Designing a multi case realist evaluation of parenting support services using an ecosystemic approach to parental empowerment

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Social health inequalities emerge early in life, when families experience unequal access to resources, support networks, and spaces of social participation. In France, parenting support policies have recently been strengthened; yet interventions remain largely centred on the individual parent, potentially overlooking the structural and contextual determinants that shape parenting experiences. Fostering parental empowerment requires a genuinely ecosystemic approach to parenting support. This article describes the design of a realist evaluation that will examine the conditions under which parenting support services promote the development of parental empowerment. Methods This study draws on a realist evaluation of nine parenting support services implemented in diverse institutional, territorial, and organisational contexts in France. Realist evaluation seeks to understand how and why interventions work (or do not work), for whom, and under what conditions, based on Context-Mechanism-Effects (CME) configurations. Data collection includes approximately 80 semi-structured interviews with parents and professionals, as well as two minimal participant observations in each service. A thematic and configurational analysis will be conducted using NVivo following an iterative logic: separate coding for parents and professionals, cross-case analyses, and the progressive reconstruction of contextual and individual Context-Mechanism-Effects configurations in order to develop middle-range theories. Discussion This study will identify the conditions that support the development of parental empowerment from an ecosystemic and a health promotion perspective. The realist approach will also make it possible to identify unintended or potentially iatrogenic effects, which are often overlooked in conventional evaluations, thus informing decisions regarding how to implement and scale-up parenting support services. The findings will provide transferable recommendations that will guide professional practices and public policies towards more systemic, inclusive, and capacity-building forms of support. Parenting first 1 000 days parental empowerment realist evaluation early childhood health promotion. Figures Figure 1 Introduction Social health inequalities emerge from the very beginning of life, when systematic differences in experiences within socially differentiated environments lead to distinct developmental trajectories ( 1 , 2 ). These early-life experiences shape health, well-being, learning, and behaviour over the entire span of an individual’s life ( 3 ). A large body of research highlights the decisive role that an infant’s social and emotional environment plays and the central place of the family context in early development ( 4 – 6 ). The period from pregnancy to the child’s third year therefore constitutes a major developmental window ( 7 – 9 ). It is during these early years that the foundations of physical, cognitive, emotional, and social health are established. Parents are the primary guardians of their children’s health ( 10 ); their parenting practices and the quality of parent–child interactions therefore play a key role in shaping these developmental trajectories ( 11 – 13 ). However, the transition to parenthood involves profound identity transformations, which take place within social and material contexts that are often fragile or constrained ( 14 ). The weakening of local communities and the reduction of spaces for social participation have contributed to increasing parental isolation ( 15 – 17 ). At the same time, contemporary norms of parenting place a strong emphasis on individual parental responsibility, thereby reinforcing parental stress and social health inequalities ( 11 , 18 , 19 ). Against this backdrop, parenting support policies have gained increasing prominence in public debate. Since 2021, France has sought to consolidate its parenting support policy by defining a shared national framework, notably via a National Charter and its explicit inclusion in the Social Action and Family Code ( 20 ). Nevertheless, parenting support policies remain characterised by tensions between support and normativity. Since the 1940s, the field of prevention has largely focused on strengthening parenting skills, reducing risk factors in order to safeguard children’s health, and ensuring that individual difficulties do not spill over into the public sphere ( 21 ). As a result, parenting support interventions have predominantly been centred on the individual parent, thus tending to individualise difficulties and obscure the structural determinants that shape parenting experiences ( 22 , 23 ). From a health promotion perspective, parenting support cannot be limited to actions that focus solely on parenting skills or parent–child interactions ( 24 ). An ecosystemic approach, by contrast, makes it possible to understand parenting as a situated experience, shaped by interrelated social relationships, material conditions, and social environments ( 25 , 26 ). Such an approach fosters the development of parental empowerment, defined as parents’ capacity to mobilise internal and external resources in order to meet their needs and to influence their environment ( 27 , 28 ). This, in turn, calls for intervention modalities that recognise, legitimise, and strengthen this capacity ( 29 , 30 ). The APPIE (Analysis of Public Policies Impacting Children) Village study aims to explore the conditions under which parenting support services may adopt an ecosystemic form that fosters parental empowerment. To better understand how, for whom, and under what conditions such programmes operate, a realist evaluation framework is employed ( 31 ). This article outlines the design and analytical framework of a multi-case realist evaluation examining the conditions under which parenting support services may promote parental empowerment. The first phase focused on the development of an initial programme theory, based on a realist review, expert interviews, and a process of co-analysis. This phase led to the formulation of realist hypotheses embedded within an analytical framework describing nine parenting support services implemented across diverse territorial, institutional, and organisational contexts. Methods/Design 1. Study design APPIE Village is a multi-case qualitative realist evaluation. Realist evaluation ( 31 , 32 ) is a form of theory-driven evaluation approach ( 33 ) that is particularly well suited to complex interventions, such as parenting support services. Its purpose is to explain the mechanisms that an intervention triggers in order to produce its observed effects within a given context ( 33 ), using the Context–Mechanism–Effect (CME) configurational heuristic ( 32 ). Whereas conventional evaluations seek to determine whether an intervention works or not (versus the absence of intervention), realist evaluation aims to understand how and why an intervention produces (or fails to produce) effects, for whom, and under what conditions ( 34 ). This approach is grounded in a generative conception of causality, whereby an intervention (A) activates a mechanism (M) that contributes to producing an effect (E) within a specific context (C), as opposed to a successionist conception of causality, in which an intervention is assumed to directly produce an effect. The Context–Mechanism–Effect (CME) configuration therefore constitutes the central unit of analysis in realist evaluation. Following the framework proposed by Cambon et al. ( 35 ), contexts are conceptualised as including both: external contexts (Ce), referring to the social, family, economic, and institutional conditions that structure parenting experiences; and intervention contexts (Ci), corresponding to the organisational, professional, and relational modalities specific to each parenting support service. Mechanisms (M) refer to parents’ responses to these contexts and to the forms of support provided (e.g., feelings of safety, recognition, trust, mutual support), which may foster or hinder the development of parental empowerment. Effects (E) depend on the extent to which the intervention’s underlying mechanisms are activated or not by contextual elements ( 33 ). In this study, effects are understood as observable changes in parenting practices, parenting experiences, and parental responsibility. This approach is particularly relevant to the field of parenting support, where intervention objectives are often implicit or plural, change mechanisms are relational and sensitive to the quality of encounters, families’ living contexts vary widely, and effects are not uniform but situated. Realist evaluation thus makes it possible to develop middle-range theories, that is, explanations that are transferable yet context-sensitive, providing actionable insights for public policy-makers and professional practices. This study follows the RAMESES II quality and reporting standards for realist evaluations ( 36 ). 2. Study aims The theoretical framework underpinning this study was developed during a preliminary phase, the results of which are reported in other publications. This phase aimed to identify the conditions conducive to an ecosystemic approach to parenting support that promotes the development of parental empowerment. This phase of research was based on three complementary sources: A qualitative study involving ten experts, including researchers, field professionals, and institutional stakeholders involved in parenting policies and services; A realist review of the literature on environments favourable to the development of parental empowerment from pregnancy to the child’s third year ( 37 ); and A working seminar (APPIE-Lab) bringing together actors from different institutional levels, enabling data triangulation and the identification of cross-cutting dimensions. The integration of these data led to the identification of a set of organisational, relational, and structural conditions that support the development of parental empowerment. Figure 1 presents the initial programme theory underlying the APPIE Village study. This theoretical framework constitutes an initial explanatory model. It does not describe how all services operate but rather proposes hypotheses regarding the configurations of contexts and mechanisms that are likely to foster parental empowerment. It will be tested and refined throughout the analysis of the nine case studies, in line with the iterative logic of realist evaluation. In the following sections, this framework serves as the basis for structuring data collection and analysing CME configurations. 