Health Education Research, Vol. 16, No. 2, 115-120,
April 2001
© 2001 Oxford University Press
Editorial |
Critical realism and health promotion: effective practice needs an effective theory
Senior Lecturer in Public Health Medicine, Nuffield Institute for Health, University of Leeds, Leeds, UK
Critical realism (CR) is a realist theory that has been applied to explain and ground claims of knowledge, truth, progress and reality obtained through research in both natural and social sciences (Bhaskar, 1975
, 1989; Archer and Bhaskar et al., 1998). CR in the social sciences, including research into health promotion, confronts other theories as inadequate in both explanatory resources and, importantly, as ethically indeterminate. For example, attempts to reach consensus amongst actors in particular social circumstances is a major aspiration and activity of researchers who espouse social constructionism as a theoretical grounds (Guba and Lincoln, 1989). For CR, however, any such consensus would be required to be supportable on the objective moral criteria of equality, justice and freedom (Bhaskar, 1989) as well as on the truth of the actor's beliefs. CR therefore has specific and exacting standards for any consensus-forming approach.
In these opening remarks I have deliberately made large claims for the superiority of CR as a theoretical ground for research and practice, and in continuing this polemical advocacy I will outline the principal features of CR within social science, sketch an approach to research methods, and explain why CR and health promotion and social science in general cannot be politically or morally neutral. The overall purpose here is to describe an alternative framework for understanding the social world and practising health promotion which is neither positivist nor merely interpretivist. CR, against positivism, argues that conscious human beings are not reducible to mere `social dupes' (Garfinkel, 1967) manipulated by structural forces, and, against interpretivism, CR opposes epistemological, ontological or ethical relativism.
CR in social science identifies the agent–agent and agent–structure relations as the objects for study. Society is nothing but the sum of these interactions. Agents in the past have organized and constructed social, economic, cultural and political structures (Archer, 1995). Present generations are therefore born into a largely pre-given social world. Our very language exemplifies how embedded such social structures are—cashing a cheque assumes a banking system, charging a criminal assumes a judicial system and so on. Our psychology is similarly socially constituted to allow us to maintain, reproduce and, crucially, change the society we are born into. Although we never made the society we are born into, we can, through concept-dependent critique and activity, remake society in toto (revolutionary change) or at the institution (social structural) level. Given this recognition of agency it is important not to confuse CR as an explanatory and action theory with methodological individualism. CR argues that such an individualism fails to recognize what is everywhere the reality—it is social relationships, whether enacted at a person level (such as in social roles, positional categories or membership of a social strata) or enacted at a collective level (such as a family, an organization or a social class), that comprise the categories of social science (Bhaskar, 1989; Archer, 1995).
Causal powers
Rejecting methodological individualism as naive and reductionist allows CR to encompass complex emergence as a real entity in a realistic account of causation (Byrne, 1998). The philosopher David Hume described a sceptical and empirically reductionist theory of causation in the 18th century, which has until now been the dominant empiricist viewpoint. Essentially for Hume all we can say is that A is taken to be a cause of B because we have always, so far, seen A followed by B. Such a `constant conjunction' of events cannot, however, give us licence to predict that B will always follow A (the `problem of induction'), it may turn out that when we next observe event A it is not followed by event B (Hume, [1739] 1967). This view of causation has been called the successionist view, it offers meagre warrant for any useful or coherent social explanation or prediction.
