what is critical realism in research

Education Studies

What is critical realism, critical realism.

Critical Realism (CR) is a branch of philosophy that distinguishes between the 'real' world and the 'observable' world. The 'real' can not be observed and exists independent from human perceptions, theories, and constructions. The world as we know and understand it is constructed from our perspectives and experiences, through what is 'observable'. Thus, according to critical realists, unobservable structures cause observable events and the social world can be understood only if people understand the structures that generate events.

Critical Realism and Science

We can use the analogy of a scientist to understand some core tenets of CR. When a scientist conducts an experiment, they establish the conditions to create the experiment and they observe the results (events). However, the results are caused by underlying theoretical mechanisms, structures and laws that they can not observe (unobservable structures).

The scientist's understanding is through epistemological constructivism and relativism. This is where the phrase Critical Realism originates from- the 'epistemic fallacy' that is reducing what we say is 'real' or exists (ontological statements) to what we can know or understand about the 'real' (epistemological statements). The real are the unobservable mechanisms that cause events. Epistemology and ontology are separate.

CR evolved from the writings of the philosopher Roy Bhaskar (A Realist Theory of Science, 1975). In this text Bhaskar lays the foundations of CR with his thesis for transcendental realism. He states that in order for science as a body of knowledge and methodology to work or be intelligible, then epistemology and ontology need to be separated and we must distinguish between the transitive and intransitive bodies of knowledge or dimensions. Transitive knowledge relates to qualities of changeability or provisionality of our knowledge of the real, thus the transitive dimension comprises of our theories of the events and structures that we seek to understand in the intransitive dimension.

Q. Does Bhaskar's notion of a stratfiied reality acount for why theories can reach different conclusions?

Q. How does Bhaskar justify the definition 'critical'? Is this a persuasive definition?

Q. CR distinguishes between causes, events and what we can know about events. In order for a causal eplanation to be valid, the explanatory power must be upheld outside of observable knowledge of specific events. Where does this definition apply to the social world and where does it not work?

Archer, M. S. (1998). Critical realism : Essential readings. London ; New York: Routledge.

Bhaskar, R. (1975). A realist theory of science. York: Books.

Bhaskar, R. (2002). Reflections on meta-reality : Transcendence, emancipation, and everyday life. New Delhi ; Thousand Oaks, Calif.: Sage Publications.

Bhaskar, R., & Danermark, B. (2006). Metatheory, interdisciplinarity and disability research: A critical realist perspective. Scandinavian Journal of Disability Research, 8(4), 278-297.

Brant, J., & Panjwani, F. (2015). School Economics and the Aims of Education: Critique and Possibilities. Journal of Critical Realism, 14(3), 306-324.

Collier, A. (1994). Critical realism: An introduction to roy bhaskar's philosophy. London ; New York: Verso.

Danermark, B. (2002). Interdisciplinary research and critical realism: The example of disability research. Journal of Critical Realism, 5(1), 56-64.

Danermark, B., Ekstrom, M., & Jakobsen, L. (2001). Explaining society: an introduction to critical realism in the social sciences. Routledge.

Danermark, B., & Gellerstedt, L. C. (2004). Social justice: Redistribution and recognition—a non-reductionist perspective on disability. Disability & Society, 19(4), 339-353.

Dean, K. (2006). Realism, philosophy and social science. Basingstoke England ; New York: Palgrave Macmillan.

Easton, G. (2010). Critical realism in case study research. Industrial Marketing Management, 39(1), 118-128. doi:DOI: 10.1016/j.indmarman.2008.06.004

Gorski, P. S. (2013). What is critical realism? And why should you care?. Contemporary Sociology: A Journal of Reviews, 42(5), 658-670.

Hartwig, M. (Ed.). (2015). Dictionary of critical realism. Routledge.

Scott, D. (2013). Education, epistemology and critical realism. Routledge.

Zachariadis, M., Scott, S. V., & Barrett, M. I. (2013). Methodological Implications of Critical Realism for Mixed-Methods Research. MIS quarterly, 37(3), 855-879.

1. A mind-map on key ideas in CR: https://www.mindmeister.com/160541119/critical-realism

2. http://understandingsociety.blogspot.co.uk/2013/03/what-is-about-critical-realism.html

3. http://international-criticalrealism.com/about-critical-realism/basic-critical-realism/

4. Links to a reading list on CR: http://jeffreylonghofer.com/page4/page38/page134/page136/

Critical Realism
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A beginner’s guide to critical realism

30th October 2020

A guest post by Tom Fryer.

A short guide to ontology and epistemology: why everyone should be a critical realist argues that positivism’s search for universal laws is like looking for a Ferrari at your local supermarket, and constructivism’s denial of reality seems pretty close to convincing yourself that you’re taking the dog-lead for a walk rather than the dog. We know critical realism gives the best alternative—but it can be really hard to explain this to new researchers, who might be quite intimidated by all this talk of ‘ontology’ and ‘epistemology’.

That’s why I wrote this short, accessible and open-access guide . And it’s completely free!

The guide is targeted at new PhD researchers and Master’s students, who might be starting to plan and design their projects. I aim to:

Give an accessible account of ontology and epistemology.
Outline the importance of these concepts for research design.
Share a simple framework to navigate this complex field.
Make the case for why everyone should be a critical realist.

As a second year PhD student, I’ve just been through this process of getting to grips with my research and thinking through the importance of my philosophical position. I hope that this experience, alongside some great illustrations (all credit to Joanna Kozak), will help a new generation of researchers to engage with this super important part of their research design.

The guide adopts a very informal and accessible tone, taking readers through some of the most important concepts and ideas. For example, I give a way to remember the difference between ontology and epistemology as:

Ontology sounds like ‘on toe logy’, or the study of what you just dropped on your toe . Now, if you just dropped a hammer on your toe, I guarantee you’re going to be thinking about reality. You’re going to be thinking about real hammers and real pain, in the real world. There’s no way you’re going to be in the mind-frame to ask: “How do I produce knowledge about this hammer?” You’ll be pretty focused on its reality. That’s ontology.
Epistemology sounds a bit like ‘epic stem ology’, or the study of epic stems . Imagine your mate, who is a plant scientist, comes up to you and says: “Hey buddy, look at the epic stem on this plant, how cool”. I’m guessing your first reaction will be: Is that really an epic stem? How does Dave know that’s an epic stem? Why does Dave have some right weird opinions? You can see these are all questions about knowledge, ie epistemology. See the illustration below!

I hope that gives you a quick flavour of the guide, which was very kindly supported by the Bhaskar Memorial Fund.

I’d really love any help and support sharing this guide with new researchers that you might have access to, or anyone else you think would enjoy it. Also, I’m very open to any critiques/improvements – and if anyone is thinking about how to communicate critical realism, I’d love to hear from you.

Tom Fryer is a PhD researcher in higher education at University of Manchester. His research is focussed on developing an alternative approach to graduate outcomes, moving beyond a narrow focus on employment status and graduate salaries. His Twitter handle is @TomFryer4 .

Understanding Causation in Healthcare: An Introduction to Critical Realism

Erica koopmans.

1 School of Health Sciences, University of Northern British Columbia, Prince George, BC, Canada

Dr. Catharine Schiller

2 School of Nursing, University of Northern British Columbia, Prince George, BC, Canada

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.

Human health and illness are complex areas of study, and our understanding of them is typically constructed from our direct observations and experiences of events ( Alderson, 2021 ). From what we observe, we try to make sense of, and interpret what we see happening; however, the philosophical stance we take as healthcare providers and researchers will influence our ways of thinking about these findings, and the conclusions we draw in understanding our area of study. Critical realism is a philosophical framework that is well suited to the health sciences to help us make sense of the ‘observable’ world and the ‘real’ world ( Alderson, 2021 ). Critical realism suggests that while we may observe and experience events, they are being generated by independent, often unobservable, but still very real, mechanisms ( O’Mahoney & Vincent, 2014 ). As healthcare providers and researchers, we are well rehearsed in looking beyond the surface of observable symptoms or factors to try and understand what is really occurring with the patients with whom we work, or the conditions and interventions which we study. The aim of this article is to introduce readers to the key tenets of critical realism, explore how it can offer healthcare providers and researchers deeper levels of explanation and understanding of causation, and examine some potential limitations of this approach.

