Building 'down' from grand theory where programme theory is lacking

Introduction Explicit programme theory for delivering public health services is often lacking. One example is the English national policy which recommends youth sexual health services which are positive, comprehensive and... [ view full abstract ]

Introduction
Explicit programme theory for delivering public health services is often lacking. One example is the English national policy which recommends youth sexual health services which are positive, comprehensive and young person friendly, but offers little guidance on how to deliver this. This paper considers an approach to building programme theory for the sustainable delivery of positive, comprehensive youth sexual health services. It acknowledges the myriad of existing theories that could be applied and proposes an efficient way of utilising such theory in programme theory building.

Method
A realist informed approach was used to uncover and develop theories and synthesise evidence relating to the sustainable delivery of positive comprehensive youth sexual health services. Programme theories developed were intended to articulate, in realist terms, how context may interact with underlying mechanisms (defined as what causes the potentialities of entities to actualise) to produce the desired outcomes. The programme theories were developed in a purposive fashion using a variety of sources and existing theory, at different levels of abstraction from the specific research topic. This included elements of:
• social theory;
• behaviour change theory;
• policy and best practice guidance;
• expert opinion, and;
• evidence relating to five case studies in the US, the UK and the Netherlands where a positive approach to youth sexual health services has been attempted. Data included: academic and grey literature, print and social media and interviews with local stakeholders involved in commissioning and delivering youth sexual health services.
Theory building was an iterative, retroductive process. An overarching theoretical model was created from the theory. Programme theories were then developed using abductive and retroductive inference based on the desired outcomes. Case studies provided evidence to substantiate (through deductive inference), refine and refute the initial theories or generate new ones (through inductive inference). Priority theories were identified during the initial interviews and through the analysis process. This enabled the researcher to refine the focus of latter interviews and directed attention to existing middle range theories to support and explain the results.

Results
Several mechanisms, at structural, cultural and agency levels may be hypothesised as important to the sustainable delivery of positive youth sexual health services. The results describe how these mechanisms may impact on the delivery of positive youth sexual health services and the contextual conditions which may hinder or enable the mechanisms acting in different circumstances.
Refined middle range theories derived from the study are also presented.

Discussion
Existing grand and middle range theory has informed, guided and strengthened theory development. However, the multitude of theories that might be applicable to any one study make selection difficult. Lessons from this study suggest that, where specific programme theory is initially lacking, existing theory may be utilised efficiently by decreasing the level of abstraction as the project develops i.e. moving from grand theory to the middle range. This paper culminates in a discussion of the utility of each theory presented in shaping the proposed programme theories.