A realist approach to the systematic review

Abstract

In clinical medicine, due to the widening gap between the demand and delivery of healthcare services in the 1970s and 1980s, priority-setting in health policies began to focus on efficiency and service costs. This situation, which is frequent inWestern societies, led to the emergence of the clinical practice known as evidence-based medicine. This is usually defined as "the conscious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Historically, the health promotion field has been slow in embracing the use of evidence, and this hesitation may be connected with the Ottawa Charter for Health Promotion (Evans, Hall, Jones, & Neiman, 2007). The Ottawa Charter (World Health Organization, 1986), considered a milestone in the development of health promotion, did not prioritize the use of evidence to measure effectiveness. It was only in 1998 that the World Health Organization launched an appeal to connect health promotion strategies with the production of health promotion evidence (Evans et al., 2007). InWestern societies, where healthcare expenditures account for a large portion of government budgets, there is continuous pressure to demonstrate that health promotion is a good investment (Evans et al., 2007), and this pressure is growing. Evidence is required to lessen the uncertainty of decision-makers and to guide action priorities (Raphael, 2000). In addition, practitioners in the field have a legitimate desire to show that their work brings tangible benefits (McQueen, 2007a). So the health promotion field really has no choice but to continue trying to assess the effectiveness of its interventions. There is an important gap between interventions that are deemed effective on the basis of evidence and interventions that are actually implemented in practice (Glasgow & Emmons, 2007). For instance, the complexity of health promotion interventions poses significant conceptual and methodological challenges for the assessment and production of results syntheses that would provide a rational basis on which to guide practices. Moreover, users of research results, such as practitioners and decision-makers, raise a broader range of questions than those addressing intervention effectiveness (Glasgow & Emmons, 2007; Petticrew & Roberts, 2003; Rychetnik & Wise, 2004). Among others, they formulate questions concerning the social, political, and economic settings in which the interventions are developed, implemented, and assessed, as well as the development and implementation of the intervention itself, and the conditions required to maintain interventions over time (Armstrong et al., 2008). So how can we respond to the challenge of producing systematic reviews that capture the essence of the practices that are transferable to other contexts (Potvin & McQueen, 2008)? This chapter presents a pragmatic reflection intended for practitioners who must incorporate evidence in their dayto- day decisions. Systematic reviews, which are large-scale projects considered to have high scientific value, also have their limitations. The objective here is to present these limitations and to propose an alternate approach to producing them. The first section describes the paradigm shift in the concept of evidence, which has been under debate for the past fifteen years. Second, an explanation is given for why systematic reviews in this field do not appear to have effectively impacted health promotion practices or policies. Third, we propose four types of criteria to include when assessing systematic reviews in order to encourage transfer of their contents to health promotion practices. In light of these criteria, we suggest a realist approach to the production of systematic reviews. Combining the generation of evidence and social values, it is a promising tool to guide intervention planning and implementation. © 2008 Springer Science+Business Media, LLC.