The Case for Critical Realism

Critical realism is not a methodology or even a theory but a way of thinking (philosophical stance), which can inform investigations into our reality ( Archer et al., 2016 ; Oltmann & Boughey, 2012 ). In healthcare, critical realism can help us understand health and illness as processes that are affected by interactions between individuals and their contexts, including the agents and structures present, and help us explain what we see but also what we do not see ( Alderson, 2021 ). In recent years, the use of critical realism by health researchers has increased as they recognize the value it provides for effectively framing, identifying and understanding complex phenomena in the healthcare sector ( Schiller, 2016 ; Sturgiss & Clark, 2020 ). This approach has appeal for healthcare providers and researchers because of its recognition of the complexity of many health interventions, and its focus on explaining what works under specific conditions or contexts ( Williams et al., 2016 ). For example, a healthcare provider may question ‘why, after trying multiple interventions that I anticipated would change the disease trajectory for my patient, am I not seeing those desired changes?’ Using critical realism, we can effectively inquire into and understand more about the unseen mechanisms that have causal influence in the situation and their effect on the patient’s health and illness ( Alderson, 2021 ). Understanding generative mechanisms has the potential to be very meaningful when we design and evaluate new programs and services that are then transposed to another context, as it enables us to understand how and why desired change might be generated instead of just believing that it will or should happen (e.g., the effectiveness of programs or interventions).

Critical realism is also appealing given its application to various research designs and methods for data collection and analysis. This approach has been applied across broad areas of health research including in several mental health focused studies ( Bergin et al., 2008 ; Lauzier-Jobin & Houle, 2021 ; Littlejohn, 2003 ; Martin, 2019 ; Sims-Schouten & Riley, 2018 ); rural health ( Reid, 2019 ); as a framework for understanding smoking and tobacco control in South Africa ( Oladele et al., 2013 ); for designing an integrated care initiative for vulnerable families in Australia ( Eastwood et al., 2019 ); and for explaining the relationship between human rights and social determinants of health ( Haigh et al., 2019 ).

Foundational Concepts of Critical Realism

Critical realism emerged as a philosophical approach in the 1970s and 1980s, led by the work of Roy Bhaskar ( Bhaskar, 1998 , 2008 ) and built further by scholars such as Margaret Archer, Dave Elder-Vass, Philip Gorski, Tony Lawson and Andrew Sayer. It was introduced as an alternative philosophical framework to the positivist and interpretivist approaches being used in the natural and social sciences ( Fletcher, 2017 ; Williams, 2003 ). To appreciate the value of critical realism it is important to understand how it compares to other key philosophical positions used in research and consider what it can offer that these other ways of thinking do not.

A Focus on Ontology

Critical realism’s focus on ontology or more simply, what is real and independent of thought, awareness or knowledge of existence by humans, distinguishes it from other metatheoretical positions ( Alderson, 2021 ). Bhaskar critiqued positivist and interpretivist philosophical frameworks because of their tendency to conflate what the world ‘is’ ( ontology ) with our experiences of it ( epistemology ) ( Oltmann & Boughey, 2012 ; Reid, 2019 ). This is referred to as the epistemic fallacy. Positivist research is what you might think of as your ‘typical’ science experiment that uses research methods to test, observe, capture, compare and evaluate data ( Hartwig, 2015 ). Positivism aims to identify universal laws in an objective way ( Fryer, 2020 ). Those who use this approach consider that there is an independent, factual reality that can be discovered ( Alderson, 2021 ). Unlike positivism, which involves searching for laws that can be generalized, interpretivist and constructivist approaches see knowledge production as fallible and theory-dependent and they tend to focus more on discourse, meaning and experiences of people ( Fryer, 2020 ). The focus is on interpreting or constructing people’s experiences rather than discovering the actual reality which they claim is subjective to the individual ( Alderson, 2021 ). Bhaskar argued positivist and interpretivist frameworks either limit ‘reality’ to what can be empirically studied and identified as universal laws (positivism), or view reality as entirely constructed through human discourse or experiences (interpretivism and constructivism) ( Fletcher, 2017 ). Bhaskar criticized that research being pursued from these philosophical stances was based only on what could be observed or experienced ( Clark et al., 2008 ). While observations and experiences might make us more confident about what exists, or what might be ‘real’, critical realists note that existence itself is not dependent on such observations ( Haigh et al., 2019 ). For example, people have the right to health even when they are not aware they hold that right or may not have experienced it ( Haigh et al., 2019 ). Much of the justification for using critical realism rests on the integrity of the epistemic fallacy. Critical realists need to accept this as a limitation of the framework since, when distinguishing between ontological and epistemic claims, they cannot move outside their own experiences to ‘prove’ that those distinguishing features actually exist. Positivist and interpretivist approaches do not attract the same corresponding critique as they argue that all knowledge is either objectively observed through deductive reasoning, where they look for general patterns and rules (positivism), or subjectively experienced and inductively analysed (interpretivism).

Intransitive and Transitive Dimensions of Knowledge

Critical realism assumes the existence of an objective world, where mechanisms and structures function as intransitive objects, meaning they exist and act independently with powers and properties that are independent of humans but are still able to be investigated ( Hartwig, 2015 ; Schiller, 2016 ). In contrast, knowledge is considered socially produced and transitive , meaning it is subjective; because knowledge is subjective, our understanding of phenomena can and will constantly change ( Haigh et al., 2019 ; Vincent & O’Mahoney, 2018 ). Critical realists argue that we cannot just observe the world and produce knowledge about universal laws as positivists claim, without acknowledging that our beliefs, values and understanding are socially produced and changeable, meaning that knowledge is intrinsically fallible and relative. Critical realists are trying to approximate the truth of reality or the world, while remaining cognizant that all knowledge developed is fallible ( Schiller, 2016 ). Critical realism combines observation and interpretation in a search for causation and allows for an understanding of the structural forces or mechanisms that influence our lives and generate outcomes. However, it is noted that the validity of explanation in critical realism rests upon these ontological presuppositions and we once again must assume that those presuppositions are both valid and correct.

Stratified Reality

Critical realism suggests that reality is stratified and consists of three domains: empirical, actual and real ( Fletcher, 2017 ). These strata can be more simply considered as experiences, events and causal mechanisms. The empirical layer captures our experiences, senses, feelings and observations. The actual refers to the events or phenomena that happen but may or may not be observed by humans. Sayer discusses that, while observability can provide confidence about what we think exists, existence itself is not dependent upon it ( Sayer, 2000 ). The final layer is the real . Critical realism claims that real, but typically unseen, forces precede and generate events; these are referred to as causal mechanisms or generative mechanisms ( Alderson, 2021 ; Hartwig, 2015 ) . Both positivism and interpretivism acknowledge the empirical level of trying to understand and analyse reality. Positivism also recognizes the actual level by acknowledging that the world does exist independently of our thoughts about that world. However, critical realism remains unique in adding the third level of real, yet typically unseen causal influences or mechanisms ( Alderson, 2021 ). To explain why events, effects or outcomes occur, critical realists describe that we need to move beyond the surface of experienced and observable factors to understand what is happening underneath, at the real level ( Clark et al., 2008 ).

Alderson (2021) supplies a helpful example, adapted here, using the condition of Type I insulin-dependent diabetes mellitus (IDDM) to demonstrate stratified reality ( Table 1 ). To begin, you are working as a healthcare provider and a patient presents to your office describing frequent occurrences of hyperactivity as well as feelings of being weak or faint. This is experienced by that person at the empirical level. You may ask additional questions to further understand their symptoms and, as a result of this information, decide to conduct a blood glucose test. You observe from the blood test results that they have irregular blood sugar levels. The actual event that is happening is the rise and fall of blood sugar levels, but this does not explain why this is happening or what is generating this event. There could be many reasons why this individual has irregular blood sugar levels. It is not until you examine further and consider what could be causing those irregular levels that you identify that this individual’s pancreas is not secreting insulin, the hormone which converts sugar into energy. While the patient may not be aware of what their pancreas is (or is not) doing, this does not change the fact that the pancreas is indeed present and its failure to secrete insulin is causing changes to the patient’s blood sugar levels. Alderson (2021) ends this simplified life sciences example here to show how outcomes can only be understood if we dive into the context and mechanisms that generate the events we observe. Yet, we can effectively take this inquiry significantly further by using critical realism to explore why the pancreas is not secreting insulin. Existing research informs us that, in such situations, something will be causing the body’s immune system (which under normal conditions fight harmful bacteria and viruses) to mistakenly destroy insulin secreting beta cells of the islets of Langerhans in the pancreas ( Leslie & Elliott, 1994 ; Lernmark & Alshiekh, 2016 ; Moini, 2019 ). Is it genetics? Is it exposure to other viruses? Is it environmental factors? What are the hidden but necessary preconditions for IDDM? Using a critical realist lens of inquiry, we may be able to better understand what is generating this outcome of irregular blood sugar levels and under what conditions this outcome will be the result.

Example of Stratified Reality Using Endocrinology and Diabetes in the Life and Social Sciences. Adapted from P. Alderson (2021) .

We can also apply this stratified reality to a social sciences example where the views and experiences of patients with IDDM, their families and their healthcare providers are observed and understood at the empirical level by asking patients about their experiences receiving health services for their condition. We could also observe their daily lives, document the number of people affected, the services accessed and the cost of care incurred to identify events associated with IDDM. However, to deeply understand events, and the ways that IDDM may be influenced by structures such as class, ethnicity, gender or income, we need to consider the real level, where unseen causal mechanisms associated with structural entities and agency are at work.

