The Georgia Health Policy Center (GHPC) has become an international leader in the application of the realist framework to research, evaluation, and synthesis aimed at improving health outcomes.

The realist approach was first introduced by Ray Pawson and Nick Tilley in 1997.¹ In contrast to evaluation approaches that seek to answer “Does an intervention work?” or “Was it effective?” the realist approach provides a framework for discovering “What works for whom in what circumstances?”¹

The realist framework is particularly appropriate for assessment of complex environments that Donald Schön refers to as the “swampy lowlands,”² where real-life problems are messy and the complexity of the environment complicates evaluability and learning from the evidence. The realist approach provides the flexibility and adaptability needed to generate reliable observation in real-time in these dynamic environments.

Realist researchers expect outcomes to vary across interventions and specific populations based on the premise that no program works the same way for all people in all places all the time. This framework helps program developers and policymakers understand the varying conditions in which an intervention takes place and explain the underlying contexts and mechanisms that influence the outcome.

The realist framework examines:

• Context — Broader conditions (individual, interpersonal, institutional, infrastructural, or geographical) into which an intervention is introduced.
• Mechanism — How the change will be achieved. Mechanisms includes two parts: resources (e.g., the intervention) and changes in mindset, reasoning, decisions, or actions that are or are not triggered by introduction of resources into a particular context.²
• Outcome — The intended and unintended results or consequences produced when different mechanisms are stimulated in varying contexts.

Emerging patterns and learnings provide a greater understanding of interventions and supportive implementation contexts for policy decisionmaking and creation of increasingly effective solutions.

Additional Resources

• Realist framework one-pager

[1] Pawson, R., & Tilley, N. (1997). Realistic Evaluation. Thousand Oaks, CA: Sage Publications.

[2] Schön DA. The Reflective Practitioner: How Professionals Think in Action. New York, NY: Basic books; 1983.