3. Methods Multi-case design This study adopts a multi-case design, enabling us to compare parenting support practices in diverse territorial, institutional, and organisational contexts across multiple regions in France, reflecting a national study. Our objective is not to compare services in order to determine which is the “best” or most effective, but to identify regularities, variations, and contextual conditions under which mechanisms that are conducive to parental empowerment emerge. The nine services included in the study were selected in order to maximise variation in observable contextual elements: territorial positioning (urban, rural, priority neighbourhoods); institutional status (non-profit organisations, local authorities, private organisations); forms of support (open-access reception, group workshops, individual support, continuous or time-limited interventions); and timing of intervention (pregnancy, immediate postnatal period, early infancy, second or third year of the child’s life). This diversity makes it possible to document how similar resources may produce different effects depending on context; it also illustrates, conversely, how similar contexts may mobilise different resources to support parenting. The characteristics of the nine parenting support services are presented in Table 1 . Table 1 description of the services Service Type of structure Type of support Location A Educational hub bringing together a childcare centre, maternal and child health service, early childhood relay, and a space dedicated to the first 1,000 days Collective meeting spaces facilitating reception, thematic workshops, peer groups. Urban priority neighbourhood B Association Family support association offering workshops, a family café, and community events. Medium-sized city C Association Thematic workshops, peer support groups, drop-in/individual sessions with a professionnal. Mobile services operating across several rural municipalities D Local social and family support centre Long-term peer group (3 years), thematic workshops, Parent-Child Drop-In Centre (LAEP, Lieu d’Accueil Enfant-Parent). Urban priority neighbourhood E Parenting support programme Attachment-focused online parent group. Fully online F Association Informal meetings in cafés, parks, and local associations, as well as thematic workshops. City centre G Multidisciplinary centre Personalised pathway from pregnancy to age three, combining group workshops and individual consultations with interdisciplinary professionals. Medium-sized city H A public family support centre dedicated to the first 1,000 days, led by the departmental maternal and child health service Parent-child reception, individual consultations, Parent-Child Drop-In Centre (LAEP, Lieu d’Accueil Enfant-Parent), thematic workshops. Priority neighbourhood I Family-oriented community hub supported by childcare centre Mobile thematic workshops, parent discussion groups, peer groups. Mobile services operating across several rural municipalities These descriptions constitute a starting point. The fine-grained characteristics of each service (Ci) will be specified and analysed during fieldwork, including reception modalities, institutional identity, family trajectories, and professional postures. Data collection and participants Data collection relies primarily on a qualitative approach, which enables us to access both the meanings that parents and professionals attribute to their experiences within the services and the contextual dynamics likely to activate or inhibit parental empowerment mechanisms. Data collection follows an iterative logic: tools (interview guides, observation frameworks) may be refined throughout the analysis process, in accordance with the principle of progressive theory refinement. Population For each service, between five and seven parents and between two and four professionals will be interviewed (approximately 80 interviews in total). Two categories of participants are included: Parents supported by one of the selected parenting support services; and Professionals involved in the design, delivery, or coordination of these services. The inclusion and exclusion criteria for parents and professionals participating in the qualitative interviews are presented in Table 2 . Table 2 Inclusion and exclusion criteria for qualitative interviews with parents and professionals. Parents Professionals Inclusion criteria Inclusion criteria • Primiparous or multiparous parents • Professionals working within one of the partner parenting support services • Parents between the fourth month of pregnancy and the child’s third year • Multidisciplinary professionals providing parenting support (conventional or non-conventional) • Single parents or parents living with a partner • Parents supported by one of the partner parenting support services • Aged 18 years or older Exclusion criteria Exclusion criteria • Parents of infants born with medical complications (e.g., low birth weight, prematurity, disability) • Professionals providing exclusively medical or healthcare interventions • Parenting in a highly specific context (e.g., parental illness, war context, extreme poverty) • Professionals not working within a partner parenting support service • Interventions exclusively targeting behavioural or conduct problems, or prevention of future problems among high-risk parents Recruitment Recruitment will be organised in collaboration with service coordinators, who inform parents and professionals about the study and provide them with an information sheet and a consent form. Interested participants then contact the service coordinator, who organises meetings with the researcher during field visits, ensuring full anonymity. Data collection: interviews Semi-structured interviews will be conducted with parents and professionals. Individual interviews with parents will last between 45 minutes and one hour. Their aim is to understand parents’ subjective relationship to the support provided. They explore: what parents seek from the service (Ci), that is, the resources, forms of support, or spaces they hope to find there; the link with their life context (Ce), namely the reasons why this need emerged along their life trajectory. This articulation makes it possible to avoid considering motivations as individual characteristics but instead as situated responses to specific environments and living conditions; how parents experience the support: identifying how the service responds to the needs that led them to participate (perceived adequacy between expectations and resources mobilised), describing how they feel within the setting and how the setting responds to why they sought it out, including their relationship to reception, listening, the place they are given, and the relationships built within the group. This involves qualifying the subjective experience of the encounter (M), for example, feelings of safety, recognition, parental legitimacy, or trust; and perceived transformations in their parenting (E), whether in terms of changes in daily practices, the relationship with their child, or the mobilisation of resources. Interviews with professionals will follow a similar logic, mobilising their situated perspective on the service. They will last between 45 minutes and one hour and explore in particular: professionals’ perceptions of parents’ motivations for participation (Ce), that is, the life situations, expectations, and needs they identify among the families supported; their professional posture with regard to the service; the support modalities mobilised on a daily basis: organisation of reception, relational positioning, space given to parental speech and experience, regulation of the framework, and collective adjustments (Ci). The aim here is to identify the relational and organisational conditions that are likely to support certain encounter dynamics; the processes they believe are activated in the encounter (M), in order to capture how they understand the mechanisms at work and their articulation within the contexts encountered; and the effects observed on parenting (E): changes in confidence, ability to ask for help, intra-family interactions, participation in collective life, or adjustment of practices. This interview framework will enable us to reconstruct configurations of the following type: In which situations do parents arrive? (Ce) Which relational or organisational modalities are implemented? (Ci) What do these elicit in parents? (M) What changes are observed in how they experience their parenting? (E) Thanks to this structure, during configurational analysis we will be able to align parental and professional perspectives without merging them, while identifying their points of convergence, complementarity, or tension. Data collection: observations One to two observations will be conducted in each of the nine services. The researcher will adopt a minimal participant observation posture; this consists of being present in the setting and taking part naturally in exchanges when they occur, without directing activities, interactions, or group dynamics. This position makes it possible for the research to integrate themselves to such an extent that they can understand the relational environment while maintaining the analytical distance required. Observation will provide direct access to dimensions that are often implicit or difficult to verbalise in interviews: the general atmosphere of the setting, spatial organisation, reception practices, circulation of speech, relational micro-adjustments, and the ways in which families appropriate the service. It also makes it possible to document the social, material, and symbolic contexts within which support is delivered, by jointly observing external contexts (Ce), such as territorial and institutional constraints, and internal intervention contexts (Ci), including reception organisation