Causal Mechanisms

As introduced above, critical realists aim to develop and provide ever-deeper levels of explanation and understanding of causal or generative mechanisms and how they work ( Bergin et al., 2008 ). A key question in critical realism is ‘for this to occur, what does the world (or the body system) need to be like?’ ( Alderson, 2021 ). Questions of inquiry include the following: How is the effect being caused? What triggers them? What inhibits them? ( Connelly, 2001 ). These questions ring true as both healthcare providers and researchers. While it is important to know about a patient’s experience and the actual phenomenon that is happening, we want to find and understand the mechanisms that are producing a given effect, event or outcome (or why those mechanisms are interacting in such a way that a given event does not happen). This contrasts the thinking of positivists who look for cause and effect relationships using lawful patterns of thinking and interpretivist approaches who do not view causality as linear but rather as meaning constructed from human activity ( Bergin et al., 2008 ).

Critical realism acknowledges that the relationship between mechanisms and events, despite initial appearances, is not as simple as ‘cause and effect’ ( Oltmann & Boughey, 2012 ) and it is not necessarily linear either (cannot be inferred from a regular sequence of events) ( Oladele et al., 2013 ). Critical realism accepts the possibility of complex causality, meaning that generative mechanisms interact in different ways and will not always play out the same as actual events or previously observed empirical experiences ( Angus & Clark, 2012 ). Sayer (2000) provides a useful description of a critical realist view of causality:

What causes something to happen has nothing to do with the number of times we have observed it happening. Explanation depends instead on identifying causal mechanisms and how they work, and discovering if they have been activated and under what conditions (p. 14)

Therefore, for critical realists it is neither the experience nor the event itself that is the most important to identify and understand, but rather how the mechanisms are coming together in the right number, combination, time and context required to generate an outcome ( Oladele et al., 2013 ; Schiller, 2016 ). Critical realism also critiques the idea that only things that are present exist ( Haigh et al., 2019 ). Consider, for example, access to health care; when access is not present, the lack of access to health care itself may generate unmet health needs as outcomes ( Haigh et al., 2019 ). Critical realists argue that reality, specifically social reality, is produced and changed by these generative mechanisms that are activated or not activated at any given time ( Connelly, 2000 ). It is possible for mechanisms to exist but not generate an effect or to generate a new, different or unexpected effect ( Oltmann & Boughey, 2012 ). Mechanisms can therefore be enabling or constraining depending on the context ( Oltmann & Boughey, 2012 ). As critical realists, we cannot assume that they will have a particular effect but rather that their interactions will result in a tendency for an effect to occur or not occur ( Oltmann & Boughey, 2012 ). When we conduct research using critical realism then, we are looking to identify those relatively enduring tendencies or repetitions (demi regs or demi regularities) ( Hartwig, 2015 ) .

Critics of critical realism may argue that this approach to causality does not avoid the problem of induction at the level of the empirical but instead just transfers it to the level of the real. Critical realists are looking to uncover the foundational unchanging, intransitive, generative mechanisms in which to ground claims about why an event will probably happen in future if these mechanisms are present. Some will question why causal mechanisms (the real) are a better candidate for this than observations or experiences (empirical)? In other words, why is there any more reason to think that these enduring tendencies are more reliable just because they exist ‘beneath’ the empirical where it is experienced. Critiques such as these need to be considered when choosing the critical realism approach over other philosophical frameworks.

An Open System

While we may try to create a closed system in which we can conduct an experiment, control for confounding factors, and yield universal laws about interaction between outcomes and their causes, the ‘real world’ is inevitably an open system. Patients, healthcare providers and the healthcare systems in which they exist and interact are complex and unpredictable, entangled in social contexts, behaviours and relationships which cannot be neatly classified into separate variables ( Alderson, 2021 ). It is challenging to work in the social realm because people cannot easily be placed in the controlled environments considered necessary to truly attribute an effect or event to a cause ( Oltmann & Boughey, 2012 ). For example, if you read in a recent research article that a new behaviour change intervention has been successful in reducing cardiovascular disease risk in a randomized control trial, you may not see the same result when you try to implement this intervention in your practice. Interventions, polices, practice guidelines and programs are frequently transposed to another context and expected to work as effectively as they worked in the context in which they were first developed or tested ( Oladele et al., 2013 ). Critical realism recognizes the difficulties that are inherent in designing social science research and helps us to understand deterministic patterns of activity ( Schiller, 2016 ). It acknowledges that there is a causal network of interacting forces counteracting or reinforcing each other and that outcomes depend upon the conditions in which these mechanisms will operate ( Schiller, 2016 ). There is demonstrable value then, in identifying causal mechanisms and searching for relatively enduring tendencies or repetitions to guide us in explaining how they work, if they have been activated, and under what conditions their interactions might produce outcomes.

Agency and Structure

In using a critical realist framework, we also need to consider agency and structure. Bhaskar (2014) and Archer (1995) explain agency and structure as separate yet interdependent entities in that neither can be ‘reduced to, explained in terms of, or reconstructed from the other. There is an ontological hiatus between society and people, as well as a mode of connection’ ( Bhaskar, 2014 , p. 37). Their writings on agency and structure are the basis for current theorists/practitioners to apply and adapt within a healthcare context. In the context of healthcare, agents are providers and users of health services. This includes (but is not limited to) patients, their family members and support system, healthcare providers and staff, administrators and policy makers. In experimental conditions it is typically implied that each agent involved has free will, choice or agency; in other words, they can act independently and make free choices. However, in the real world, human agency is constrained by structures, other agents and resources ( Alderson, 2015 ). As Fryer (2020) frankly describes it, people do not just wander around, acting freely and doing whatever they want. Alternatively, if they do behave in this way, they do not usually get away with it for long. The world has social structures within which we live and, due to this, we will not often make completely individual decisions that are entirely unaffected by external influence.

Structures are powerful, objective and enduring entities that exist in and through human social relationships ( Alderson, 2021 ). Examples of these social structures include social class, gender and race. While these structures are not typically visible (although manifestations of them might be), nor are they tangible in and of themselves, they are no less real than the law of gravity ( Reid, 2019 ). Agents do not individually construct structures, but they will reproduce, resist, change or work within them, either through direct interaction with these structures or simply via the agent’s movement through the world ( Alderson, 2021 ). Structures would not continue to exist without agents continuing to reproduce and transform them ( Martin, 2019 ). Further, agents will each have their own reasons, motives, decisions, hopes and intentions (conscious and unconscious) brought to bear on the influence they wield and the choices they make; these can then be very real causal influences with effects and outcomes generated through the actions they produce, maintain and transform ( Alderson, 2021 ; Connelly, 2000 ). If we are to think as critical realists, we need to be aware of our own histories and motives and how they might be affecting our experiences and observations, as well as the way in which we are interpreting the experiences and observations of others ( Oltmann & Boughey, 2012 ), such as patients or coworkers. We should also consider how the social histories of patients or coworkers may be affecting their own experiences and observations ( Oltmann & Boughey, 2012 ). If we persist in the belief that everyone has free will or choice, for example the agency to rise above difficult life circumstances such as poverty, abuse or discrimination, then this places the power of agency above the power of structures. It implies that agency is a single overriding power instead of acknowledging the variety and complexity of the multiple powers that will exist in an open system ( Alderson, 2015 ). While the power of social structures is not absolute, it is immense and though some individuals may be able to overcome these powers, others may not for a variety of reasons ( Alderson, 2015 ). It is therefore vital, when conducting social research in the realm of health sciences, to pay attention to and acknowledge these complex agency-structure relationships and interactions as much as possible. If we only look at agency, we fail to consider the impact of structures and what constraints they may have on how and why someone acts in a particular way ( Martin, 2019 ). Conversely, if we only explore structures, we assume individuals are only influenced by these constraints and have no agency or influence ( Martin, 2019 ).

Next Steps for Advancing Your Practice

This article attempted to make the key principles of critical realism accessible for those who are just beginning their journey with this approach. It is a high-level introduction to critical realist concepts and supplied some examples of how critical realism can be helpful in health research, health practice inquiry, and interpretation of findings and observations. There are many more comprehensive resources available to support continued learning on this subject. While readings on philosophy can often feel dense and complex, Fryer’s (2020) A Short Guide to Ontology and Epistemology (Why Everyone Should Be a Critical Realist) , makes it easy to ‘wrap one’s head around’ some difficult concepts. Fryer navigates the basics of ontology and epistemology and reviews different philosophical positions through entertaining and easy to understand examples. For a user-friendly and detailed expansion on critical realism and its application for health research, Alderson’s (2021) book Critical Realism for Health and Illness Research: A Practical Introduction is a particularly excellent guide . Those interested in clarifying concepts and connecting critical realist theory and methodology may wish to read Danermark, Ekstrom and Karlsson’s (2019) recently revised Explaining Society: Critical Realism in the Social Sciences which includes illustrative examples of recent research, and Edwards et al. (2014) Studying organizations using critical realism: A practical guide. Lastly, if you are interested to dive into more complex reading in this area, Critical Realism: Essential Readings contains key works of many thought leaders in the field, including Archer, Bhaskar and Collier ( Archer et al., 2013 ).

