Context-mechanism-outcome Configurations Research Articles

Supports for informal caregivers of people living with dementia in the Middle East and North Africa Region: realist review

In the Middle East and North Africa (MENA) region, the commitment to honour parents and keep private ‘issues’ within the home combine to shape caregiving styles and needs. Evidence on the effectiveness of interventions for informal caregivers for people living with dementia in the MENA region is lacking. This study offers an overview of interventions for caregivers. It also explores informal caregivers’ needs, preferences and views on addressing intervention through online content. A middle-range programme theory is developed to provide insight into the mechanisms underpinning the interventions. A realist review approach was used to explore what intervention types and features support the informal caregivers of people living with dementia throughout the MENA region and to examine in which contexts and how these interventions worked. The realist synthesis included 23 articles and eight interviews with health professionals. Eight context–mechanism–outcome configurations (CMOCs) were extrapolated to build and iteratively refine a middle-range programme theory and finalise it for testing. Contextual conditions that emerged include stigma, long care duration, culture, lack of support and the effect of this on intervention uptake. Mechanisms reported include feeling supported and empowering caregivers with the skills, knowledge and support they need, which led to outcomes such as improved quality of life for people living with dementia and caregivers and reduction in stress for caregivers. This article contributes to the limited literature by addressing an identified gap in knowledge, providing insights into informal caregivers of people living with dementia in the MENA region to understand why particular interventions work or not, and in what contexts.

Implementing and sustaining dementia care coordinators across integrated care systems: a realist evaluation

BackgroundGlobally, dementia care is under strain. Rising rates across ageing populations, coupled with overstretched health and care systems, mean that people living with dementia and their carers are missing out on crucial support. Addressing dementia care is a key priority for the UK government. This has led to a period of care transformation, including the implementation of new dementia support services across integrated care systems (ICS). However, little is known about how these new services work. This evaluation identifies how a dementia care coordinator service, implemented in the largest ICS in England, works for people living with dementia, their carers and the workforce.MethodsA realist evaluation using mixed methods was carried out between 2022 and 2024. This involved a repeat survey with dementia care coordinators, carried out a year apart, alongside 57 interviews with coordinators, service managers, healthcare practitioners, people living with dementia and their carers. A realist logic of analysis was applied across all data sets.ResultsThree broad concepts were identified including (1) workforce design and organisational culture, (2) meeting the needs of people living with dementia and their carers and (3) connecting to services and integrating care. A total of 23 context-mechanism-outcome configurations (CMOCs) across these concepts highlighted that whilst tensions exist between the service and wider system, dementia care coordinators ultimately act as bridge builders, connecting people to much-needed support. However, services like this could become a victim of their own success due to increasing caseloads and the risk of staff burnout.ConclusionsThe dementia care coordinator service is capable of supporting people who are pre- and post-dementia diagnosis despite the care system being under strain. This is a direct result of the bridge building work of the dementia care coordinators. Our findings support evidence-based recommendations for those wanting to implement and sustain a system-wide service and provide evidence for policy makers to consider increased funding for this service nationwide.

A rapid realist review of literature examining Co-production in mental health services for youth.

An overview of internationally published literature on what works for co-production in youth mental health services is missing, despite a practice and policy context strongly recommending this approach. This rapid realist review develops a theory about how and why co-production methods in youth mental health services work, for whom and in which circumstances. Relevant evidence was synthesised to develop Context-Mechanism-Outcome configurations (CMOs) that can inform policy and practice. Stakeholders were iteratively involved by engaging an expert panel including young people and a separate youth advisory group. Searches across eight databases and expert panel suggestions identified 5716 documents which were screened at abstract level, 532 at full-text and 57 documents were included in the review. Data extracted from 57 papers contributed to five CMO configurations to describe the generative mechanisms by which co-production in youth mental health services are linked to outcomes and influenced by context. The final programme theory is: Youth experts by experience (YEBE), particularly those from minoritised communities, provided with a supportive organisational culture can experience authentic engagement where their knowledge is perceived as credible by wider stakeholders. This leads to personal development for participating YEBE as well as service improvements from their input. Rich data from a heterogenous sample of papers along with stakeholder consultation enabled this review to refine a clear programme theory for co-production in mental health services for young people. Nevertheless, further information is needed to identify what constitutes a supportive organisational culture and to explore rival theories or under-evidenced areas.

Developing an initial explanatory theory for Partnering for Change using realist evaluation.