and professional practices. From a realist evaluation perspective, observation thus will contribute to analysing how these contexts support, inhibit, or transform the activation of mechanisms such as recognition, trust, feelings of safety, or parental legitimacy. By multiplying observed contexts, the study will be able to identify regularities in the relationships between contexts, mechanisms, and effects, enabling our research to identify transferable logics of action ( 34 ). Observations will be recorded in the form of field notes taken during sessions, then transcribed and integrated into NVivo. They will be coded primarily within categories relating to external contexts (Ce) and intervention contexts (Ci) before being mobilised during configurational analysis to illuminate and refine the interpretation of mechanisms (M) identified in the interviews. In particular, the observations will allow us to grasp what is at stake in the encounter that lies beyond discourse: presence, everyday professional gestures, collective rhythms, and forms of informal support. As such, observation constitutes an essential component in the construction of Ce-Ci-M-E configurations and the formulation of middle-range theories. Data analysis Data analysis will follow both a thematic and a configurational approach, in line with the principles of realist evaluation. All interviews will be fully transcribed and analysed using NVivo software. Analytical approach The analysis will first follow a thematic approach. Coding will be based on a thematic framework structured according to the Context–Mechanism–Effect (CME) model. External contexts (Ce) refer to the social, economic, family, and institutional dimensions that shape parenting conditions (macrosystem and exosystem). Intervention contexts (Ci) relate to the characteristics specific to the services studied, such as reception modalities, professional postures, and institutional organisation (mesosystem and microsystem). Mechanisms (M) correspond to the cognitive, emotional, and relational processes activated in parents when they interact with the services (ontosystem). Finally, effects (E) refer to observable transformations in parenting experience, the mobilisation of resources, or in everyday practices. The analysis will be conducted in several stages. First, an individual analysis will be carried out for each participant in order to reconstruct their subjective experience and the specific dynamics of the support received. Second, separate cross-case analyses will be conducted for the parent interviews and the professional interviews in order to identify regularities in contexts, activated mechanisms, and perceived effects. Data from field observations will be integrated into this cross-case analysis in order to enrich the understanding of intervention environments. Configurational analysis The second stage will comprise a configurational analysis that focuses on mechanisms. Based on the mechanisms identified in individual interviews and observations, Ce-Ci-M-E configurations will be reconstructed, thus making explicit how certain contexts activate (or inhibit) specific processes and under which conditions these processes lead to effects on parental empowerment. The unit of analysis is therefore the configuration rather than isolated elements. This configurational analysis will first be conducted within each group (parents and professionals) before being consolidated through a second cross-case analysis aimed at identifying both environment-specific features and regularities across environments. The objective of this approach is to allow recurrent Ce-Ci-M-E configurations to emerge through progressive saturation, making it possible to understand why and under which conditions certain aspects of support foster the development of parental empowerment, while others may hinder it. This stage may lead to the refinement of existing middle-range theories and to the emergence of new explanatory hypotheses. Development of middle-range theories Based on stabilised configurations, middle-range theories will be formulated. These aim to produce transferable explanations regarding the conditions under which ecosystemic parenting support effectively promotes the development of parental empowerment. These theories will contribute to guiding the evolution of professional practices, service organisation, and, more broadly, public policies in the field of parenting support. In terms of knowledge transfer, our findings will be presented and discussed with the stakeholders involved in order to foster their appropriation and implementation in local contexts. Ethical considerations All participants (parents and professionals) will receive an information sheet detailing the objectives of the study, participation procedures, expected benefits, and potential risks, as well as their rights. Participation is voluntary and based on the signing of a written informed consent form. Participants may withdraw from the study at any time, without justification and without any consequences for the support they receive. Interviews will be audio-recorded, fully transcribed, and anonymised. No names, locations, or elements allowing identification of participants or services will be retained in the transcripts. Data will be stored on a secure server at the University of Bordeaux and accessible only to members of the research team. Data processing complies with the General Data Protection Regulation (GDPR). A declaration has been submitted to the University’s Data Protection Officer. Given that some topics discussed may involve sensitive experiences (parental exhaustion, isolation, feelings of incompetence), the researcher adopts an active listening posture and ensures that no emotional distress is caused. In case of signs of vulnerability, participants will be referred to appropriate support services. Discussion This article presents the design of a realist evaluation of parenting support services, focused on analysing the conditions that foster the development of parental empowerment. The chosen approach makes it possible to move beyond an evaluation logic centred on the overall effectiveness of interventions, towards a situated understanding of change processes. This perspective is particularly relevant in the field of parenting support, which is characterised by a high diversity of intervention contexts, family trajectories, and forms of support. The study is expected to identify Context-Mechanism-Effect (CME) configurations through which specific relational and organisational dimensions may foster mechanisms conducive to parental empowerment. By analysing these processes across contrasting environments, the study will contribute to clarifying the conditions that are required to implement a genuinely ecosystemic approach to parenting support. These findings may inform the development of parenting support policies aimed at reducing early-life social health inequalities across diverse contexts. However, this approach also brings a number of challenges. First, the distinction between external contexts (Ce) and intervention contexts (Ci) requires sustained analytical attention, as these factors tend to be strongly intertwined within parenting experiences. Second, the iterative logic of the study implies continuous adjustments to data collection tools and data interpretation, requiring the adoption of a reflexive research posture. Finally, the diversity of the services studied may generate a high level of configurational heterogeneity, making rigorous cross-case analysis essential to identifying meaningful regularities. Despite these anticipated challenges, this study has several strengths. It is embedded in a co-construction process with institutional and field actors, fostering the appropriation of the knowledge produced. It is also grounded in an initial theoretical framework that ensures analytical coherence. Finally, it aims to generate results that are directly actionable for professional practices and public policy-makers, notably through the development of transferable recommendations. The realist approach will also enable the identification of unintended or potentially iatrogenic effects, thus offering decision-makers a critical and nuanced perspective when assessing how and whether to implement or scale-up parenting support services. Beyond describing the structure of an ongoing evaluation, this article contributes to methodological discussions within qualitative health research by illustrating how realist evaluation can be operationalised in the field of parenting support and health promotion. By articulating external contexts (Ce), intervention contexts (Ci), mechanisms (M), and effects (E) within a multi-case design, it proposes a structured yet flexible analytical framework for examining empowerment processes as situated and relational phenomena. In doing so, it demonstrates how realist approaches can strengthen ecosystemic analyses of complex social interventions, particularly in early childhood and family health contexts. Conclusion This article outlines a realist evaluation designed to understand the conditions under which parenting support services foster the development of parental empowerment, taking into account the diverse contexts in which families live. Based on an initial programme theory, the study adopts a multi-case design and an iterative approach to identify Context-Mechanism-Effect (CME) configurations that support or hinder parental transformation processes. The anticipated findings will generate transferable middle-range theories capable of supporting the evolution of professional practices and guiding public policies towards more ecosystemic, inclusive, and capacity-building forms of support. By focusing on the first 1,000 days, a critical period for development, the study seeks to better align interventions with the lived realities of families and contribute to reducing early-life social health inequalities. The evaluation will also identify not only the conditions that foster intended effects, but also unintended or potentially counterproductive consequences, which are often overlooked in traditional assessments. By making these dynamics visible, the study will provide decision-makers with a critical perspective to inform decisions about whether and how to implement, adapt, or scale up parenting support services. Findings will be disseminated in close collaboration with professionals, institutions, and public decision-makers, thereby facilitating their appropriation and implementation in diverse local contexts. Declarations Ethics approval and consent to participate Ethical approval for this study was granted by the Ethics Review Committee of the University of Bordeaux (CER-UB-2024-3A-F). Written informed consent was obtained from the participants prior to the study. All procedures involving human participants were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Clinical trial number Not applicable. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Data availability Data sharing not applicable to this article as no datasets were generated or analysed during the current study. Funding This study is funded by the French National Institute of Cancer (INCa), the Institute for Research in Public Health (IReSP), and the National League Against Cancer (Ligue contre le cancer). The funders had no role in the design of the study, data collection, analysis, interpretation of data, or writing of the manuscript. Authors’ contributions MB and LC conceptualised and designed the study and drafted the initial programme theory. MB drafted the manuscript. LC and YS reviewed the manuscript and provided feedback and critical insights. All authors contributed to and approved the final manuscript. MB is the guarantor of the work. Acknowledgements The authors would like to thank the parenting support services partners involved in the APPIE-Village project for their collaboration in the development of this research. We are also grateful to the members of the APPIE-Lab and institutional partners who contributed to the co-construction of the programme theory and study design. References Case A, Lubotsky D, Paxson C. Economic Status and Health in Childhood: The Origins of the Gradient. Am Econ Rev. 2002;92(5):1308–34. doi:10.1257/000282802762024520 PubMed PMID: 29058397. Lang T, Kelly-Irving M, Lamy S, Lepage B, Delpierre C. Construction de la santé et des inégalités sociales de santé : les gènes contre les déterminants sociaux ? Santé Publique. 2016;28(2):169–79. 10.3917/spub.162.0169 . Located at: Cairn.info. Hertzman C. Inégalités sociales de santé, développement de la petite enfance et incorporation biologique. 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Matern Child Health J. 2020;24(5):575–86. 10.1007/s10995-019-02849-7 . Located at: Scopus. Sitruk P. Politiques de soutien à la parentalité en France. Perspect Psy. 2023;62(4):356–61. 10.1051/ppsy/2023624356 . Tarabulsy G, Poissant J, Saïas T, Delawarde-Saïas C. Programmes de prévention et développement de l’enfant: 50 ans d’expérimentation. 2019. 10.1515/9782760550827 Lemay L. Le pouvoir et le développement du pouvoir d’agir (empowerment): un cadre d’intervention auprès des familles en situation de vulnérabilité. In. 2009. pp. 101–27. Vandenbroeck M. Être parent dans notre monde néolibéral [Internet]. Érès; 2024 [cité 26 août 2024]. Disponible sur: https://shs.cairn.info/etre-parent-dans-notre-monde-neoliberal--9782749279268?lang=fr 10.3917/eres.vande.2024.01 Coulon N. Quelle posture d’accompagnement adopter pour promouvoir la santé des jeunes enfants et celle de leurs parents ? J Droit Jeunes. 2012;314(4):22–7. 10.3917/jdj.314.0022 . Bronfenbrenner U. Ecology of the family as a context for human development: Research perspectives. Dev Psychol. 1986;22(6):723–42. 10.1037/0012-1649.22.6.723 . Demoustier S. Le pouvoir d’agir des personnes en situation de vulnérabilité: un nouveau paradigme à partir duquel le travail social peut se réinventer ? Sci Actions Soc. 2021;15(2):154–76. 10.3917/sas.015.0154 . Located at: Cairn.info. Le Bossé Y, Bilodeau A, Chamberland M, Martineau S. Développer le pouvoir d’agir des personnes et des collectivités: Quelques enjeux relatifs à l’identité professionnelle et à la formation des praticiens du social. Nouv Prat Soc 25 janv. 2010;21(2):174–90. 10.7202/038969ar . Vallerie B, Bossé YL. Le développement du pouvoir d’agir (empowerment) des personnes et des collectivités: de son expérimentation à son enseignement. Sci Léducation - Pour LÈre Nouv. 2006;39(3):87–100. 10.3917/lsdle.393.0087 . Girard K, Miron JM, Couture G. Le développement du pouvoir d’agir au sein des relations parents-professionnels en contexte d’intervention précoce. Phronesis. 2014;3(3):52–62. 10.7202/1026394ar . Miron JM, Tochon F. La difficile reconnaissance de « l’expertise parentale » [Internet]. 2004. 10.3406/refor.2004.1927 Pawson R. Evidence-based Policy: The Promise of `Realist. Synthesis’ Evaluation 1 juill. 2002;8(3):340–58. 10.1177/135638902401462448 . Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review–a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy juill. 2005;10(Suppl 1):21–34. doi:10.1258/1355819054308530 PubMed PMID: 16053581. Blaise P, Marchal B, Lefèvre P, Kegels G. Au-delà des méthodes expérimentales, l’approche réaliste en évaluation. Réduire Inégalités Soc Santé 1 janv 2010;285–96. Cambon L. Évaluer les interventions en santé des populations: les apports de l’évaluation fondée sur la théorie. Rev DÉpidémiologie Santé Publique. 1 avr 2023;L’évaluation et la recherche sur les interventions en santé publique71(2):101398. 10.1016/j.respe.2022.08.006 Cambon L, Alla F. Understanding the complexity of population health interventions: assessing intervention system theory (ISyT). Health Res Policy Syst 19 juin. 2021;19(1):95. 10.1186/s12961-021-00743-9 . PubMed PMID: 34147105; PubMed Central PMCID: PMC8214800. Wong G, Westhorp G, Manzano A, Greenhalgh J, Jagosh J, Greenhalgh T. RAMESES II reporting standards for realist evaluations. BMC Med 24 juin. 2016;14(1):96. 10.1186/s12916-016-0643-1 . Brémont M, Cambon L. Ecosystemic parenting empowerment, from pregnancy to the child’s third year: a realist review. Accepted, in. Children&Society. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8965136","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":617461081,"identity":"9a7e6937-3447-46b2-bfb3-8e4e5cdf4f8b","order_by":0,"name":"Melanie BREMONT","email":"data:image/png;base64,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","orcid":"","institution":"University of Bordeaux","correspondingAuthor":true,"prefix":"","firstName":"Melanie","middleName":"","lastName":"BREMONT","suffix":""},{"id":617461082,"identity":"035391de-87f3-4dce-8cbb-69b1af57d72b","order_by":1,"name":"Linda Cambon","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Bordeaux","correspondingAuthor":false,"prefix":"","firstName":"Linda","middleName":"","lastName":"Cambon","suffix":""},{"id":617461083,"identity":"082a2fdb-fb13-44b9-aaf4-f5ccdbc85dd1","order_by":2,"name":"Yael Saada","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Bordeaux","correspondingAuthor":false,"prefix":"","firstName":"Yael","middleName":"","lastName":"Saada","suffix":""}],"badges":[],"createdAt":"2026-02-25 08:24:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8965136/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8965136/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106309393,"identity":"fa364195-7130-4b99-98fd-191be42f992a","added_by":"auto","created_at":"2026-04-07 10:17:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":105248,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eEcosystemic environments favourable to enhancing parental empowerment\u003c/em\u003e (37)\u003c/p\u003e","description":"","filename":"Figure1.Ecosystemicenvironmentsfavourabletoenhancingparentalempowerment.png","url":"https://assets-eu.researchsquare.com/files/rs-8965136/v1/d4b7f873721f654959aa8b78.png"},{"id":106404000,"identity":"155e1249-06aa-4b7f-9a93-526e761ff357","added_by":"auto","created_at":"2026-04-08 09:15:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":726563,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8965136/v1/c8b66647-7891-43dd-b59f-6982f37d9b54.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Designing a multi case realist evaluation of parenting support services using an ecosystemic approach to parental empowerment","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSocial health inequalities emerge from the very beginning of life, when systematic differences in experiences within socially differentiated environments lead to distinct developmental trajectories (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These early-life experiences shape health, well-being, learning, and behaviour over the entire span of an individual\u0026rsquo;s life (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). A large body of research highlights the decisive role that an infant\u0026rsquo;s social and emotional environment plays and the central place of the family context in early development (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The period from pregnancy to the child\u0026rsquo;s third year therefore constitutes a major developmental window (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). It is during these early years that the foundations of physical, cognitive, emotional, and social health are established. Parents are the primary guardians of their children\u0026rsquo;s health (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e); their parenting practices and the quality of parent\u0026ndash;child interactions therefore play a key role in shaping these developmental trajectories (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, the transition to parenthood involves profound identity transformations, which take place within social and material contexts that are often fragile or constrained (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The weakening of local communities and the reduction of spaces for social participation have contributed to increasing parental isolation (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). At the same time, contemporary norms of parenting place a strong emphasis on individual parental responsibility, thereby reinforcing parental stress and social health inequalities (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Against this backdrop, parenting support policies have gained increasing prominence in public debate. Since 2021, France has sought to consolidate its parenting support policy by defining a shared