Health and illness affect every aspect of our lives and are influenced by many factors, including the context, policies, behaviours and beliefs that surround us ( Alderson, 2021 ). Patients with the same diagnosis can differ in their presentation of symptoms and how they respond to interventions. Interventions developed and studied with demonstrated efficacy in one context may fail to result in the same outcomes in another context. This article provided an overview of foundational critical realist concepts using examples from the healthcare setting. The aim was to support healthcare providers and health science researchers to consider how critical realism can help them understand causation at a deeper level and thus support more effective change, while also noting the assumptions and critiques they may encounter when using this approach. Critical realism offers many opportunities as described, including an affinity with the way many of us in healthcare see the world fitting together ( O’Mahoney & Vincent, 2014 ). While we may observe what we think are universal laws, and experience actual events which shape our stories and guide our thinking, critical realism helps us avoid conflating what is real with our experiences. It can assist us in understanding the open system of our social world where relationship between mechanisms and events is not as simple as ‘cause and effect’, and where context, structures, and agents can interact in diverse ways to generate or constrain effects, events or outcomes. This way of thinking can help us examine beyond the surface of observable symptoms or obvious factors to understand what is really happening with patients and health services. As we attempt to make sense of the ‘real’ world and the ‘observable’ world, critical realism is a way of approaching healthcare issues that can allow us to be more successful in this endeavour.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Statement: Our study did not require a research ethics board approval because it did not contain human or animal trials.

Erica Koopmans https://orcid.org/0000-0003-2001-7128

Catharine Schiller https://orcid.org/0000-0003-3656-2171

Critical Realism in the Social Sciences

First Online: 07 May 2022

Cite this chapter

Jenny Gilbert 3 &
Simon Pratt-Adams 4

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Critical realism is a naturalist epistemology, one that is applicable across the sciences and the social sciences. Following the introduction in Chap. 2 of critical realism as an underpinning philosophy, this chapter focuses on its application within the social sciences. Research in the social sciences differs from that in the sciences in several ways and this factor is explored under the headings of transitive/intransitive objects and through the comparison of the ‘context of discovery’ with the ‘context of justification’. The four tenets of critical realism are described and several theoretical frameworks that inform the Womposo research strategy, devised in Chap. 4 , are presented. These include the five-stage social ontology of Dave Elder-Vass, David Scott’s five social objects, Margaret Archer’s four-part model related to structure and agency, and Amartya Sen’s Capability Approach, together with its application in an educational research setting. Using examples from the field of botany, the real, the actual and the empirical domains of critical realism are illustrated, providing examples of morphogenesis and morphostasis. The powers of social groups, variously entitled social objects or social structures, are discussed. Norm circles generate emergent causal powers, these powers exercise downward causation on the entities, the people, within the norm circle.

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Article Contents

Introduction, what is critical realism, the contribution of critical realism, using a critical realist approach in primary care research, declarations.

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Using critical realism in primary care research: an overview of methods

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Elizabeth A Sturgiss, Alexander M Clark, Using critical realism in primary care research: an overview of methods, Family Practice , Volume 37, Issue 1, February 2020, Pages 143–145, https://doi.org/10.1093/fampra/cmz084

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Primary care research seeks to answer a wide variety of complex questions: how do we most effectively manage patients with multiple illnesses? When is the practice nurse the best-placed health professional to provide patient support? What is the likelihood that medicines found to be effective in randomized trials will benefit my patient?

To answer primary care research questions, we need diverse research methods that are responsive to the context and nested complexities of patients, their settings and the broader health system ( 1 ). Primary care occurs within a social reality—that is—it is embedded in how people, and their actions, influence the multiple interconnected parts of a social system ( 2 ). No patient, part of the health care system or community exists in isolation: each is made up of and influenced by the actions of people ( 3 ). These actions produce a social reality. This paper explores one approach to research methods that seek to understand the complexity of how and why things work (or do not work) in primary care settings whilst incorporating the perspective of social reality.

Although ‘complexity’ and ‘complex’ are everyday words, we use them here with a specific meaning. Complex processes have so many inputs that the outcome is unpredictable and past experience does not reflect what might happen in the future. As such, a set recipe for how to generate a particular outcome is not possible. This is in contrast to complicated processes that have outcomes that are reliably predictable if the ‘recipe’ is followed ( 4 ).

There are limitless research questions about primary care and different methodological tools are available to enhance our understanding of how the case works. Critical realism is not a method in itself but is an approach that can be used to inform how methods are applied ( 5 ). Questions about how and why things are effective, or ineffective, are well placed to be answered by methods guided by critical realism.

Critical realism is a philosophy that grew from a critique of positivism from philosopher Roy Bhaskar—particularly the assumption that humans are able to fully and infallibly know and measure reality ( 6 ). Instead, critical realism states that the evidence we observe can come close to reality but is always a fallible, social and subjective account of reality. Yet, in contrast to constructivism, critical realism also challenges the assumption that equates human perceptions of reality with reality itself ( 7 ). Instead, critical realism posits that reality is mind independent ( 6 ). While human perspectives are important, these are always ‘accounts of reality’. For example, a person who smokes can believe that smoking tobacco does not harm their lungs but the objective biological state of their lungs is not determined by the person’s beliefs. Reality remains mind independent.

Critical realism also claims that the mind-independent nature of reality applies not only to physical dimensions (such as the chair beneath you or car driving towards you) but also to social and cultural aspects ( 8 ). The mind-independent nature of culture means that human perceptions of cultures remain that and cannot be equated with the cultures themselves. This respects that people can have beliefs and personal understandings, but that this also does not change the state of that independent reality.

Critical realism can be used for research methods to explain outcomes and events in natural settings—pertaining to questions about how and why events or phenomena occur. From this approach, critical realism recognizes that interventions and systems consist of ‘emergent mechanisms’ ( 9 ) that can explain the outcomes. Emergence describes the synergism that occurs between components of a complex process so that the outcome is ‘more than the sum of the parts’ and that different components can combine across multiple layers of a system ( 9 ). Emergence is a big contributor to the unpredictability of outcomes in a complex system.

These features of critical realism fit in well with the ontology of complexity that recognizes the synergistic nature of context and mechanisms where the addition of multiple elements results in more than the sum of the parts involved ( 1 ). This understanding is aligned with the complexities of primary care where we work with patients who have multiple, interconnected conditions, living in communities that influence outcomes. A critical realist approach can help us to answer research questions about how and why interventions and programs work within the complexities of primary care.

Critical realism is not a research method per se but a set of philosophical tenets that can inform a wide variety of quantitative, qualitative or mixed-methods designs, which seek to understand different phenomena. It is particularly useful for understanding how and why things happen, as well as unpacking the influence of context on the outcomes of a program.

For example, to better the influence that context has on intervention outcomes, consider Mr. Tickle—the infamous Mister Men children’s character ( 10 )—who spreads happiness and joy by tickling his friends in Tickletown. From his many successes, one could conclude that a ‘program’ that involves wiggling one’s digits in the armpits of another can lead to happiness and joy as it has appeared to cause considerable mirth in Tickletown. Inspired by this positive outcome, you could visit your local bus station to ‘scale-up’ this successful happiness intervention by unexpectedly tickling those waiting for a bus. This translation of the successful Mr Tickle ‘program’ is unlikely to lead to replication of the mirth seen in the original Mister Men situation and, indeed, is very likely to result in shocked locals and a custodial sentence.

In recounting this example at numerous workshops, participants consistently recognize the palpable ridiculousness of expecting a positive outcome to arise from replicating Mr. Tickle’s intervention. Yet, similar assumptions about the intrinsic ‘power’ of a program to bring positive outcomes are common with implementation discussions predominantly focussed on ‘what programs work’ ( 4 ). Research exploring health care programs predominantly neglects the crucial role context plays in moderating effectiveness. Critical realism can be used to overcome this weakness in understanding program effectiveness by bringing context back in.

Guided by these concepts from critical realism, it is possible to apply research methods that acknowledge, seek and explore the real-world complexities of primary care. Here, we highlight some specific methods using a critical realist lens.

The interview informed by a critical realist approach

An alternative approach to an interview is the ‘teacher–learner’ style, where the interviewee is cast as the expert or ‘teacher’ and the interviewer, as the learner, asks questions to progressively deepen, refine and re-formulate their understandings of how and why interventions are effective ( 11 ). The researchers develop different theories about how and why an intervention might work and present these to the interviewee. Most often, this occurs through a series of ‘why’ questions related to the experience of the interviewee. The interviewee is asked to comment on the researchers’ theory based on their own real-world experience and teach the interviewer about their own theories about the subject ( 12 , 13 ). This is a very different approach to other interview studies (e.g. grounded theory) as the interviewer is very open about their own ideas and seeks to learn from the experience of the participant.