Partnering for Change (P4C) is an innovative practice model for school-based occupational therapy developed in Canada and informed by a program of research spanning nearly two decades. National and international interest in P4C necessitated development of an explanatory theory to guide implementation in varied contexts. The purpose of this study is to document the process of theory development and to provide an overview of the initial P4C explanatory theory. Realist evaluation was used to construct an initial explanatory theory of P4C drawing on P4C developers' conceptualisations of the model, document analysis, and analysis of transcripts from interviews and focus groups. No consumers were involved in the study design or analysis. Four sets of premises expressed as context-mechanism-outcome configurations (CMOCs) comprise the initial explanatory theory of P4C. An abstracted summary of these four sets along with contexts, mechanisms, and outcomes central to the P4C initial explanatory theory is presented. An exemplar CMOC is shared to illustrate how theoretical premises are developed and expressed using realist evaluation. This study advances knowledge regarding the hypothesised core elements of P4C and provides an example of using realist evaluation to advance knowledge in occupational therapy. Preliminary implications for clinical practice are discussed. Partnering for Change (P4C) is a way of providing occupational therapy services in schools that helps all children to learn and participate successfully. P4C was created in Ontario, Canada, and has been researched for almost 20 years. People in different parts of Canada and other countries are interested in trying P4C. As the researchers who created P4C, we think there is a need to explain how it works so it can be used in different places. This study explains how we created a theory to describe P4C. To develop this theory, we used a method called realist evaluation that would help us explain how, why, and in what situations P4C works best. To do this, we analysed documents and transcripts of interviews and focus groups. Our findings are organised into four main ideas, each explained in terms of contexts (the situations), mechanisms (how and why P4C works), and outcomes (the impacts of P4C). One detailed example is given to show how these ideas were formed and work together. In conclusion, our study helps us understand the key parts of P4C and shows how realist evaluation can be used to improve knowledge in occupational therapy. The study also suggests some early ideas on how P4C can be used in practice.

Dementia Friendly communities (DFCs) to improve quality of life for people with dementia: a realist review

BackgroundCurrently, there are more than 55 million people living with dementia worldwide. Supporting people with dementia to live as independently as possible in their communities is a global public health objective. There is limited research exploring the implementation of such interventions in the community context. The aim of the review was to create and refine programme theory – in the form of context mechanism-outcome configurations – on how the characteristics of dementia-friendly communities (DFCs) as geographical locations interact with their social and organisational contexts to understand what works for whom and why.MethodsThis realist review sourced literature from 5 electronic databases: Cochrane Library, CINAHL, Medline, Scopus, PsychINFO and Google Scholar, as well as relevant websites such as Alzheimer’s Society to identify grey literature. Methodological rigour was assessed using the Joanna Briggs Institute critical appraisal tool.ResultsSeven papers were included in this realist review that focused on DFCs in a geographical context The implementation of DFC interventions emerged as a process characterised by two pivotal implementation phases, intricately linked with sub-interventions. The first intervention, termed Hierarchy Commitment (I1a/b), involves the formalisation of agreements by businesses and organizations, along with the implementation of dementia-friendly action plans. Additionally, Educational Resources (I1c) play a significant role in this phase, engaging individuals with dementia and their caregivers in educational initiatives. The second phase, Geographical/Environmental Requirements (I2), encompasses the establishment of effective dementia-friendly signage, accessible meeting places, and community support.ConclusionsThis realist review highlighted a theoretical framework that might guide the development of dementia-friendly communities to enhance the experiences of individuals with dementia and their caregivers within DFCs. Emphasising the need for a theoretical framework in developing geographical DFCs, the review outlines contextual elements, mechanisms, and outcomes, providing a foundation for future studies. The ultimate goal is to establish a robust body of evidence for the sustainable implementation of dementia-friendly communities, thereby improving the quality of life for those with dementia.Study registrationThis study is registered as PROSPERO 2022 CRD42022317784.

Improving Pain mAnagement for childreN and young people attendeD by Ambulance (PANDA): protocol for a realist review.

