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Using the realist approach to unravel the complexity of health programmes: the evaluation of smoke-free school policies as a case study
  1. Michael Schreuders,
  2. Karien Stronks,
  3. Anton E Kunst
  1. Department of Public Health, Amsterdam Public Health Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
  1. Correspondence to Michael Schreuders;schreuders{at}


Numerous commentaries plea for the use of methods that take into account complexity when evaluating health programmes. These commentaries provide compelling arguments on why evaluations of health programmes should not rely exclusively on methods that were designed for making universal claims about whether and to what extent a policy is effective. However, there exist only few concrete examples showing how to take this complexity into account during the evaluation of health programmes. One increasingly popular approach to do so is the realist approach. In this paper, we explain the realist approach for taking into account complexity, discuss how we applied this approach to study the impact of smoke-free school policies and reflect on the practical value of the resultant insights. We hope this case study may inspire fellow scholars to use the realist approach for evaluating health programmes.

  • Smoking
  • methodology
  • health policy
  • health behaviour

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  • Contributors MS, KS and AEK conceived the study, critically revised the manuscript and contributed to subsequent iterations. AEK obtained funding for the study. MS wrote the first draft of the manuscript.

  • Funding This study is part of the SILNE-R project, which is funded by the European Union’s Horizon 2020 research and innovation programme, under grant agreement 635056. The funder had no role in this study.

  • Competing interests None.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.

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