Process evaluation—understanding how context influences intervention outcomes

A critical realist approach can help to unpack the influence of context on intervention effectiveness. Rather than assuming that interventions hold the power in and of themselves to effect change, a realist approach recognizes the intertwining between context (the elements that make up the setting of an intervention), mechanisms (the unseen forces that trigger change) and the outcomes of an intervention ( 4 ).

Simply picking up a program and dumping it in another setting may have unintended outcomes. For example, in a feasibility trial of a weight management program in primary care, a quantitative tool was to measure the doctor–patient alliance and a trend was seen between the strength of the alliance and clinical outcomes ( 14 ). In another, qualitative data was used to explore the effectiveness of heart failure programs after myocardial infarction and social mechanisms were found to be essential to outcomes ( 12 ). This approach to evaluation gives a better understanding of the factors needed for the intended outcomes to occur.

Process evaluation, using qualitative and/or quantitative data, can be used to understand the factors influencing outcomes. While a large and heterogeneous literature has existed for 30 years around such approaches ( 15 ), the Medical Research Council (MRC) have provided a comprehensive and readily applicable overview of the approach for complex interventions, which is currently under revision and will include specific reference to realist methods ( 16 ).

The surprising outlier in randomized controlled trials

Among the realist evaluation community, there is heated debate about whether randomized controlled trials (RCTs) are a credible method for understanding complex interventions ( 17 ). While we do not seek to replicate this debate here, we acknowledge the possibility of using a critical realist approach to understand the outcomes of an RCT in primary care. RCTs report an average effect size across groups ( 18 ). Typically, in each arm of the trial, there will be cases that are ‘surprising outliers’ as either intervention success or failure. These outliers are a rich source of understanding when using a critical realist lens: why do interventions for some people have no or even the opposite of the expected effects? This approach is also useful for epidemiological data as was seen in this study exploring the low prevalence of childhood obesity in disadvantaged areas ( 19 ).

Rather than merely measuring outcomes, realist methods provide an important means to understand outcomes better—and to learn both from what appears to work and from what does not. For example, a case study approach could be used to explore a surprisingly successful case using in-depth interviews with both the participant and provider to understand how and why the person was able to effect change.

Realist evaluation and synthesis

A realist evaluation can be used to understand how and why complex interventions are effective or ineffective ( 20 ). The archetypal question of the realist evaluation is:

‘What works for whom, when and why?’

The latest draft of the MRC’s guidelines for the development of complex interventions suggests realist evaluation for questions related to how context influences interventions and what ‘unseen mechanisms’ are involved in making an intervention work ( 21 ). Usefully, reporting standards have now been published that present an account of how to maintain rigor and quality in such work ( 22 ).

For example, a review of primary care for people with long-term mental illness used qualitative data from participants and providers to discover that team-based working was essential for success but often did not result in appropriate follow-up ( 23 ). Another example explored physical activity for children with disability using qualitative data and found that relational aspects of the programs were important ( 24 ).

A realist evaluation provides an account of how aspects of and combinations of context and mechanisms interact to influence outcomes. This can be in a narrative form or expressed as ‘CMO’ equations, which describe the Context and Mechanisms that can lead to wanted Outcomes. As these evaluations often explore complex programs within complex systems, the CMO equation should not be viewed as a mathematical formula but as a description of patterned occurrences.

A critical realist lens can also be applied to synthesize multiple studies about a particular topic ( 25 ). For example, a secondary review of a Cochrane systematic review of school lunch programs ( 26 ) was able to give policymakers more insight into the effectiveness of the programs to ensure that local implementation was effective. This method of synthesis is attractive for the in-depth understanding it can provide, although if primary studies are not reported with enough detail or attention to contextual factors, the synthesis can be difficult ( 27 ).

Both qualitative and quantitative data describe situations and events that have already occurred. However, these descriptions may or may not predict future outcomes for patients and populations. We can learn from other disciplines like economics, which uses the most advanced descriptive methods but, even then, economists failed to predict the global financial crisis ( 28 ). Alternatively, a critical realist lens seeks to understand the process and, therefore, what is more or less likely to be feasible.

Our most challenging health problems are not simple, linear processes and we need research methods that can explore complexity to improve our understanding of primary care. Primary care processes are transformative, dynamic and ever-changing and understanding the process can help to better translate and implement effective interventions.

Funding: there is no external funding associated with this work.

Conflicts of interest: the authors declare no potential conflict of interest.

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Published: 27 November 2019

Developing a critical realist informed framework to explain how the human rights and social determinants of health relationship works

Fiona Haigh ORCID: orcid.org/0000-0002-5706-5118 1 , 2 ,
Lynn Kemp 3 ,
Patricia Bazeley 3 &
Neil Haigh 4

BMC Public Health volume 19 , Article number: 1571 ( 2019 ) Cite this article

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That there is a relationship between human rights and health is well established and frequently discussed. However, actions intended to take account of the relationship between human rights and social determinants of health have often been limited by lack of clarity and ambiguity concerning how these rights and determinants may interact and affect each other. It is difficult to know what to do when you do not understand how things work. As our own understanding of this consideration is founded on perspectives provided by the critical realist paradigm, we present an account of and commentary on our application of these perspectives in an investigation of this relationship.

We define the concept of paradigm and review critical realism and related implications for construction of knowledge concerning this relationship. Those implications include the need to theorise possible entities involved in the relationship together with their distinctive properties and consequential power to affect one another through exercise of their respective mechanisms (ways of working). This theorising work enabled us identify a complex, multi-layered assembly of entities involved in the relationship and some of the array of causal mechanisms that may be in play. These are presented in a summary framework.

Researchers’ views about the nature of knowledge and its construction inevitably influence their research aims, approaches and outcomes. We demonstrate that by attending to these views, which are founded in their paradigm positioning, researchers can make more progress in understanding the relationship between human rights and the social determinants of health, in particular when engaged in theorizing work. The same approaches could be drawn on when other significant relationships in health environments are investigated.

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Context and case

Global initiatives such as the WHO Commission on Social Determinants of Health, the 2011 Rio Declaration, and 2015 Sustainable Development Goals, identify human rights as key to addressing inequities in social determinants of health. Correspondingly, there have also been calls from human rights monitoring bodies – including the United Nations (UN) Commission on Human Rights, the UN Committee on the Rights of the Child, the UN Committee on Economic, Social and Cultural Rights and the UN Special Rapporteur on the right to health [ 1 , 2 , 3 ] - for the development of health impact assessment tools and approaches that can provide insights into ways government actions affect the right to health. However, action specifically based in a human rights approach to identifying and addressing social determinants of health has been limited and these major global initiatives have been critiqued. While acknowledging the role of rights, few initiatives have explicitly attempted to incorporate rights into actions and priorities [ 4 , 5 , 6 , 7 , 8 ]. Chapman describes how

reticence to recognize the shared agenda and potential contribution of the human rights paradigm is particularly surprising in view of the Commission secretariat’s recommendation that the CSDH adopt a rights-based approach as an appropriate conceptual framework to advance towards health equity through action on the social determinants of health [ 5 ]

However, we think that this situation is not unsurprising as there is currently a lack of underpinning understanding of how human rights (HRs) and social determinants of health (SDOH) interact and affect each other: how the relationship can ‘work’. Further, there are differing conceptualisations of the determinants of health used in human rights and public health that have important implications for how relationships between SDOH and health rights are understood [ 4 , 7 ]. For example, human rights conceptualisations of social determinants of health often fail to take into account how determinants interact with each other and also to consider the structural determinants of health [ 5 ]. Current human rights interpretations of the right to the highest attainable standard of health and healthcare and health determinants contained in reports from human rights bodies may miss important causes due to human rights narrower conceptualisation of determinants of health. Conceptual models used to understand and describe how the SDOH shape people’s lives are often limited to a narrow range of causal pathways that reflect particular disciplinary perspectives [ 9 , 10 , 11 ].

We also propose that these apparent disciplinary differences may reflect, in turn, more fundamental differences and variations in points of view about reality, the nature of knowledge that we attempt to construct about what we construe to be real and how we should go about constructing and evaluating knowledge: different ‘paradigms’ may be in play. From this perspective, we believe that attempts to develop knowledge about particular phenomena require explicit attention by researchers to their ‘paradigm positioning’. As Carter and Little [ 12 ] observe, it is impossible to create knowledge “without at least tacit assumptions about what knowledge is and how it is constructed”. Conversely, those who read accounts of such attempts need to take into account the paradigm position of the researchers.

To clarify and illustrate the implications of this stance, we define the notion of a paradigm, outline the key tenets of our own paradigm position – critical realism, and then describe in detail how we applied these tenets to develop theory about the relationship between human rights and the social determinants of health.