national framework, notably via a National Charter and its explicit inclusion in the Social Action and Family Code (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNevertheless, parenting support policies remain characterised by tensions between support and normativity. Since the 1940s, the field of prevention has largely focused on strengthening parenting skills, reducing risk factors in order to safeguard children\u0026rsquo;s health, and ensuring that individual difficulties do not spill over into the public sphere (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). As a result, parenting support interventions have predominantly been centred on the individual parent, thus tending to individualise difficulties and obscure the structural determinants that shape parenting experiences (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). From a health promotion perspective, parenting support cannot be limited to actions that focus solely on parenting skills or parent\u0026ndash;child interactions (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). An ecosystemic approach, by contrast, makes it possible to understand parenting as a situated experience, shaped by interrelated social relationships, material conditions, and social environments (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Such an approach fosters the development of parental empowerment, defined as parents\u0026rsquo; capacity to mobilise internal and external resources in order to meet their needs and to influence their environment (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This, in turn, calls for intervention modalities that recognise, legitimise, and strengthen this capacity (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe APPIE (Analysis of Public Policies Impacting Children) Village study aims to explore the conditions under which parenting support services may adopt an ecosystemic form that fosters parental empowerment. To better understand how, for whom, and under what conditions such programmes operate, a realist evaluation framework is employed (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This article outlines the design and analytical framework of a multi-case realist evaluation examining the conditions under which parenting support services may promote parental empowerment. The first phase focused on the development of an initial programme theory, based on a realist review, expert interviews, and a process of co-analysis. This phase led to the formulation of realist hypotheses embedded within an analytical framework describing nine parenting support services implemented across diverse territorial, institutional, and organisational contexts.\u003c/p\u003e "},{"header":"Methods/Design","content":"\u003cp\u003e1. Study design\u003c/p\u003e\n\u003cp\u003eAPPIE Village is a multi-case qualitative realist evaluation.\u003c/p\u003e\n\u003cp\u003eRealist evaluation (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e) is a form of theory-driven evaluation approach (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e) that is particularly well suited to complex interventions, such as parenting support services. Its purpose is to explain the mechanisms that an intervention triggers in order to produce its observed effects within a given context (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e), using the Context\u0026ndash;Mechanism\u0026ndash;Effect (CME) configurational heuristic (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e). Whereas conventional evaluations seek to determine whether an intervention works or not (versus the absence of intervention), realist evaluation aims to understand how and why an intervention produces (or fails to produce) effects, for whom, and under what conditions (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThis approach is grounded in a generative conception of causality, whereby an intervention (A) activates a mechanism (M) that contributes to producing an effect (E) within a specific context (C), as opposed to a successionist conception of causality, in which an intervention is assumed to directly produce an effect.\u003c/p\u003e\n\u003cp\u003eThe Context\u0026ndash;Mechanism\u0026ndash;Effect (CME) configuration therefore constitutes the central unit of analysis in realist evaluation. Following the framework proposed by Cambon et al. (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e), contexts are conceptualised as including both:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eexternal contexts (Ce), referring to the social, family, economic, and institutional conditions that structure parenting experiences; and\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eintervention contexts (Ci), corresponding to the organisational, professional, and relational modalities specific to each parenting support service.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eMechanisms (M) refer to parents\u0026rsquo; responses to these contexts and to the forms of support provided (e.g., feelings of safety, recognition, trust, mutual support), which may foster or hinder the development of parental empowerment. Effects (E) depend on the extent to which the intervention\u0026rsquo;s underlying mechanisms are activated or not by contextual elements (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e). In this study, effects are understood as observable changes in parenting practices, parenting experiences, and parental responsibility.\u003c/p\u003e\n\u003cp\u003eThis approach is particularly relevant to the field of parenting support, where intervention objectives are often implicit or plural, change mechanisms are relational and sensitive to the quality of encounters, families\u0026rsquo; living contexts vary widely, and effects are not uniform but situated. Realist evaluation thus makes it possible to develop middle-range theories, that is, explanations that are transferable yet context-sensitive, providing actionable insights for public policy-makers and professional practices.\u003c/p\u003e\n\u003cp\u003eThis study follows the RAMESES II quality and reporting standards for realist evaluations (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e2. Study aims\u003c/p\u003e\n\u003cp\u003eThe theoretical framework underpinning this study was developed during a preliminary phase, the results of which are reported in other publications. This phase aimed to identify the conditions conducive to an ecosystemic approach to parenting support that promotes the development of parental empowerment.\u003c/p\u003e\n\u003cp\u003eThis phase of research was based on three complementary sources:\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003e\n\u003cp\u003eA qualitative study involving ten experts, including researchers, field professionals, and institutional stakeholders involved in parenting policies and services;\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eA realist review of the literature on environments favourable to the development of parental empowerment from pregnancy to the child\u0026rsquo;s third year (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e); and\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eA working seminar (APPIE-Lab) bringing together actors from different institutional levels, enabling data triangulation and the identification of cross-cutting dimensions.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe integration of these data led to the identification of a set of organisational, relational, and structural conditions that support the development of parental empowerment.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 1 presents the initial programme theory underlying the APPIE Village study.\u003c/p\u003e\n\u003cp\u003eThis theoretical framework constitutes an initial explanatory model. It does not describe how all services operate but rather proposes hypotheses regarding the configurations of contexts and mechanisms that are likely to foster parental empowerment. It will be tested and refined throughout the analysis of the nine case studies, in line with the iterative logic of realist evaluation. In the following sections, this framework serves as the basis for structuring data collection and analysing CME configurations.\u003c/p\u003e\n\u003cp\u003e3. Methods\u003c/p\u003e\n\u003cp\u003eMulti-case design\u003c/p\u003e\n\u003cp\u003eThis study adopts a multi-case design, enabling us to compare parenting support practices in diverse territorial, institutional, and organisational contexts across multiple regions in France, reflecting a national study. Our objective is not to compare services in order to determine which is the \u0026ldquo;best\u0026rdquo; or most effective, but to identify regularities, variations, and contextual conditions under which mechanisms that are conducive to parental empowerment emerge.\u003c/p\u003e\n\u003cp\u003eThe nine services included in the study were selected in order to maximise variation in observable contextual elements:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eterritorial positioning (urban, rural, priority neighbourhoods);\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003einstitutional status (non-profit organisations, local authorities, private organisations);\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eforms of support (open-access reception, group workshops, individual support, continuous or time-limited interventions); and\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003etiming of intervention (pregnancy, immediate postnatal period, early infancy, second or third year of the child\u0026rsquo;s life).\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis diversity makes it possible to document how similar resources may produce different effects depending on context; it also illustrates, conversely, how similar contexts may mobilise different resources to support parenting.\u003c/p\u003e\n\u003cp\u003eThe characteristics of the nine parenting support services are presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003edescription of the services\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eService\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eType of structure\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eType of support\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eLocation\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEducational hub bringing together a childcare centre, maternal and child health service, early childhood relay, and a space dedicated to the first 1,000 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCollective meeting spaces facilitating reception, thematic workshops, peer groups.