, and/or health-care providers (HCPs) in an ICU environment.

RESULTS

Five studies reported data from 83 patients, 109 family members, and 57 HCPs across 5 institutions in Canada and the United States. Overall, we found that morally ambiguous social expectations of treatment tended to lock in HCPs to focus on prescriptive work of preserving life, despite pathways that could "open" access to augmenting palliation and EOLC. This process limited space for families' reflexivity and reappraisal of CCI as a phase liminal to active dying. Notably, EOLC mechanisms were informal and less visible.

CONCLUSION

The management of dying is one of the central tenets of ICU care. Our findings suggest that patients and families need help in negotiating meanings of this situation and in using mechanisms that allow reappraisal and permit understanding of CCI as a phase liminal to dying. Moreover, these mechanisms may paradoxically reduce the ambiguity of patients' future, allowing them to live more fully in the present.

Moving from conceptual ambiguity to knowledgeable action: using a critical realist approach to studying moral distress

Moral distress is a phenomenon that has been receiving increasing attention in nursing and other health care disciplines. Moral distress is a concept that entered the nursing literature - and subsequently the health care ethics lexicon - in 1984 as a result of the work done by American philosopher and bioethicist Andrew Jameton. Over the past decade, research into moral distress has extended beyond the profession of nursing as other health care disciplines have come to question the impact of moral constraint on individual practitioners, professional practice, and patient outcomes. Along with increased interest in the phenomenon of moral distress have come increasing critiques - critiques that in their essence point to a serious lack of conceptual clarity in the definition, study, and application of the concept. Foundational to gaining conceptual clarity in moral distress in order to develop strategies to prevent and ameliorate the experience is a careful revisiting of the epistemological assumptions underpinning our knowledge and use of the concept of moral distress. It is our contention that the conceptual challenges reveal flaws in the original understanding of moral distress that are based on an epistemological stance that holds a linear conception of cause and effect coupled with a simplistic perspective of 'constraint' and 'agency'. We need a more nuanced approach to our study of moral distress such that our ontological and epistemological stances help us to better appreciate the complexity of moral agents acting in organizational contexts. We believe that critical realism offers such a nuanced approach.

The construction of context-mechanisms-outcomes in realistic evaluation

AIM

To discuss the construction of context-mechanisms-outcomes (CMOs) developed as part of a realistic evaluation study of two aggression management training programmes.

BACKGROUND

Realistic evaluation draws on theories and methods derived from the social sciences. It provides a distinctive account of the nature of programmes and how they work. Realistic evaluation is a form of evaluation that is driven by theory, and was based by Pawson and Tilley ( 1997 ) on the philosophy of critical realism. Critical realism is an important perspective in modern philosophy and social science, but it is largely absent in the field of healthcare research.

REVIEW METHODS

This paper provides a critical discussion on the construction of CMOs as part of a realistic evaluation study.

DATA SOURCES

This paper draws on the personal experiences of the author in using realistic evaluation to evaluate training in aggression management.

DISCUSSION

Realistic evaluation stresses four key linked concepts for explaining and understanding programmes: 'mechanism', 'context', 'outcome pattern' and 'context-mechanisms-outcomes (CMO) pattern configuration'. A CMO configuration is a proposition stating what it is about an initiative that works, for whom and in what circumstances. In this way, the effectiveness of the programme is understood, with an explanation of why the outcomes developed as they did and how the programme was able to react to underlying mechanisms and in what contexts. Therefore, a realistic evaluation researcher is not just inspecting outcomes to see if an initiative (implementation) works, but is analysing the outcomes to discover if the conjectured mechanism or context theories are confirmed. This analysis provides not only evidence of effectiveness, but also an explanation that helps to develop and improve the content and the targeting of future programmes.

CONCLUSION

The development of CMOs requires a great deal of skill on the part of the researcher and requires a flexibility of approach when collecting and analysing the data and in understanding the topic being investigated.

IMPLICATIONS FOR RESEARCH/PRACTICE

Applications of realistic evaluation have focused largely on evaluating initiatives in the field of social policy and, more recently, social work practice. To date, however, there have been few published realistic evaluation studies within nursing; therefore this study is novel in its use of the methodology.

Open access support groups for people experiencing personality disorders: do group members' experiences reflect the theoretical foundations of the SUN project?

