Women's College Hospital, Institute for Health System Solutions and Virtual Care, Toronto, Canada.
University of Toronto, Institute of Health Policy, Management and Evaluation, Toronto, Canada.
BMC Med Res Methodol. 2018 Dec 27;18(1):178. doi: 10.1186/s12874-018-0641-4.
The concept of "mechanism" is central to realist approaches to research, yet research teams struggle to operationalize and apply the concept in empirical research. Our large, interdisciplinary research team has also experienced challenges in making the concept useful in our study of the implementation of models of integrated community-based primary health care (ICBPHC) in three international jurisdictions (Ontario and Quebec in Canada, and in New Zealand).
In this paper we summarize definitions of mechanism found in realist methodological literature, and report an empirical example of a realist analysis of the implementation ICBPHC.
We use our empirical example to illustrate two points. First, the distinction between contexts and mechanisms might ultimately be arbitrary, with more distally located mechanisms becoming contexts as research teams focus their analytic attention more proximally to the outcome of interest. Second, the relationships between mechanisms, human reasoning, and human agency need to be considered in greater detail to inform realist-informed analysis; understanding these relationships is fundamental to understanding the ways in which mechanisms operate through individuals and groups to effect the outcomes of complex health interventions.
We conclude our paper with reflections on human agency and outline the implications of our analysis for realist research and realist evaluation.
“机制”的概念是现实主义研究方法的核心，但研究团队在将该概念应用于实证研究时却难以将其操作化和应用。我们的大型跨学科研究团队在研究整合社区初级卫生保健模式（ICBPHC）在三个国际司法管辖区（加拿大的安大略省和魁北克省以及新西兰）的实施情况时，也遇到了使该概念发挥作用的挑战。
在本文中，我们总结了现实主义方法论文献中发现的机制定义，并报告了 ICBPHC 实施的现实主义分析的实证示例。
我们使用我们的实证示例来说明两点。首先，上下文和机制之间的区别最终可能是任意的，随着研究团队将分析注意力更集中地集中在感兴趣的结果上，更远处的机制会变成上下文。其次，需要更详细地考虑机制、人类推理和人类能动性之间的关系，以告知现实主义启发式分析；理解这些关系是理解机制通过个人和群体对复杂健康干预结果产生影响的方式的基础。
我们在本文的结论部分对人类能动性进行了反思，并概述了我们的分析对现实主义研究和现实主义评估的影响。