Background Each year in England, 450,000 children and young people (CYP) under 18 years of age are transported by ambulance to emergency departments. Approximately 20% of these suffer acute pain caused by illness or injury. Pain is a highly complex sensory and emotional experience. The intersection between acute pain, unwell CYP and the unpredictable pre-hospital environment is convoluted. Studies have shown that prehospital pain management in CYP is poor, with 61% of those suffering acute pain not achieving effective pain relief (abolition or reduction of pain score by 2 or more out of 10) when attended by ambulance. Consequences of poor acute pain management include altered pain perception, post-traumatic stress disorder and the development of chronic pain. This realist review will aim to understand how ambulance clinicians can provide improved prehospital acute pain management for CYP. Methods A realist review will be conducted in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance. A five-stage approach will be adopted; 1) Developing an Initial Programme Theory (IPT): develop an IPT with key stakeholder input and evidence from informal searching; 2) Searching and screening: conduct a thorough search of relevant research databases and other literature sources and perform screening in duplicate; 3) Relevance and rigour assessment: assess documents for relevance and rigour in duplicate; 4) Extracting and organising data: code relevant data into conceptual “buckets” using qualitative data analysis software; and 5) Synthesis and Programme Theory (PT) refinement: utilise a realist logic of analysis to generate context-mechanism-outcome configurations (CMOCs) within and across conceptual “buckets”, test and refine the IPT into a realist PT. Conclusion The realist PT will enhance our understanding of what works best to improve acute prehospital pain management in CYP, which will then be tested and refined within a realist evaluation. Registration PROSPERO Registration: CRD42024505978

Feasibility and desirability of a realist CMOC database: Lessons learned

Central to realist evaluation is its focus on underlying generative mechanisms that cause outcomes in particular contexts, often presented as context–mechanism–outcome configurations. The first author brought together 22 realist evaluation experts in a Delphi technique-inspired exercise to explore the potential of creating a database from context–mechanism–outcome configurations identified in the empirical literature, to enhance learning about what context–mechanism–outcome configurations are and to further the cumulation of knowledge. The exercise, and the comments it evoked, showed why developing such a database is not straightforward and the views on its desirability and utility are mixed. The main reasons are the lack of common concepts to organize the database and the problem of the triple hermeneutic, different uses and non-uses of the context–mechanism–outcome configuration heuristic, and different perceptions of the quality of a context–mechanism–outcome configuration. The discussion points raised in this exercise offer valuable insights into realist reasoning and highlight interesting avenues for further research and debate.

Realist evaluation of a community-based antiretroviral therapy (CBART) programme for key populations in Benue State in Nigeria

BackgroundWorld Health Organization recommended community-based ART (CBART) approaches to improve access to antiretroviral treatment (ART) and treatment outcomes among key populations living with (KPLHIV). Key populations (KP) are female sex workers, men who have sex with men, persons who inject drugs, and transgender people. How CBART for KP (KP-CBART) worked and why, for whom and in what circumstances it worked within KP communities or at community sites, are yet to be described. The aim of this study is to describe the different KP-CBART approaches or models in Nigeria, identifying the context conditions and mechanisms that are likely to produce the desired outcomes.MethodBuilding on our previous study eliciting an initial programme theory for KP-CBART, we used a multiple case design and cross-case analysis to evaluate 3 KP-CBART approaches, namely: One Stop Shop clinic; community drop-in centre; and outreach venue. Between 2021 and 2023, we conducted a retrospective cohort study, 99 indepth interviews and 5 focused group discussions with various actors. Using realist evaluation, we synthesised context-mechanism-outcome configurations (CMOCs) and developed programme theory for each of the cases and an overall theory.ResultThe analysis showed the central importance of decentralizing ART service delivery to a safe place within the community for KPLHIV. The provision of ART in a KP friendly environment triggered a feeling of safety and trust in the healthcare workers among KPLHIV, resulting in KP-CBART acceptance and improved ART uptake, medication adherence and retention on ART. KP community engagement in ART delivery, peer support through support group meetings, and linkages with KP-led organizations improved self-efficacy, fostered solidarity and a sense of belonging among KP. These resources encouraged and motivated clients to engage with the KP-CBART model. However, fear of disclosure of HIV and KP status, and lack of trust between KP groups, demotivated and discouraged KPLHIV from initiating ART and continuing their treatment in KP-CBART.ConclusionTo optimise access to ART and treatment outcomes for KPLHIV, policy makers and health practitioners should ensure the provision of a safe place for ART service delivery that can be trusted by the clients and the KP communities.

Realist analysis of qualitative data in health professions education research.