To demonstrate key points, we use a case study of the Vermont Right to Health Care Campaign [ 13 ]. Vermont is a small state in the northeast of the USA with a population of just over 600,000. The United States does not have a Universal Health Care (UHC) system. Healthcare is paid for through a mix of private insurance and government funded health insurance schemes for particular population groups. In 2008, the Vermont Workers’ Center (VWC) began a “Health Care is a Human Right” campaign. The campaign adopted human rights principles to guide all its work. The VWC developed a staged approach which first focussed on building power through activating Vermonters, then directly targeting the legislature. We applied a CR explanatory framework to explain how a human rights-based approach can work to influence access to health care. Details of the case study are described in a separate publication [ 13 ]. In conjunction with this case study, we provide a reflective critique on our use of a CR-based theorizing methodology.

The concept of a research paradigm

The matter with human beans is that they is absolutely refusing to believe in anything unless they is actually seeing it right in front of their own schnozzles The BFG

We understand a paradigm to constitute four categories of interrelated views that underpin our conceptions of knowledge and knowing: ontology – one’s understanding of the nature of reality and what can be known about that reality; epistemology – understanding of the nature of knowledge, the ‘getting to know’ process, the relationship between the person who seeks to know and the knowledge they construct, and the criteria for making claims about knowledge; methodology – approach to the construction of knowledge; and axiology – the influence of values on knowledge that is acquired and how it is acquired. A coherent set of views in relation to these four considerations constitutes a paradigm position.

As previously noted, different disciplines and subject matter fields have developed traditions in relation to these views. For example, medical sciences have tended to adopt a positivist or post-positivist paradigm, based on the view that what is real, and therefore knowable, is what can be observed ‘out there’ and measured. This perspective is also apparent in some conceptions of human rights as legal rules found within treaties [ 14 ]. In contrast, social sciences often adopt a social constructivist paradigm which rests on the view that what is real is what our individual minds ‘make’ real to us; reality is a construction – by and of the mind. And, the knowledge that we construct about these in-the-mind realities is influenced by the social relationships in which we are embedded. From this perspective, “there exist multiple, socially constructed realities ungoverned by natural laws, causal or otherwise” [ 15 ]. The relationship between different fields and paradigm positions is more nuanced than presented here and within specific fields there exist a mix paradigm perspectives [ 16 , 17 ] but for the purposes of this paper the main point is that differing ontological and epistemological positions have implications for the questions researchers seek to answer, the methodologies they employ, the data they gather - and the ways in which data are gathered, analysed and interpreted. For example, while social constructionists are more likely than positivists to be interested in investigating qualitative differences in the meanings people give to experiences, positivists are more likely to be interested in identifying stable relationships between things and substantiating these relationships using generalisable quantitative data. Differences in paradigm positioning might also be linked to different social groups or cultures. For example, in New Zealand researchers give explicit consideration to Maori ontology and epistemology [ 18 ] and Maori specific research methodology (Kaupapa Maori). Some researchers, especially those employing mixed methods, adopt a pragmatic paradigm position in which their view of reality is based on and tested through experience. They choose methods, therefore, based on their experience of what works best for answering their research questions. While some researchers have an explicit awareness of their paradigm position and communicate it in research publications, others have an implicit position only.

Critical realism research paradigm – key features and relevance to human rights and social determinants of health

Critical realism (CR) is a relatively new paradigm position. It represents a combination of views that contrast with those associated with traditional positivist and interpretivist positions [ 19 , 20 , 21 ]. An increasing number of public health, and to a lesser extent human rights, scholars are adopting a CR position [e.g] [ 9 , 22 , 23 , 24 , 25 ]. There is also now a large body work in the area of realist evaluation which is informed by a critical realist research paradigm [ 26 ], including examples in this journal [e.g] [ 27 , 28 , 29 ].

In the following sections we briefly elaborate on the key features of the critical realist research paradigm.

According to CR, there is a reality that exists independent of our thoughts about it, and while observing may make us more confident about what exists, existence itself is not dependent on observation [ 19 ]. An example of this is that people have the right to health even when they are not aware of it. While we can acquire or construct knowledge about reality, that knowledge can be fallible, or mistaken.

Reality is stratified into three domains: empirical, actual and real. The real domain consists of entities or structures which have properties that give them the power to activate mechanisms that can affect other structures (i.e. causal mechanisms); the actual domain consists of events and their effects that have been caused by the activation of causal mechanisms; and the empirical domain represents actual events-effects that can be, or have been, observed or experienced. For example, human rights may be observable at the empirical level through asking people about their beliefs and attitudes towards human rights. The actual level consists of what happens when people’s rights to the determinants of health such as education, housing, health care, freedom from discrimination are fulfilled or neglected. These events-effects can only be explained with reference to the real level, where unseen causal powers associated with such entities as class, gender, and capitalism are triggered.

The world is made up of entities that have properties that endow them with powers and liabilities. Events happen when the powers of one or more entities are activated. Because of the stratified nature of reality, entities can be invisible or visible. This means they can include non-physical things such as ideas, theories, concepts or institutions, as well as physical entities such as cigarettes or guns. In the social world, entities are often invisible (e.g. human rights, discrimination, capitalism). These invisible entities are not observable at the empirical level, but the effects of their activated powers/mechanisms may be observable (e.g. health outcomes, access to health services, health service costs, measured inequalities). A CR approach also understands absence of entities as being causally efficacious. Critical realism provides a critique of ‘ontological monovalence’, which is the idea that only things that are present exist [ 21 , 30 ]. Just as when lack of rain causes a drought, or in the case of Vermont, lack of access to health care causes unmet health needs or lack of respect for rights causes suffering, rights are often most causally powerful and important when they are absent. Activation, which involves the exercise of particular mechanisms, is contingent on other entities and their mechanisms (context).

Knowledge is transitive– our understanding of a phenomenon can change. While entities exist independent of our ability to perceive and conceive that they exist, we do use our minds to construct knowledge about them. As the construction of knowledge can never be infallible – sometimes we construct misconceptions or mistaken theories – our knowledge of the world is transitive. It is open to challenge and change. This CR epistemological perspective means that we recognize that theory that we have developed about human rights and health may in time be extended, modified or rejected, notwithstanding our attempt to ensure its trustworthiness and practical adequacy. A theory is not intransitive, as reality is.

The social world is a layered, complex and open system. Within this system, multiple entities are present, the types of entities are wide ranging, each entity may subsume other entities or be subsumed within other entities, and a vast array of these entities’ mechanisms may be activated and in play moment by moment. For example, within the Vermont case study, entities that were attended to included organizations such as the Vermont Workers Centre, people such as political representatives, policies such as Health Care Policy, plans including those of the VWC campaign, goals such as improving access to health services, methods and tools such as letter writing and human rights assessment of proposals. Some people had multiple roles (e.g. doctor, campaigner, parent). As each entity had properties that endowed it with mechanisms which could enable, constrain or block the mechanisms of other entities, the actual interactions between entities and their effects were extremely complex. The exercise of mechanisms was often contingent on the mechanisms of another entity being activated. For example, the Vermont Workers Centre had its latent causal powers-mechanisms (e.g. to empower, to inform) activated when a group of people decided to exercise their power to ‘campaign for universal health care’. And, the exercise of some mechanisms was a manifestation of personal power to act (i.e. the exercise of agency by a Vermonter to write a letter) or the power of social structures over personal action (e.g. the activation of compliance mechanisms associated with the rules of accessing the Vermont Legislature). It was evident that causal power could shift between agency and structure. The exercise of some mechanisms (e.g. informing mechanisms of conducting human rights assessments of new proposals) lead to changes in the properties of entities (e.g. Vermont citizens gained knowledge of rights and corresponding state duties) and, in turn, power to exercise new mechanisms (e.g. to claim rights through a right to health rights campaign). They also lead to the emergence of new entities (e.g. new legislative proposals). In this sense, a social system is always open to and characterized by change. This contrasts with a system in which law-like regularities can be identified (e.g. signing human rights treaties invariably leads to decreases in human rights violations). In an open system, such relationships are context dependent [ 31 , 32 ].

Critical Realist methodology

From a CR perspective, the primary purpose of research, and therefore of the application of a methodology, is the theorizing of explanations for ‘tendencies’ in phenomena that have been observed or experienced (e.g. events, effects). These explanations focus on the mechanisms of entities that can generate events – as well as the properties of entities that empower them with such mechanisms. Bhaskar describes how “This is the arduous task of science: the production of the knowledge of those enduring and continually active mechanisms of nature that produce the phenomena of our world” (Bhaskar, 1975, p.47).

Tendencies may include recurrent relationships between phenomena, variability in such relationships or the absence of a relationship – and complexity is likely to characterize the interactions between entities and their associated mechanisms. Critical realists are pragmatic in their approach to methodology and methods. Because of the layered nature of reality, multiple disciplines and methodological approaches may be needed to understand the multilevel relationships between human rights and social determinant of health. Research design should be ‘practically adequate’: that is,‘fit for purpose’ [ 30 ]. This allows space for the members of different disciplines to work together to understand a topic such as human rights and the social determinants of health.

