Building initial programme theory with global stakeholders: methodological lessons from a realist evaluation on community participation in quality maternal and newborn care

Abstract

Realist evaluations are increasingly used to examine complex health interventions, and their methods and tools continue to evolve. Developing initial programme theories, which explain how and why an intervention is expected to work, constitutes a critical preliminary stage of a realist evaluation. Methodological guidance on developing initial programme theories has expanded, but guidance on stakeholder involvement during this theory-building stage remains limited. To promote transparency and contribute to advancing realist methodology, this paper presents a structured approach to developing initial programme theories that explore how, why, and under what conditions community participation can be institutionalised in support of health service quality. Aligned with RAMESES guidelines, initial programme theories were developed using a multi-method, iterative, four-phase approach, which foregrounded the perspectives of practitioner and policy-level stakeholders as active theory-builders. Phase 1 established an explanatory framework for theory-building. Phase 2 involved a scoping review of the literature, complemented by a targeted call for additional literature. In Phase 3, seventy-two stakeholders from ten Ministries of Health and supporting partners formed an expert group to surface practice-based knowledge and generate candidate programme theories. Phase 4 refined these theories for field-testing through a participatory workshop involving forty-nine experts at an international health conference. This approach to developing initial programme theories within realist evaluation placed policymakers’ and implementers’ knowledge at the centre of theory development, ensuring the resulting six initial programme theories were conceptually informed and contextually grounded. These six initial programme theories are ready to be tested through country-level case studies involving community-, facility-, and district-level actors, with potential implications for policy and practice on institutionalising community participation. The process demonstrates that leveraging existing networks and convenings, particularly where published evidence is limited, can provide access to grey literature, practice-based knowledge and diverse stakeholder perspectives for understand complex interventions.