Qualitative realist analysis is gaining in popularity in health professions education research (HPER) as part of theory-driven program evaluation. Although realist approaches such as syntheses and evaluations typically advocate mixed methods, qualitative data dominate currently. Various forms of qualitative analysis have been articulated in HPER, yet realist analysis has not. Although realist analysis is interpretive, it moves beyond description to explain generative causation employing retroductive theorising. Ultimately, it attempts to build and/or 'test' (confirm, refute or refine) theory about how, why, for whom, when and to what extent programs work using the context-mechanism-outcome configuration (CMOC) heuristic. This paper aims to help readers better critique, conduct and report qualitative realist analysis. We describe four fundamentals of qualitative realist analysis: (1) simultaneous data collection/analysis; (2) retroductive theorising; (3) configurational analysis (involving iterative phases of identifying CMOCs, synthesising CMOCs into demi-regularities and translating demi-regularities into program theory); and (4) realist analysis quality (relevance, rigour, richness). Next, we provide a critical analysis of realist analyses employed in 15 HPER outputs-three evaluations and 12 syntheses. Finally, drawing on our understandings of realist literature and our experiences of conducting qualitative realist analysis (both evaluations and syntheses), we articulate three common analysis challenges (coding, consolidation and mapping) and strategies to mitigate these challenges (teamwork, reflexivity and consultation, use of data analysis software and graphical representations of program theory). Based on our critical analysis of the literature and realist analysis experiences, we encourage researchers, peer reviewers and readers to better understand qualitative realist analysis fundamentals. Realist analysts should draw on relevant realist reporting standards and literature on realist analysis to improve the quality and reporting of realist analysis. Through better understanding the common challenges and mitigation strategies for realist analysis, we can collectively improve the quality of realist analysis in HPER.

A REALIST EVALUATION OF A SELF-MANAGEMENT APP TO HELP PEOPLE WITH CHRONIC LOW BACK PAIN

BackgroundMobile apps have shown promise in helping people to self-manage conditions like chronic low back pain (CLBP). However, it is unclear who benefits most, why, and under what circumstances. This limits our understanding of how to maximize the potential of mobile app technology.AimThis study aimed to test and refine programme theories about how mobile apps support people to self-manage CLBP in a real-world setting. The theories were based on a previously published realist review.MethodsA realist evaluation was conducted using one-to-one realist interviews by telephone with participants who had used the Curable app to self-manage their CLBP for three months. The interviews were guided by programme theories from the realist review. Analysis of the interviews used abductive and retroductive logic to create chains of inferences, which were then developed into context-mechanism-outcome configurations (CMOCs). These CMOCs offered causal explanations about who might benefit from a mobile app to self-manage CLBP, why and in what circumstances.ResultsTen interviews were conducted (nine with people with CLBP who trialled the app and one with a founding member of Curable LLC). Twenty CMOCs were created that identified key mechanisms such as agency, control and reassurance that interact with contextual factors such as acceptance, internal capacity, and a biopsychosocial approach to pain management. These factors influence whether a person with CLBP will benefit from a mobile app for self-management.ConclusionsTwenty CMOCs were created to support three programme theories centering around concepts of empowerment, burden of care, and timing.Conflicts of interestNoneSources of fundingR Hunter's work was supported by the Inverness and Highland City-Region Deal Studentship Award [2018].Presented at: 13th Congress of the European Pain Federation (EFIC), September 2023, Budapest, Hungary.

Case management in primary healthcare for people with complex needs to improve integrated care: a large-scale implementation study protocol

IntroductionCase management (CM) is among the most studied effective models of integrated care for people with complex needs. The goal of this study is to scale up and assess CM...

Improving Pain mAnagement for childreN and young people attendeD by Ambulance (PANDA): protocol for a realist review.

Background Each year in England, 450,000 children and young people (CYP) under 18 years of age are transported by ambulance to emergency departments. Approximately 20% of these suffer acute pain caused by illness or injury. Pain is a highly complex sensory and emotional experience. The intersection between acute pain, unwell CYP and the unpredictable pre-hospital environment is convoluted. Studies have shown that prehospital pain management in CYP is poor, with 61% of those suffering acute pain not achieving effective pain relief (abolition or reduction of pain score by 2 or more out of 10) when attended by ambulance. Consequences of poor acute pain management include altered pain perception, post-traumatic stress disorder and the development of chronic pain. This realist review will aim to understand how ambulance clinicians can provide improved prehospital acute pain management for CYP. Methods A realist review will be conducted in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance. A five-stage approach will be adopted; 1) Developing an Initial Programme Theory (IPT) – develop an IPT with key stakeholder input and evidence from informal searching; 2) Searching and screening – conduct a thorough search of relevant research databases and grey literature sources and perform screening in duplicate; 3) Document selection – assess documents for relevance and rigour in duplicate; 4) Extracting and organising data – code relevant data into conceptual “buckets” using qualitative data analysis software; and 5) Synthesis and Programme Theory (PT) refinement – utilise a realist logic of analysis to generate context-mechanism-outcome configurations (CMOCs) within and across conceptual “buckets”, test and refine the IPT into a realist PT. Conclusion The realist PT will enhance our understanding of what works best to improve acute prehospital pain management in CYP, which will then be tested and refined within a realist evaluation. Registration PROSPERO Registration: CRD42024505978