OBJECTIVES

The SUN Project is an innovative, open access support group, based in the community, for people experiencing personality disorders, developed in response to UK Department of Health policy advocating improvements in personality disorders services. The aim of this article is to critically explore where and how the theoretically informed model underpinning the SUN Project is reflected in the view and experiences of people attending the project.

DESIGN

This article reports an in-depth, qualitative interview-based study employing a critical realist approach.

METHODS

As part of a larger study about self-care and mental health, in-depth qualitative interviews were held with 38 people new to the SUN Project, and again 9 months later. Data were extracted that were relevant to core components of the project model and were subjected to thematic analysis. The critical realist approach was used to move back and forth between empirical data and theory underpinning the SUN project, providing critical insight into the model.

RESULTS

Participant accounts were broadly concordant with core components of the SUN Project's underlying model: Open access and self-referral; group therapeutic processes; community-based support; service users as staff. There were some tensions between interviewee accounts and theoretical aspects of the model, notably around the challenges that group processes presented for some individuals.

CONCLUSIONS

The model underlying the SUN Project is useful in informing good practice in therapeutic, community-based peer support groups for people experiencing personality disorders. Careful consideration should be given to a limited multi-modal approach, providing focused one-to-one support for vulnerable individuals who find it hard to engage in group processes.

PRACTITIONER POINTS

Facilitated peer support groups based in the community may act as a powerful therapeutic resource for people experiencing personality disorders. Promoting open access and self-referral to support groups may increase feelings of empowerment and engagement for people experiencing personality disorders. Some individuals experiencing personality disorders who could potentially benefit from therapeutic groups may need focused one-to-one support to do so.

The interplay of deductive and inductive reasoning in psychoanalytic theorizing

Deductive and inductive reasoning both played an essential part in Freud's construction of psychoanalysis. In this paper, the author explores the happy marriage of empiricism and rationalism in Freud's use of deductive reasoning in the construction of psychoanalytic theory. To do this, the author considers three major amendments Freud made to his theory: (i) infant and childhood sexuality, (ii) the structural theory, and (iii) the theory of signal anxiety. Ultimately, the author argues for, and presents Freud as a proponent of, the epistemological position that he calls critical realism.

If it didn't exist we'd have to invent it... Further reflections on the ontological status of the state

In this brief response to Bob Jessop's probing yet sympathetic critique, I clarify further the 'as if realist' political ontology of the state. I suggest that critical realism's appeal to the ontological stratification of social reality and to the logic of retroduction are the principal stumbling blocks for 'as if realists', that the appeal to state power(s) as distinct from the state as real cannot circumvent the 'as if realist' ontological objection to the state as real since both remain conceptual abstractions, but that there is a natural affinity between the strategic-relational approach developed by Jessop and others and the 'as if realist' ontology of the state that I here elucidate.

Social theory and current affairs: a framework for intellectual engagement

The paper aims to facilitate more adequate critical engagement with current affairs events by journalists, and with current affairs texts by audiences. It draws on social theory to provide the intellectual resources to enable this. The academic ambition is for the framework to be adopted and developed by social thinkers in producing exemplary critical readings of news and current affairs texts. To this end it is offered as a research paradigm. The paper situates its argument in relation to the wider literature in media and cultural studies, acknowledging the subtle skills required to appreciate the relative autonomy of texts. However, it draws attention to the lack of an adequate perspective with which to assess the frames, representations, and judgments within news and current affairs texts. To address this lacuna it proposes the conception of a social-theoretical frame, based on a number of meta-theoretical approaches, designed to provide audiences with a systematic means of addressing the status and adequacy of individual texts. Social theoretical frames can reveal the shortcomings of media framing of the contextual fields within which news and current affairs events take place. Two illustrative case studies are used to indicate the value and potential of the approach: the analysis of a short newspaper report of the return of protesters to Cairo's Tahrir Square in 2011, and a critique of four current affairs reports from various genres on the political turmoil in Thailand leading up to the clashes of May 2010.

Dialysis modality decision-making for older adults with chronic kidney disease

AIMS AND OBJECTIVES

To examine the personal and structural facilitators and barriers for home-dialysis decision-making for older adults with chronic kidney disease.