CR elaborates a very different account of causation, one which allows depth explanation and underpins the elaboration of a set of empirical methods for use in health promotion research. The causal powers and tendencies of a thing or event A are, in a context where these powers are active, responsible for the observation of B. For example, it is because A [a person] is in a position with organizational power as a manager that A is enabled to direct the work priorities of B, which is observed as a rescheduling of B's work by A. However, in the real world it cannot be said that A will always and everywhere be an efficacious cause of B making the new schedule—what if B felt exploited? What if A's authority was countermanded by his/her superior? Moreover, in an adequate analysis of this situation the existence of the causal power possessed by A as an unused power, which if used may well be efficacious, should be noted. It will be seen that this understanding of causal power is both complex and depth-explanatory, causal powers and tendencies are the principal objects which social science and, specifically, a health-promoting practise should seek to uncover in what are called generative mechanisms. It is generative mechanisms which cause the maintenance and reproduction of society, and it is often possible to change the social world through efficacious mechanisms. The principal research questions for CR social science and specifically for health promotion are the identification and elucidation of the nature of generative mechanisms: How do they cause their effects? What triggers them? What inhibits them? How are they reproduced and maintained? Are they politically and ethically legitimate? If not, how can they be changed?
CR as a research method and practice orientation
It is interesting that a first attempt at doing CR social research often resembles a familiar, even routine, empirical approach (Pawson and Tilley, 1998). Although at a theoretical and meaning level CR is distinct, the research methods it uses are, so far, those that are based upon established routines. To begin a piece of CR research the observations of interest (e.g. poverty) are described epidemiologically (poverty in terms of who, where and when?). Typically the actors themselves (poor people) and others (politicians, richer people) are interviewed to obtain accounts of how poverty happens, to whom it happens, when and where it happens, and what might be done about it. CR research tries to be as differentiating as possible, it is interested in generative mechanisms and how they are effected for each discovered category of poverty (e.g. poor single parents, poor pensioners, poor single adults) not just poverty in general.
In terms of the C (context), M (mechanisms) and O (observation) configuration devised by Pawson and Tilley (Pawson and Tilley, 1998), the C factors in this example might be a particular housing estate in an urban area with a predominantly young single-parent population; M factors might be lack of incentives for paid work, unavailability of jobs, inaccessibility of jobs due to skills shortage or lack of transport and so on. After sifting the possible interventions with the key actors for likely effectiveness (in the `realist interview') and, where appropriate, learning from other studies, an intervention (or series of interventions) might be devised which targets (and aims to effectively neutralize) a generative mechanism for a particular group. For example, laying on free and reliable transport might be expected to enable certain single parents (those, say, who are motivated, have marketable skills and who have no or inadequate personal transport resources) to find employment and so move out of poverty. In planning a CR intervention this thinking-through of mechanisms is done before any attempt at implementation. In the given example baseline data on motivation, skills level and personal transport resources would be required so that the predicted post-intervention changes could be observed.
This CMO framework requires expansion and elaboration for it to cope with the whole panoply of health promotion work and its evaluation. In particular, the `realist interview' seems to be privileged in the sense that it is the primary source for both identifying and predicting the generative mechanisms at work in the specific context being studied. This ignores the real possibility of people being only aware of some of their reality—this situation is, according to Giddens, foundational for social sciences which offer a `double hermeneutic', that is a further (social scientific) interpretation on an already (but incomplete) personal (everyday) interpretation (Giddens, 1984).
In addition to the understanding of persons who are interacting within a specific context, critical realism brings a requirement to understand the generative mechanisms which (historically) have produced the situation. In particular, CR prompts the examination of the truth, justice and worth of the facts and values which acted as motivational forces in the founding of the social institutions and roles we (the successor generation) encounter as pre-given.
The CR approach to health promotion thus necessitates a depth-explanatory methodology regulated by an orientation towards what is described as a radical pluralist democratic politics. Ernesto Laclau and Chantel Mouffe (Laclau and Mouffe, 1985) have theorized such politics and have identified the contemporary forms of radical democratic engagement (e.g. `identity politics', social movements, anti-exclusionary politics). Consequently the CR approach sees empowerment as a central goal because it is committed to democratic emancipation and self-actualization. Public policies that nurture these goals are therefore advocated whilst constraining and exclusionary policies are contested (Smith, 1988). These features of CR bring it close to Tones and Tilford's influential grounding of health education/health promotion analysis and action (Tones and Tilford, 1994).