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUrban priority neighbourhood\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eB\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAssociation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFamily support association offering workshops, a family caf\u0026eacute;, and community events.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedium-sized city\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAssociation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThematic workshops, peer support groups, drop-in/individual sessions with a professionnal.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMobile services operating across several rural municipalities\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLocal social and family support centre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLong-term peer group (3 years), thematic workshops, Parent-Child Drop-In Centre (LAEP, Lieu d\u0026rsquo;Accueil Enfant-Parent).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUrban priority neighbourhood\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eE\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eParenting support programme\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAttachment-focused online parent group.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFully online\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAssociation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInformal meetings in caf\u0026eacute;s, parks, and local associations, as well as thematic workshops.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCity centre\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eG\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMultidisciplinary centre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePersonalised pathway from pregnancy to age three, combining group workshops and individual consultations with interdisciplinary professionals.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedium-sized city\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA public family support centre dedicated to the first 1,000 days, led by the departmental maternal and child health service\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eParent-child reception, individual consultations, Parent-Child Drop-In Centre (LAEP, Lieu d\u0026rsquo;Accueil Enfant-Parent), thematic workshops.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePriority neighbourhood\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFamily-oriented community hub supported by childcare centre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMobile thematic workshops, parent discussion groups, peer groups.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMobile services operating across several rural municipalities\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThese descriptions constitute a starting point. The fine-grained characteristics of each service (Ci) will be specified and analysed during fieldwork, including reception modalities, institutional identity, family trajectories, and professional postures.\u003c/p\u003e\n\u003ch3\u003eData collection and participants\u003c/h3\u003e\n\u003cp\u003eData collection relies primarily on a qualitative approach, which enables us to access both the meanings that parents and professionals attribute to their experiences within the services and the contextual dynamics likely to activate or inhibit parental empowerment mechanisms. Data collection follows an iterative logic: tools (interview guides, observation frameworks) may be refined throughout the analysis process, in accordance with the principle of progressive theory refinement.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003ePopulation\u003c/h2\u003e\n\u003cp\u003eFor each service, between five and seven parents and between two and four professionals will be interviewed (approximately 80 interviews in total).\u003c/p\u003e\n\u003cp\u003eTwo categories of participants are included:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eParents supported by one of the selected parenting support services; and\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eProfessionals involved in the design, delivery, or coordination of these services.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe inclusion and exclusion criteria for parents and professionals participating in the qualitative interviews are presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eInclusion and exclusion criteria for qualitative interviews with parents and professionals.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eParents\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eProfessionals\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eInclusion criteria\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eInclusion criteria\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Primiparous or multiparous parents\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Professionals working within one of the partner parenting support services\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Parents between the fourth month of pregnancy and the child\u0026rsquo;s third year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Multidisciplinary professionals providing parenting support (conventional or non-conventional)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Single parents or parents living with a partner\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Parents supported by one of the partner parenting support services\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Aged 18 years or older\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Parents of infants born with medical complications (e.g., low birth weight, prematurity, disability)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Professionals providing exclusively medical or healthcare interventions\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Parenting in a highly specific context (e.g., parental illness, war context, extreme poverty)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Professionals not working within a partner parenting support service\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Interventions exclusively targeting behavioural or conduct problems, or prevention of future problems among high-risk parents\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003ch3\u003eRecruitment\u003c/h3\u003e\n\u003cp\u003eRecruitment will be organised in collaboration with service coordinators, who inform parents and professionals about the study and provide them with an information sheet and a consent form. Interested participants then contact the service coordinator, who organises meetings with the researcher during field visits, ensuring full anonymity.\u003c/p\u003e\n\u003cp\u003eData collection: interviews\u003c/p\u003e\n\u003cp\u003eSemi-structured interviews will be conducted with parents and professionals.\u003c/p\u003e\n\u003cp\u003eIndividual interviews with parents will last between 45 minutes and one hour. Their aim is to understand parents\u0026rsquo; subjective relationship to the support provided. They explore:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003ewhat parents seek from the service (Ci), that is, the resources, forms of support, or spaces they hope to find there;\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003ethe link with their life context (Ce), namely the reasons why this need emerged along their life trajectory. This articulation makes it possible to avoid considering motivations as individual characteristics but instead as situated responses to specific environments and living conditions;\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003ehow parents experience the support: identifying how the service responds to the needs that led them to participate (perceived adequacy between expectations and resources mobilised), describing how they feel within the setting and how the setting responds to why they sought it out, including their relationship to reception, listening, the place they are given, and the relationships built within the group. This involves qualifying the subjective experience of the encounter (M), for example, feelings of safety, recognition, parental legitimacy, or trust; and\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eperceived transformations in their parenting (E), whether in terms of changes in daily practices, the relationship with their child, or the mobilisation of resources.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eInterviews with professionals will follow a similar logic, mobilising their situated perspective on the service. They will last between 45 minutes and one hour and explore in particular:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eprofessionals\u0026rsquo; perceptions of parents\u0026rsquo; motivations for participation (Ce), that is, the life situations, expectations, and needs they identify among the families supported;\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003etheir professional posture with regard to the service;\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003ethe support modalities mobilised on a daily basis: organisation of reception, relational positioning, space given to parental speech and experience, regulation of the framework, and collective adjustments (Ci). The aim here is to identify the relational and organisational conditions that are likely to support certain encounter dynamics;\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003ethe processes they believe are activated in the encounter (M), in order to capture how they understand the mechanisms at work and their articulation within the contexts encountered; and\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003ethe effects observed on parenting (E): changes in confidence, ability to ask for help, intra-family interactions, participation in collective life, or adjustment of practices.