BACKGROUND

Chronic illness is a global problem. Older adults with chronic kidney disease form a large and growing segment of the dialysis population in many high-income countries but are less likely to uptake home-dialysis despite its benefits.

DESIGN

This qualitative ethnography framed in social theory took place in Canada and included adults with chronic kidney disease not on dialysis, older than 65 years of age.

METHODS

Thirteen people (seven men and six women, aged 65-83 years of age) who received care in a team chronic kidney disease clinic took part. Persons with chronic kidney disease were interviewed and group interviews were conducted with four of their chronic kidney disease clinic healthcare professionals. Content analysis was used for data analysis.

RESULTS

The factors influencing older adults' chronic kidney disease modality decisions are similar to younger adults. However, older adults with chronic kidney disease are in a precarious state with persistent uncertainty. Age imposes some limitations on modality options and transplantation. Modality decisions were influenced by health status, gender, knowledge, values, beliefs, past experience, preferences, lifestyle and resources. Support from family and healthcare professionals was the largest determinant to home-dialysis selection.

CONCLUSION

The social and contextual factors associated with age influenced home-dialysis decision-making. Adequate social support, functional status and resources enabled home-dialysis selection.

RELEVANCE TO CLINICAL PRACTICE

Understanding more about the decision-making processes for older adults with chronic kidney disease is important for quality interventions and the economic sustainability of dialysis services.

Critical reflections on realist review: insights from customizing the methodology to the needs of participatory research assessment

Realist review has increased in popularity as a methodology for complex intervention assessment. Our experience suggests that the process of designing a realist review requires its customization to areas under investigation. To elaborate on this idea, we first describe the logic underpinning realist review and then present critical reflections on our application experience, organized in seven areas. These are the following: (1) the challenge of identifying middle range theory; (2) addressing heterogeneity and lack of conceptual clarity; (3) the challenge of appraising the quality of complex evidence; (4) the relevance of capturing unintended outcomes; (5) understanding the process of context, mechanism, and outcome (CMO) configuring; (6) incorporating middle-range theory in the CMO configuration process; and (7) using middle range theory to advance the conceptualization of outcomes - both visible and seemingly 'hidden'. One conclusion from our experience is that the degree of heterogeneity of the evidence base will determine whether theory can drive the development of review protocols from the outset, or will follow only after an intense period of data immersion. We hope that presenting a critical reflection on customizing realist review will convey how the methodology can be tailored to the often complex and idiosyncratic features of health research, leading to innovative evidence syntheses.

Critical realism: a practical ontology to explain the complexities of smoking and tobacco control in different resource settings

BACKGROUND

This paper presents critical realism (CR) as an innovative system for research in tobacco prevention and control. CR argues that underlying mechanisms are considered and explored to ensure effective implementation of any program/policy or intervention. Any intervention or program/policy that is transposed from one country to another or one setting to another is complex.

METHODS

The research was undertaken and analyzed through a critical ethnography lens using CR as a philosophical underpinning. The study relied upon the following components: original fieldwork in Nigeria including participant observation of smokers, in-depth interviews and focus groups with smokers, and in-depth interviews with health professionals working in the area of tobacco control in Nigeria.

RESULTS

Findings from this small ethnographic study in Nigeria, suggest that Critical Realism holds promise for addressing underlying mechanism that links complex influences on smoking.

CONCLUSION

This paper argues that understanding the underlying mechanisms associated with smoking in different societies will enable a platform for effective implementation of tobacco control policies that work in various settings.

Resistance in Unjust Times: Archer, Structured Agency and the Sociology of Health Inequalities

Few sociologists dissent from the notion that the mid- to late 1970s witnessed a shift in capitalism's modus operandi. Its association with a rapid increase of social and material inequality is beyond dispute. This article opens with a brief summation of contemporary British trends in economic inequalities, and finds an echo of these trends in health inequalities. It is suggested that the sociology of health inequalities in Britain lacks an analysis of agency, and that such an analysis is crucial. A case is made that the recent critical realist contribution of Margaret Archer on 'internal conversations' lends itself to an understanding of agency that is salient here. The article develops her typology of internal conversations to present characterizations of the 'focused autonomous reflexives' whose mind-sets are causally efficacious for producing and reproducing inequalities, and the 'dedicated meta-reflexives' whose casts of mind might yet predispose them to mobilize resistance to inequalities.