CR does not accept the fact–value distinction
The ethical and political aspects of the analysis of a social situation are also seen as centrally relevant in understanding generative mechanisms, and in any subsequent planning, implementation and interpretation of interventions for change. Human interest in emancipation is seen as self-grounding (Habermas, 1971). In the example given above a deeper analysis of the epidemiology of poverty would not fail to notice that an underlying mechanism of competitive employment was in this context generating winners and losers. Moreover, the consequences for losers include higher life-time rates of almost every disease and mental disorder, and a high chance that these adverse effects will continue over generations (Independent Inquiry Committee, 1998). As indicated already, CR identifies the foundational history of such generative mechanisms and asks questions about the legitimacy of such a system of competitive employment. Are its effects publically known and have they been democratically debated? Are its effects on children possibly defensible on any coherent ethics? What are the wider social, economic, cultural and political effects of this system? The answers to such questions provide the grounds for a critique of such a system and supply in outline an ethical and political case for social action to change things (Bhaskar, 1989). Neutrality in social science and particularly in public health is not possible (Taylor, 1973; Bhaskar, 1989; Connelly and Worth, 1997) even if it is considered desireable (Weber, [1903] 1949)
CR as a foundation for practice
The sociologist Pierre Bourdieu has criticized what he sees as the inappropriate application of social science research methods to practical questions, including the work and activity of professionals (Bourdieu, 1993). For Bourdieu much social analysis of practical questions misses the unique features of a situation and applies a normalizing formula which though it renders the situation understandable to academics further distances the worker. CR as an orientation is applicable to both the day-to-day practice of health promotion and (as a research methodology) is capable of providing an understanding of the reality of interactions and institutions; it is, and insists upon being seen as, both a realism and a practical activity (Bhaskar, 1994; Collier, 1999). Being both a way of understanding the world and, simultaneously, of transforming it, CR is not open to a `normalizing' critique from social scientists who continue, despite Bourdieu, to misapply a `disinterested' (pseudo `value neutral') set of categories.
Against postmodernism CR insists that the truth of a situation can be identified and that this truth inescapably carries with it a set of values. Against ethical relativism CR does not celebrate all instances of difference and diversity. Authoritarian and anti-democratic discourses need to be contested and subjected to a radical pluralist democratic critique which seeks to uphold universal principles of truth, justice and freedom (Smith, 1998; Collier, 1999). Although the `craft knowledge' so necessary to maintaining and developing CR health promotion practices is currently unavailable (as it is from other areas such as environmental health, public health, policy analysis and clinical medicine) some work in economics (Lawson, 1997), ethics (Collier, 1999) and health sector management (Connelly, 2000) has been done. It will take time for sufficient CR knowledge in these and other areas to accumulate. In the absence of this work CR can be put to use (1) as a more adequate explanatory framework in the analysis of health promotion (or health sector management or environmental health, etc.) work, (2) as a research design which unlike the randomized controlled trial is applicable to the complex social world which is the arena of health promotion, and (3) as a means of understanding the reality of the social world, the economic, cultural and political generative mechanisms, and their interaction with our embodied identities (personal being), our social self and our physiological being (Harré, 1979, 1983, 1994).
Conclusion
In this introductory summary I have been an advocate of a philosophical understanding which places the real existence of persons, objects, structures and events as the starting point for analysis and politico-ethical critique. The importance of theory is foregrounded because of the central importance of identifying and acting on generative mechanisms. Reality is produced and reproduced by the causal powers of generative mechanisms whether these are our activities and attitudes or our encounters with social structures. It is their identification, assessment, strengthening or undermining that is the work of a CR health promotion. Why we should want to strengthen some or undermine other generative mechanisms emerges from the inescapable reality of making ethical and political decisions in the light of our human interest in emancipation and enlightenment. For health promotion theory and practice to make a difference an engagement with critical realism is now long overdue.
Notes
We welcome any comments on Dr Connelly's editorial and its subject matter—either in the form of correspondence or a `Short communication' [Editor].
References
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