Exploring how and why a sports-based multi-component intervention works for disengaged students: a longitudinal realist evaluation

ABSTRACT School dropout is associated with numerous detrimental consequences including prolonged unemployment, poverty, a wide range of psychological and physical health problems, and premature mortality. As such, designing and implementing interventions to prevent school dropout and ensure successful school completion is crucial. The purpose of the current study was to conduct a longitudinal realist evaluation to understand how, and under which circumstances, a multi-component intervention delivered through the charitable foundation of a professional sports team may impact the developmental outcomes of disengaged students. The intervention comprised one-to-one mentoring, classroom-based learning, sport and physical activity. Participant observations and fifty-two interviews were conducted with teachers and students over a ten-month period to form context-mechanism-outcome configurations (CMOCs) and to refine initial programme theories. The CMOCs developed highlighted the importance of students developing healthy conflict resolution skills and emotional regulation strategies, the potential of sporting content to re-ignite interest in academic learning, the powerful effects of deviant peer contagion, the synergistic impact of a multi-component intervention, and the role of pre-existing and ongoing contextual factors in determining whether interventions can create sustainable and lasting desirable outcomes among students. The findings provide practical recommendations for future sport-framed intervention design, implementation, and evaluation.

Health technology assessment implementation in WHO South-East Asia Region: a realist review protocol.

A robust Health Technology Assessment (HTA) framework is crucial to address the rising burden of healthcare costs and to inform decision-making to promote high-quality health systems. This research aims to describe the HTA methods and mechanisms for the successful implementation of HTA in the WHO South-East Asia region, and contextualize the synthesized evidence relevant to Indian settings. Realist review involves developing a program theory by conducting a systematic search strategy, screening, study selection, data extraction, and data synthesis. A systematic search for literature will be conducted on PubMed (NCBI), EMBASE (Elsevier), Scopus (Elsevier), Web of Science (Clarivate), and ProQuest Central for identifying the methods used for HTA of health technology interventions. Stakeholder consultations will be conducted to develop a program theory following the Context-Mechanism-Outcome configurations (CMOcs) framework. Searches for primary evidence will be conducted iteratively. Data will be extracted and tested against the programme theory. The proposed realist review will be reported as per the Realist and MEta-narrative Evidence Syntheses: Evolving Standards [RAMESES II] guidelines. To our knowledge, there has been no comprehensive review conducted to understand the mechanisms of HTA methods in the WHO South-East Asia region. The findings from the realist review will help us understand the mechanisms through which the HTA could work in WHO South-East Asian countries. We will then contextualize the findings obtained from evidence to Indian settings, based on program theory development through stakeholder consultation. A framework will be developed that can be used by policymakers/HTA experts in India for effective implementation of the same.

Guiding Through Turbulent Times: Coaching During Merger and Acquisition

ABSTRACT Mergers and acquisitions put organizations through significant disruptions, often taking a toll on employee well-being. This qualitative study aims to analyze how coaching supports employees in coping with the impact of mergers. Eleven semi-structured interviews were conducted with employees and managers. Using realist evaluation, four context-mechanism-outcome configurations (CMOCs) were developed, providing evidence for the following working mechanisms: (1) Increased self-awareness and assertiveness led to greater self-efficacy, empowering participants to advocate for themselves. (2) Breaking down big things into manageable steps helped participants cope with overwhelming issues. (3) Leaders’ support and guidance played a crucial role in helping employees navigate change. And (4) managing a high workload led to increased self-efficacy and well-being at work. These CMOCs demonstrate the diverse working mechanisms of coaching interventions implemented in a disruptive context. The study's insights into these mechanisms offer valuable guidance for designing future interventions to support employees during organizational changes, such as mergers and acquisitions. By tailoring interventions to address employees’ individual challenges and needs, organizations can enhance the effectiveness of these initiatives and promote employee well-being during times of transition. MAD statement This study aims to Make A Difference (MAD) by revealing how coaching works in the context of mergers and acquisitions; more specifically, it identifies the working mechanisms contributing to the intervention's success. By its detailed identification of the interplay of context, mechanism and outcome, it highlights the multifaceted impacts of coaching, ranging from enhanced self-efficacy to coping strategies. It adds to the theoretical discussion on the effectiveness of workplace interventions by not only analyzing what works but also how they work under specific circumstances. As such, it can inform employers on how to support employees during times of organizational change.