Critical Realist axiology

Emancipatory objectives form part of a critical realist research agenda. Danermark points out that “A critical science often takes its starting point in notions that improvement of society is possible” [ 20 ].

The implication of this emancipatory worldview is that when phenomena are under investigation it may be possible to identify how these features may be influenced (e.g. properties, and therefore mechanisms, changed) in order to ameliorate harmful effects or to enhance beneficial effects. Thus, CR research has an inherent focus on ‘what to do’ to improve people’s human rights situation.

Critical realism, the social determinants of health and human rights

In the following sections, we describe how we drew on critical realist perspectives to develop theory about the relationship between human rights and social determinants of health. In doing so, we focus on two processes; structural analysis of human rights and social determinants of health and identifying causal relationships between social determinants of health and human rights. A framework summarizing the outcomes of these analysis and theorising processes is presented.

The general case for attending to paradigm position when undertaking such research is also made.

In order to develop explanatory theory, concerning the relationship between human rights and the social determinants of health, the entities themselves need to be described. What are human rights? What are social determinants of health? Each of these entities has a structure, a set of properties or attributes that differentiate it from other entities. In turn, those properties give the entity the power to activate or exercise mechanisms that can cause effects. These effects may, in turn, involve changes to the properties of an entity and, therefore its potential mechanisms. Description of these entities, from both perspectives (cause and effect), involves structural analysis.

Human rights attributes include the following: rights are norms ; rights exist within relationships between claim holders and duty bearers; rights have core principles that provide a framework for application; rights have substantive and procedural elements. These various properties may be further differentiated and described. For examples norms may be universal/community specific, clear/unclear, accepted/contested, non/conflicting. The specifics of properties determine whether and what mechanisms can be activated. In this instance, the mechanisms may include informing, guiding, persuading, preventing and enforcing. These mechanisms are latent because their activation is contingent on the mechanisms of another entity being activated (e.g. someone reads and thinks about the norm). Such contingent relationships are common in social environments. For example, the exercise of mechanisms associated with human rights norms can change the capacity of a community to hold duty bearers accountable for impacts on health and health rights. However, the capacity of rights holders to claim rights may also be contingent on the exercise of the mechanisms of education programs that are intended to facilitate learning about rights and ways of claiming rights (e.g. in Vermont, information derived from a human rights analysis was presented to Vermonters to inform them about how policy changes impacted on human rights obligations).

Social determinants of health are entities that can cause health-related effects on individuals and communities and that have the following general properties: they exist within the social environment, they result from decisions about how societies should be organised and ‘work’ (e.g. social norms, policies, practices, economic arrangements, politics, education) and they may change over time and vary across social groups and contexts. Again, the properties and associated mechanisms of specific entities (e.g. a health policy, housing policy, an education programme) can be elaborated and delineated with much greater precision using CR ontological perspectives and analysis processes. Questions that can help identify the properties of entities include:

What does the existence of this object/practice presuppose? What are its preconditions?

Can/could object A exist without B? If so, what else must be present?

What is it about this object, that enables it to do certain things (there may be several mechanisms at work and we need to seek ways to distinguish their respective efforts)?

What cannot be removed without making the object cease to exist in its present form?

[ 20 , 30 ].

When making a structural analysis of entities, it should not be assumed that entities that share the same name (e.g. disadvantaged community, race, gender, sexuality, disability, and ethnicity) have similar properties and consequential powers. This needs to be taken into account when the applicability of evidence from other research involving similar entities is considered. To what extent do they (e.g. affected communities) have common properties and therefore powers? Are the findings from other research relevant given contrastive properties and powers?

A further caveat concerns the attention that is given to what can be observed (the empirical domain). Critical realists contest the notion that what can be observed and measured is the thing itself [ 31 ]. This view, that Bhaskar calls the epistemic fallacy, reduces statements about the world (ontology) to statements about our knowledge of the world (epistemology) [ 21 ]. We see epistemic fallacy in some existing approaches to the right to health, that tend to focus on identifying changes to indicators. Indicators are used as proxies for human rights (e.g. ratification of human rights conventions, overall finance commitments for respecting human rights, number of employees and community members that have access to complaints, disputes, and grievance processes, access to health insurance). However, the focus on such observable and measurable indicators ignores whether or how the indicators correspond to the ‘actual’ experience of human rights and the ‘real’ properties and mechanisms of human rights. Without attention to the structural features of human rights and social determinants of health, it is difficult to theorize explanatory linkages between them and to develop recommendations that could result in changes to that relationship – and consequential health effects.

From a CR perspective, the way health rights are interpreted and discussed is also based on our understanding that may change over time – they are transitive understandings. The transitive nature can be seen in how legal conceptualisations of the right to health have been broadened over the years. And, if we are to avoid conflating entities with our ideas about them, we need to recognise that rights as ‘real things’ are not the same as our local/personal/temporal interpretations of them.

Theorising an explanatory framework

We present a critical realist informed framework for describing the environment that incorporates human rights and social determinants of health-related entities – and defines their relationship (Fig. 1 ). This framework emphasizes that these entities and relationships can be understood to exist within a stratified, laminated, emergent, open system that contains an assemblage of entities that have a relationship to human rights. Entities in health rights environments can take different forms such as physical, cultural, biological or social. Actors can be described in terms of the social relations and institutional structures they belong to. Actors belong to, and are influenced by, multiple institutions and structural relations – but also have agency to influence and change those structures. Differentiating between actors and structures emphasises people and their capabilities as one unit of analysis and institutions and social relations associated with systems as another. In this context, the key human rights relational structure is that between rights holders and duty bearers.

Critical Realist Human Rights and Social Determinants of Health Explanatory Framework

The framework can be subject to substantial elaboration, as below, which emphasizes the complexity of this environment. That complexity is reflected in the array of relationships that potentially exist between the numerous entities involved. Those relationships, which are defined by the activation and effects of mechanisms, explain how the environment ‘works’ (e.g. see Fig. 2 ). The framework can assist researchers to identify the mechanisms that may be in play and that should be subject to further in-depth investigation and development of explanatory theory. Key features of the framework are now identified and discussed. Some of the potential relationships and associated mechanisms are illustrated using the Vermont case study.

Vermont Case Study: Towards a theory of how the campaign worked

When we conceptualise the spaces where human rights play out as being laminated, we can begin to identify what entities and related mechanisms exist at different laminations and also to consider how the interplay of mechanisms and the specific context influences those mechanisms. Analysis of the relationship between human rights and health that doesn’t take account of the linkages between laminations may result in a focus on specific levels. For example, individual lifestyle factors (such as excessive alcohol use) may be attended to without a concurrent focus on possible more distal causes (for example, the colonisation history and racism within the country) that emanate from other laminations [ 9 , 32 ]. Bhaskar [ 33 ] identifies seven laminations and in the table below we identify examples of HR and SDOH entities and relationships across these laminations (see Table 1 ). The levels identify people, the physical environment and social structures as key entities. People themselves are also layered and “can be understood as a uniquely laminated layered structure, shaped by genetics, nurture and culture, so that each person has strong and partly predictable tendencies” [ 34 ]. People interact with entities and structures across these layers.

The relationships that exist between entities within and across laminations can often be characterized in terms of the relative power that entities have. Bhaskar describes two types of power relations linked to structure and agency [ 35 ]. Human rights infringements are often the result of repressive power relationships that enable some agents to maintain destructive, coercive and oppressive advantages over others’ interests [ 36 ]. These power relationships are often related to structures and beliefs related to class, gender, age and ethnicity. At the same time, power relationships can trigger creative, emancipatory and transformative mechanisms that enable and empower agents [ 36 ]. Although described by Alderson as different dimensions, these contrastive types of power could also be viewed as the extremes of one dimension (interpersonal relations). We can take account of dimensions of power when developing causal explanations and identifying what to do. In line with CRs emancipatory values, actions should target development of enabling and empowering relationships. Such relationships were evident in the campaign in Vermont which involved civil society actions intended to minimize coercive repressive relationships that were associated with neoliberal health care policies. The latter involved a relationship between access to money and access to health services. Attention to human/health rights emphasizes the need to consider power-related relationships and associated accountabilities, in particular between states and communities. As London and Schneider observe, this can help ensure there is

“the space for civil society action to engage with the legislature to hold public officials accountable and confirms the importance of rights as enabling civil society mobilization, reinforcing community agency to advance health rights for poor communities” [ 37 ]

Different types of data and disciplinary perspectives may be required to describe the entities that make up different slices or laminations of reality and the interplay between them [ 11 ]. To facilitate understanding of complex health rights environments and decisions about evidence, researchers and practitioners are likely to need to make use of more varied conceptual frameworks that are grounded in different disciplines and their related methodologies [ 20 ]. Understanding the role of entities within these different laminations may also require transdisciplinary work that goes beyond disciplines working in parallel or sequence, in order to utilise integrative approaches [ 38 , 39 ]. CR provides a coherent rationale for, and guidance on, the use of multiple data, methodologies and methods within SDOH and HR research. The coherence rests on the ontological and epistemological perspectives of CR which leads to a pluralist, as well as pragmatic, stance on these considerations.

