It seems surprising that accessibility, visitability, and universal design were not discovered as key mechanisms in this study.  Aging overlaps with disability to a large extent, with concomitant needs for physical and program accessibility.  Perhaps these concepts are discussed in the article.  Perhaps Irene can provide us the full text; unfortunately, it's hiding behind a paywall.

By the way, I may not be alone is not having dealt with the term "realist synthesis" before.  Here's a discussion of what the phrase means:

Implement Sci. 2012 Apr 19;7:33. doi: 10.1186/1748-5908-7-33.

Realist synthesis: illustrating the method for implementation research.



Realist synthesis is an increasingly popular approach to the review and synthesis of evidence, which focuses on understanding the mechanisms by which an intervention works (or not). There are few published examples of realist synthesis. This paper therefore fills a gap by describing, in detail, the process used for a realist review and synthesis to answer the question 'what interventions and strategies are effective in enabling evidence-informed healthcare?' The strengths and challenges of conducting realist review are also considered.


The realist approach involves identifying underlying causal mechanisms and exploring how they work under what conditions. The stages of this review included: defining the scope of the review (concept mining and framework formulation); searching for and scrutinising the evidence; extracting and synthesising the evidence; and developing the narrative, including hypotheses.


Based on key terms and concepts related to various interventions to promote evidence-informed healthcare, we developed an outcome-focused theoretical framework. Questions were tailored for each of four theory/intervention areas within the theoretical framework and were used to guide development of a review and data extraction process. The search for literature within our first theory area, change agency, was executed and the screening procedure resulted in inclusion of 52 papers. Using the questions relevant to this theory area, data were extracted by one reviewer and validated by a second reviewer. Synthesis involved organisation of extracted data into evidence tables, theming and formulation of chains of inference, linking between the chains of inference, and hypothesis formulation. The narrative was developed around the hypotheses generated within the change agency theory area.


Realist synthesis lends itself to the review of complex interventions because it accounts for context as well as outcomes in the process of systematically and transparently synthesising relevant literature. While realist synthesis demands flexible thinking and the ability to deal with complexity, the rewards include the potential for more pragmatic conclusions than alternative approaches to systematic reviewing. A separate publication will report the findings of the review.

Marc Brenman


From: "Irene Yen" <>
Sent: Wednesday, June 4, 2014 11:55:15 AM
Subject: [H+T--Friends] place and street design features and walking for        older adults

Hi all -

I thought this might be of interest to you:

Objective: The objective of this study was to determine the environmental features that best support aging in place. Method: We conducted a realist synthesis, a theory-driven interpretive method of evidence synthesis, of 120+ articles (published 1991-2011) that attempts to explain how place may influence older adults’ decisions about mobility (e.g., physical activity). We developed an initial program theory, reviewed the literature, identified outcomes, analyzed and synthesized patterns, and created a final program theory. Results: Safety was a central mechanism, serving as one of the bridges between environmental components (e.g., connectivity, aesthetics, retail and services) and decisions about mobility. Population density, sidewalk presence, and park proximity did not emerge as key factors. Discussion: Safety considerations are one of the most prominent influences of older adults’ decisions about mobility. Street connectivity, pedestrian access and transit, and retail and services were also important. These factors are amenable to change and can help promote mobility for older adults.



Irene H. Yen, Ph.D., M.P.H.
Associate Professor
Division of General Internal Medicine
Department of Medicine
University of California, San Francisco
Associate Director, Experiential Learning, Health & Society Pathway
3333 California Street, Suite 335
Box 0856
San Francisco, CA 94143-0856 [for FedEx - use 94118]
(415) 502 8291 (fax)

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