Community Engagement in Health Promotion: Results from a Realist Multiple Case Study

Community engagement (CE) has long been endorsed by policy makers and health practitioners. However, uncertainties remain about the workings and outcomes of CE. This study aims to provide in-depth insights into them. In a multiple case study, we investigated three participatory health promotion projects for families in vulnerable situations in the Netherlands. We adopted a realist approach combined with a theory of change (ToC) model. We then analysed the qualitative data for context–mechanism–outcome (CMO) configurations to refine this ToC. Results show that CE can strengthen social networks, empower families, and increase perceived health. However, specific contexts in combination with CE project approaches may or may not trigger positive responses. Participants may feel that they matter when asked to actively contribute to a project, which in turn can enhance their self-confidence. In another context, we found that families were overwhelmed by the responsibilities given to them in the project, leading to feelings of stress and withdrawal from the project. We present a list of CMO configurations and refine the ToC accordingly. Our main conclusion is that flexibility is key when CE is implemented in health promotion. Also, our findings question physical health outcomes as a realistic ambition for CE projects with groups in vulnerable situations.

What contributes to promote sexual health in cancer palliative care? A realist review.

Sexuality is an important determinant of the overall health of a population and remains so at the end of life and in patients with advanced cancers. Despite the abundant literature on sexuality and intimacy, these topics have been rarely discussed in the context of cancer palliative care, and very few interventions to promote sexual health in patients undergoing cancer palliative care have been explored. In this study we sought to identify which factors and mechanisms contribute to promoting sexual health in cancer palliative care. A realist review was performed according to the guidelines of the realist and meta-narrative evidence synthesis method guidelines. Articles published between January 2010 and June 2021 were searched in 4 databases. Records were screened for their relevance regarding a predefined list of context-mechanism-outcome (CMO) configurations. Abstracts were independently screened by 2 authors before the data were extracted from the full-text articles selected for inclusion. With the use of abductive and retroductive reasoning techniques, each article was examined for evidence of its contribution to one of the CMO configurations, which could be refined when relevant. The data were summarized according to the final CMO configurations. Of the 2056 articles identified, 38 articles were included in the review. The data reported in these articles contributed to 7 CMO hypotheses: (1) improving communication skills, (2) healthcare provider training, (3) reorganizing the patient environment in care settings or at home, (4) managing sexual symptoms and also general symptoms, (5 and 6) patient-centered counseling or couple counseling, and (7) lifting the taboo. The findings reported here highlight various ways to improve sexual health for patients in cancer palliative care but are limited to genital cancers. Further research should consider all types of cancer rather than being restricted to genital cancers.

The Use of Vignettes to Improve the Validity of Qualitative Interviews for Realist Evaluation.

Although realist evaluation (RE) requires multiple data collection methods, qualitative interviews are considered most valuable and are most frequently used. The guiding principles of RE may limit the emergence of new Context-Mechanism-Outcome (CMO) configurations by evoking particular underlying mechanisms. This paper proposes a new method for conducting semi-structured interviews in the RE context by drawing on the literature and examining the ability of vignettes to explore perceptions about specific situations. Vignettes are developed based on researchers' knowledge of the setting and program theory and are updated through an iterative process throughout data collection. Interviews focus on situations illustrated in the vignette to capture variations in interviewees' perceptions. This method constrains interviewees to using retroduction to identify the hidden underlying mechanisms that link contextual elements to outcomes based on their experiences. This method allows researchers to focus on CMO configurations without evoking mechanisms, which contributes to the rigor of the method.

Realist evaluation of maternity waiting home intervention models in Inhambane, Mozambique: protocol for a comparative embedded case study, the Mozambique-Canada Maternal Health Project

IntroductionThis is a study protocol that tests and refines realist theories regarding the uptake and scale-up of the linked maternity waiting home (hereafter MWH) and facility birth intervention in the...

A realist synthesis of multicentre comparative audit implementation: exploring what works and in which healthcare contexts

BackgroundMulticentre comparative clinical audits have the potential to improve patient care, allow benchmarking and inform resource allocation. However, implementing effective and sustainable large-scale audit can be difficult within busy and...