In Vermont the laminated nature of the relationship between the human rights driven campaign and access to health care is illustrated using examples in Table 1 .

As illustrated in Fig. 2 , a wide range of mechanisms associated with the varied entities involved in the campaign were activated. These mechanisms related to learning about the right to health, community mobilisation, awareness raising in decision makers, framing of ideas, and responding to new developments. These mechanisms were contingent on contextual factors such as Vermont’s history of being a progressive state and the Vermont Workers Centre being well established with an existing base and relationships. Ultimately the campaign contributed to a number of outcomes described in Fig. 2 including human rights principles being incorporated into Vermont legislation.

We have argued that in order to advance our knowledge and understanding across a field that is characterised by multiple disciplinary perspectives and approaches, we need to think about the meaning of knowledge and knowing: we need to consider our research paradigm. To confirm this stance, we have presented and account of, and commentary on, our application of the critical realist paradigm in a project focusing on the relationship between HR and SDOH. The presentation is also intended to provide a transferable case study and model of critical realism ‘in action’. While this paradigm now underpins the research of an increasing number of researchers involved in health and rights related research, for many it is unfamiliar, challenging or even troublesome newcomer.

Given this agenda, we have highlighted the following aspects of the CR paradigm:

Critical realist ontology acknowledges the complexity inherent in social phenomena and provides a conceptual framework for describing this complexity. Descriptions of complexity, as we have illustrated, necessarily go beyond the empirical domain of reality (i.e. beyond what can be observed, experienced and measured).

Critical realists take a pluralist and pragmatic stance with respect to methodologies and methods that might be drawn on to theorising this complexity - and to the associated use of perspectives and approaches that may be multi-disciplinary, interdisciplinary and transdisciplinary. Critical realists seek to avoid being trapped within the silos of single disciplinary views. When theories that are founded in different paradigm positions and across different disciplines are drawn on, they are re-interpreted through a critical realist ontological lens. This represents a form of ‘abductive reasoning’ which, along with retroduction, is a distinctive feature of a CR theorising methodology.

CR adopts ‘practical adequacy’ as one of the criteria for evaluating new theory. Does the explanatory theory provide a foundation for actions that can be demonstrated to be beneficial rather than harmful? With this in mind, CR axiology supports social critique as a dimension of the research process.

Critical realists recognize that the constancy of change and emergence means that a ‘settled’ theory concerning the relationships between phenomena cannot be formulated. This calls into question the notion of determinants, as the term can imply a degree of stability that is not present. Constructs and propositions may be transient. At the same time, some differentiation of entities (properties, mechanisms and relationships) that may be relatively stable is possible, as illustrated in the Vermont case study.

The key features of human rights and SDOH environments, identified as an our outcome of our theorising work, include the following:

HR and SDOH environments are understood to be open, laminated, complex and adaptive systems.

Entities can take different forms such as physical, cultural, biological or social.

Actors can be described in terms of the social relations and institutional structures they belong to.

There is intersectionality of actors whereby actors belong to, and are influenced by, multiple institutions and structural relations - and can also be simultaneously individual, primary and corporate actors.

Understanding and explaining the relationship between human rights and SDOH requires going beyond the observable to consider structures, powers, and mechanisms and requires transdisciplinary work.

With respect to practical implications of our theorising work, we argue that successful implementation of global initiatives such as the Sustainable Development Goals requires more than the setting of targets and indicators. Structural analysis and development of explanatory theory is necessary if we are to understand what things are, how they work – and how they might work better. This type of research will enable the fields of public health and human rights to identify the fundamental causes of health and human rights inequities such as economic structures, class and racism, and to conceive ways of addressing them. Explicit and indepth consideration of the relationship between human rights and the social determinants of health is critical to strengthening accountability and governance mechanisms.

Finally, we recommend some practical steps to facilitate greater consideration of the place of paradigms in research on human rights and social determinants of health. As researchers when reporting on research on SDOH and HR, we can outline, as in this paper, the paradigm perspectives that influenced our research and related assumptions about the knowledge that we have constructed and evaluated. As practitioners, we can have conversations in our work with communities and other stakeholders about how we understand knowledge, the role of different types of evidence and ways of theorizing explanations and evaluating their practical adequacy. We cannot and should not assume that our views about these matters are shared by others. However, as Huber and Morreale [ 42 ] observe about interdisciplinary encounters

growth in knowledge also comes at the borders of disciplinary imagination....It is in this borderland that scholars from different disciplinary cultures come to trade their wares – insights, ideas and findings – even though the meanings and methods behind them may vary considerably (p. 1) .

Availability of data and materials

Abbreviations.

Critical realism

Health Impact Assessment

Human rights

Social Determinants of Health

Universal Health Care

United Nations

Vermont Workers’ Centre

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Acknowledgements

We would like to acknowledge the research team who contrinuted to the Vermont Case Study and the case study participants.

This manuscript draws on research carried out by FH during her doctoral studies. These studies were funded by an Australian National Health and Medical Research Council Postgraduate Scholarship. The case study used within the paper to illustrate key points was partially funded by the World Health Organization.

The funding bodies had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

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FH developed the draft manuscript. All authors were involved in conceptualising and revising the manuscript. The paper draws FH’s PhD thesis. LK and PB were supervisors of the PhD and NH provided substantial input into the research planning and writing. All authors have read and approved the manuscript.

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Haigh, F., Kemp, L., Bazeley, P. et al. Developing a critical realist informed framework to explain how the human rights and social determinants of health relationship works. BMC Public Health 19 , 1571 (2019). https://doi.org/10.1186/s12889-019-7760-7

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Received : 04 February 2019

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Published : 27 November 2019

DOI : https://doi.org/10.1186/s12889-019-7760-7

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Social determinants of health
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Qualitative Research in Organizations and Management

ISSN : 1746-5648

Article publication date: 16 June 2020

Issue publication date: 15 October 2020

Traditional approaches in qualitative research have adopted one research paradigm linked to an established typology. This paper addresses the unconventional application of two research paradigms in one study. A critical realist approach was used to augment a constructivist analysis of data in a research project seeking to explore the meaning that managers in small to medium enterprises (SMEs) attach to hazard identification, the construction of a hazard profile reflective of the business and its use in assisting to manage hazards within the SME's safety management system framework. Critical realism offered a complementary but essential framework to explore causal mechanisms that led to a deeper understanding of the findings by searching for the processes and causality that lay beneath the social and organizational phenomena observed.

Design/methodology/approach

This paper compares the two research paradigms in order to seek junctures and apply them to a research project. Analytical tools applied to each research paradigm within the project are presented, followed by a new multiparadigm conceptual model that integrates critical realism and constructivism, providing an original contribution of knowledge to this field of qualitative research.

The adoption of a multiparadigm model enabled not only the interpretation of social phenomena but also the determination of its causality, enabling a more insightful answering of the research question and leading to a deeper insight into the phenomenology that was studied. This research approach widens the boundaries of qualitative inquiry within organizational research by promoting strategies that challenge more traditionally anchored research typologies, and consequently contributes to better research outcomes.

Research limitations/implications

This study was conducted across four organizations. Similar research is encouraged across a greater number of case studies to validate the process of using a constructivist and critical realist paradigm to gain a more insightful understanding of events and their causality.

Practical implications

The comparison of two research paradigms and consequent provision of a conceptual model (Figure 3) provides potential for the development of further multiparadigm models for research projects within the field of organizational management.

Social implications

This paper has the potential to promote engagement and collaboration between research scholars seeking to explore the use of multiple research paradigms.

Originality/value

Such an approach has not previously been widely discussed or adopted to examine qualitative data, and advances theory in qualitative research. The application of two research paradigms using such an approach can be applied to businesses in a number of different contexts to gain a more insightful understanding of research participant perspectives, observable events arising from those perspectives and their associated causality.

Constructivism
Qualitative study
Critical realism
Research paradigm

Acknowledgements

Declaration of interest statement: No potential conflict of interest is reported by the authors.

Bogna, F. , Raineri, A. and Dell, G. (2020), "Critical realism and constructivism: merging research paradigms for a deeper qualitative study", Qualitative Research in Organizations and Management , Vol. 15 No. 4, pp. 461-484. https://doi.org/10.1108/QROM-06-2019-1778

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Using critical realism in primary care research: an overview of methods

The interview informed by a critical realist approach

Process evaluation—understanding how context influences intervention outcomes

The surprising outlier in randomized controlled trials

Realist evaluation and synthesis

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Developing a critical realist informed framework to explain how the human rights and social determinants of health relationship works

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Critical realism research paradigm – key features and relevance to human rights and social determinants of health

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