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis interview framework will enable us to reconstruct configurations of the following type:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eIn which situations do parents arrive? (Ce)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eWhich relational or organisational modalities are implemented? (Ci)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eWhat do these elicit in parents? (M)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eWhat changes are observed in how they experience their parenting? (E)\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThanks to this structure, during configurational analysis we will be able to align parental and professional perspectives without merging them, while identifying their points of convergence, complementarity, or tension.\u003c/p\u003e\n\u003cp\u003eData collection: observations\u003c/p\u003e\n\u003cp\u003eOne to two observations will be conducted in each of the nine services. The researcher will adopt a minimal participant observation posture; this consists of being present in the setting and taking part naturally in exchanges when they occur, without directing activities, interactions, or group dynamics. This position makes it possible for the research to integrate themselves to such an extent that they can understand the relational environment while maintaining the analytical distance required.\u003c/p\u003e\n\u003cp\u003eObservation will provide direct access to dimensions that are often implicit or difficult to verbalise in interviews: the general atmosphere of the setting, spatial organisation, reception practices, circulation of speech, relational micro-adjustments, and the ways in which families appropriate the service. It also makes it possible to document the social, material, and symbolic contexts within which support is delivered, by jointly observing external contexts (Ce), such as territorial and institutional constraints, and internal intervention contexts (Ci), including reception organisation and professional practices.\u003c/p\u003e\n\u003cp\u003eFrom a realist evaluation perspective, observation thus will contribute to analysing how these contexts support, inhibit, or transform the activation of mechanisms such as recognition, trust, feelings of safety, or parental legitimacy. By multiplying observed contexts, the study will be able to identify regularities in the relationships between contexts, mechanisms, and effects, enabling our research to identify transferable logics of action (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eObservations will be recorded in the form of field notes taken during sessions, then transcribed and integrated into NVivo. They will be coded primarily within categories relating to external contexts (Ce) and intervention contexts (Ci) before being mobilised during configurational analysis to illuminate and refine the interpretation of mechanisms (M) identified in the interviews. In particular, the observations will allow us to grasp what is at stake in the encounter that lies beyond discourse: presence, everyday professional gestures, collective rhythms, and forms of informal support. As such, observation constitutes an essential component in the construction of Ce-Ci-M-E configurations and the formulation of middle-range theories.\u003c/p\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eData analysis will follow both a thematic and a configurational approach, in line with the principles of realist evaluation. All interviews will be fully transcribed and analysed using NVivo software.\u003c/p\u003e\n\u003cp\u003eAnalytical approach\u003c/p\u003e\n\u003cp\u003eThe analysis will first follow a thematic approach. Coding will be based on a thematic framework structured according to the Context\u0026ndash;Mechanism\u0026ndash;Effect (CME) model.\u003c/p\u003e\n\u003cp\u003eExternal contexts (Ce) refer to the social, economic, family, and institutional dimensions that shape parenting conditions (macrosystem and exosystem). Intervention contexts (Ci) relate to the characteristics specific to the services studied, such as reception modalities, professional postures, and institutional organisation (mesosystem and microsystem). Mechanisms (M) correspond to the cognitive, emotional, and relational processes activated in parents when they interact with the services (ontosystem). Finally, effects (E) refer to observable transformations in parenting experience, the mobilisation of resources, or in everyday practices.\u003c/p\u003e\n\u003cp\u003eThe analysis will be conducted in several stages. First, an individual analysis will be carried out for each participant in order to reconstruct their subjective experience and the specific dynamics of the support received. Second, separate cross-case analyses will be conducted for the parent interviews and the professional interviews in order to identify regularities in contexts, activated mechanisms, and perceived effects. Data from field observations will be integrated into this cross-case analysis in order to enrich the understanding of intervention environments.\u003c/p\u003e\n\u003cp\u003eConfigurational analysis\u003c/p\u003e\n\u003cp\u003eThe second stage will comprise a configurational analysis that focuses on mechanisms. Based on the mechanisms identified in individual interviews and observations, Ce-Ci-M-E configurations will be reconstructed, thus making explicit how certain contexts activate (or inhibit) specific processes and under which conditions these processes lead to effects on parental empowerment.\u003c/p\u003e\n\u003cp\u003eThe unit of analysis is therefore the configuration rather than isolated elements. This configurational analysis will first be conducted within each group (parents and professionals) before being consolidated through a second cross-case analysis aimed at identifying both environment-specific features and regularities across environments.\u003c/p\u003e\n\u003cp\u003eThe objective of this approach is to allow recurrent Ce-Ci-M-E configurations to emerge through progressive saturation, making it possible to understand why and under which conditions certain aspects of support foster the development of parental empowerment, while others may hinder it. This stage may lead to the refinement of existing middle-range theories and to the emergence of new explanatory hypotheses.\u003c/p\u003e\n\u003cp\u003eDevelopment of middle-range theories\u003c/p\u003e\n\u003cp\u003eBased on stabilised configurations, middle-range theories will be formulated. These aim to produce transferable explanations regarding the conditions under which ecosystemic parenting support effectively promotes the development of parental empowerment. These theories will contribute to guiding the evolution of professional practices, service organisation, and, more broadly, public policies in the field of parenting support.\u003c/p\u003e\n\u003cp\u003eIn terms of knowledge transfer, our findings will be presented and discussed with the stakeholders involved in order to foster their appropriation and implementation in local contexts.\u003c/p\u003e\n\u003cp\u003eEthical considerations\u003c/p\u003e\n\u003cp\u003eAll participants (parents and professionals) will receive an information sheet detailing the objectives of the study, participation procedures, expected benefits, and potential risks, as well as their rights. Participation is voluntary and based on the signing of a written informed consent form. Participants may withdraw from the study at any time, without justification and without any consequences for the support they receive.\u003c/p\u003e\n\u003cp\u003eInterviews will be audio-recorded, fully transcribed, and anonymised. No names, locations, or elements allowing identification of participants or services will be retained in the transcripts. Data will be stored on a secure server at the University of Bordeaux and accessible only to members of the research team.\u003c/p\u003e\n\u003cp\u003eData processing complies with the General Data Protection Regulation (GDPR). A declaration has been submitted to the University\u0026rsquo;s Data Protection Officer.\u003c/p\u003e\n\u003cp\u003eGiven that some topics discussed may involve sensitive experiences (parental exhaustion, isolation, feelings of incompetence), the researcher adopts an active listening posture and ensures that no emotional distress is caused. In case of signs of vulnerability, participants will be referred to appropriate support services.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis article presents the design of a realist evaluation of parenting support services, focused on analysing the conditions that foster the development of parental empowerment. The chosen approach makes it possible to move beyond an evaluation logic centred on the overall effectiveness of interventions, towards a situated understanding of change processes. This perspective is particularly relevant in the field of parenting support, which is characterised by a high diversity of intervention contexts, family trajectories, and forms of support.\u003c/p\u003e \u003cp\u003eThe study is expected to identify Context-Mechanism-Effect (CME) configurations through which specific relational and organisational dimensions may foster mechanisms conducive to parental empowerment. By analysing these processes across contrasting environments, the study will contribute to clarifying the conditions that are required to implement a genuinely ecosystemic approach to parenting support. These findings may inform the development of parenting support policies aimed at reducing early-life social health inequalities across diverse contexts. However, this approach also brings a number of challenges. First, the distinction between external contexts (Ce) and intervention contexts (Ci) requires sustained analytical attention, as these factors tend to be strongly intertwined within parenting experiences. Second, the iterative logic of the study implies continuous adjustments to data collection tools and data interpretation, requiring the adoption of a reflexive research posture. Finally, the diversity of the services studied may generate a high level of configurational heterogeneity, making rigorous cross-case analysis essential to identifying meaningful regularities.\u003c/p\u003e \u003cp\u003eDespite these anticipated challenges, this study has several strengths. It is embedded in a co-construction process with institutional and field actors, fostering the appropriation of the knowledge produced. It is also grounded in an initial theoretical framework that ensures analytical coherence. Finally, it aims to generate results that are directly actionable for professional practices and public policy-makers, notably through the development of transferable recommendations. The realist approach will also enable the identification of unintended or potentially iatrogenic effects, thus offering decision-makers a critical and nuanced perspective when assessing how and whether to implement or scale-up parenting support services.\u003c/p\u003e \u003cp\u003eBeyond describing the structure of an ongoing evaluation, this article contributes to methodological discussions within qualitative health research by illustrating how realist evaluation can be operationalised in the field of parenting support and health promotion. By articulating external contexts (Ce), intervention contexts (Ci), mechanisms (M), and effects (E) within a multi-case design, it proposes a structured yet flexible analytical framework for examining empowerment processes as situated and relational phenomena. In doing so, it demonstrates how realist approaches can strengthen ecosystemic analyses of complex social interventions, particularly in early childhood and family health contexts.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis article outlines a realist evaluation designed to understand the conditions under which parenting support services foster the development of parental empowerment, taking into account the diverse contexts in which families live. Based on an initial programme theory, the study adopts a multi-case design and an iterative approach to identify Context-Mechanism-Effect (CME) configurations that support or hinder parental transformation processes.\u003c/p\u003e \u003cp\u003eThe anticipated findings will generate transferable middle-range theories capable of supporting the evolution of professional practices and guiding public policies towards more ecosystemic, inclusive, and capacity-building forms of support. By focusing on the first 1,000 days, a critical period for development, the study seeks to better align interventions with the lived realities of families and contribute to reducing early-life social health inequalities.\u003c/p\u003e \u003cp\u003eThe evaluation will also identify not only the conditions that foster intended effects, but also unintended or potentially counterproductive consequences, which are often overlooked in traditional assessments. By making these dynamics visible, the study will provide decision-makers with a critical perspective to inform decisions about whether and how to implement, adapt, or scale up parenting support services. Findings will be disseminated in close collaboration with professionals, institutions, and public decision-makers, thereby facilitating their appropriation and implementation in diverse local contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eEthical approval for this study was granted by the Ethics Review Committee of the University of Bordeaux (CER-UB-2024-3A-F). Written informed consent was obtained from the participants prior to the study. All procedures involving human participants were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing not applicable to this article as no datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThis study is funded by the French National Institute of Cancer (INCa), the Institute for Research in Public Health (IReSP), and the National League Against Cancer (Ligue contre le cancer). The funders had no role in the design of the study, data collection, analysis, interpretation of data, or writing of the manuscript.\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026rsquo; contributions\u003c/h3\u003e\n\u003cp\u003eMB and LC conceptualised and designed the study and drafted the initial programme theory. MB drafted the manuscript. LC and YS reviewed the manuscript and provided feedback and critical insights. All authors contributed to and approved the final manuscript. MB is the guarantor of the work.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eThe authors would like to thank the parenting support services partners involved in the APPIE-Village project for their collaboration in the development of this research. We are also grateful to the members of the APPIE-Lab and institutional partners who contributed to the co-construction of the programme theory and study design.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCase A, Lubotsky D, Paxson C. Economic Status and Health in Childhood: The Origins of the Gradient. Am Econ Rev. 2002;92(5):1308\u0026ndash;34. doi:10.1257/000282802762024520 PubMed PMID: 29058397.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLang T, Kelly-Irving M, Lamy S, Lepage B, Delpierre C. Construction de la sant\u0026eacute; et des in\u0026eacute;galit\u0026eacute;s sociales de sant\u0026eacute; : les g\u0026egrave;nes contre les d\u0026eacute;terminants sociaux ? 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Children\u0026amp;Society.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Parenting, first 1,000 days, parental empowerment, realist evaluation, early childhood, health promotion.","lastPublishedDoi":"10.21203/rs.3.rs-8965136/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8965136/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe first 1,000 days represent a critical developmental window, during which social, material, and relational environments exert a lasting influence on children\u0026rsquo;s health, well-being, and developmental trajectories. Social health inequalities emerge early in life, when families experience unequal access to resources, support networks, and spaces of social participation. In France, parenting support policies have recently been strengthened; yet interventions remain largely centred on the individual parent, potentially overlooking the structural and contextual determinants that shape parenting experiences. Fostering parental empowerment requires a genuinely ecosystemic approach to parenting support. This article describes the design of a realist evaluation that will examine the conditions under which parenting support services promote the development of parental empowerment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study draws on a realist evaluation of nine parenting support services implemented in diverse institutional, territorial, and organisational contexts in France. Realist evaluation seeks to understand how and why interventions work (or do not work), for whom, and under what conditions, based on Context-Mechanism-Effects (CME) configurations. Data collection includes approximately 80 semi-structured interviews with parents and professionals, as well as two minimal participant observations in each service. A thematic and configurational analysis will be conducted using NVivo following an iterative logic: separate coding for parents and professionals, cross-case analyses, and the progressive reconstruction of contextual and individual Context-Mechanism-Effects configurations in order to develop middle-range theories.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eThis study will identify the conditions that support the development of parental empowerment from an ecosystemic and a health promotion perspective. The realist approach will also make it possible to identify unintended or potentially iatrogenic effects, which are often overlooked in conventional evaluations, thus informing decisions regarding how to implement and scale-up parenting support services. The findings will provide transferable recommendations that will guide professional practices and public policies towards more systemic, inclusive, and capacity-building forms of support.\u003c/p\u003e","manuscriptTitle":"Designing a multi case realist evaluation of parenting support services using an ecosystemic approach to parental empowerment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-07 10:17:10","doi":"10.21203/rs.3.rs-8965136/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-21T12:20:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-14T06:42:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-13T22:41:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-11T01:00:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-09T18:14:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-09T16:18:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"101522132460341466714203165099486517255","date":"2026-04-08T04:06:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270055600790850179879675298998758808500","date":"2026-04-07T13:46:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"311631354201264801509424418086274325197","date":"2026-04-07T12:45:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192196876012797875220861895507649558957","date":"2026-04-06T22:59:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53205044981899892605744825082078589387","date":"2026-04-06T09:37:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33577258021415322752268288496918659712","date":"2026-04-03T14:53:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217391398126735373878736726464197205655","date":"2026-04-03T09:04:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-01T08:14:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-10T04:40:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-09T11:52:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-08T08:28:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-03-08T08:23:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4ec84735-c3f3-4dea-8897-9ecaf654d094","owner":[],"postedDate":"April 7th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-19T11:23:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-07 10:17:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8965136","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8965136","identity":"rs-8965136","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}