Context-mechanism-outcome Configurations Research Articles

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...

How do medical schools influence their students' career choices? A realist evaluation.

The career choices of medical graduates vary widely between medical schools in the UK and elsewhere and are generally not well matched with societal needs. Research has found that experiences in medical school including formal, informal and hidden curricula are important influences. We conducted a realist evaluation of how and why these various social conditions in medical school influence career thinking. We interviewed junior doctors at the point of applying for speciality training. We selected purposively for a range of career choices. Participants were asked to describe points during their medical training when they had considered career options and how their thinking had been influenced by their context. Interview transcripts were coded for context-mechanism-outcome (CMO) configurations to test initial theories of how career decisions are made. A total of 26 junior doctors from 12 UK medical schools participated. We found 14 recurring CMO configurations in the data which explained influences on career choice occurring during medical school. Our initial theories about career decision-making were refined as follows: It involves a process of testing for fit of potential careers. This process is asymmetric with multiple experiences needed before deciding a career fits ('easing in') but sometimes only a single negative experience needed for a choice to be ruled out. Developing a preference for a speciality aligns with Person-Environment-Fit decision theories. Ruling out a potential career can however be a less thought-through process than rationality-based decision theories would suggest. Testing for fit is facilitated by longer and more authentic undergraduate placements, allocation of and successful completion of tasks, being treated as part of the team and enthusiastic role models. Informal career guidance is more influential than formal. We suggest some implications for medical school programmes.

Health Insurance Schemes and Their Influences on Healthcare Variation in Asian Countries: A Realist Review and Theory's Testing in Thailand.

Various features in health insurance schemes may lead to variation in health care. Unwarranted variations raise concerns about suboptimal quality of care, differing treatments for similar needs, or unnecessary financial burdens on patients and health systems. This realist review aims to explore insurance features that may contribute to health care variation in Asian countries; and to understand influencing mechanisms and contexts. We undertook a realist review. First, we developed an initial theory. Second, we conducted a systematic review of peer-reviewed literature in Scopus, MEDLINE, EMBASE, and Web of Science to produce a middle range theory for Asian countries. The Mixed Methods Appraisal Tool (MMAT) was used to appraise the methodological quality of included studies. Finally, we tested the theory in Thailand by interviewing nine experts, and further refined the theory. Our systematic search identified 14 empirical studies. We produced a middle range theory in a context-mechanism-outcome configuration (CMOc) which presented seven insurance features: benefit package, cost-sharing policies, beneficiaries, contracted providers, provider payment methods, budget size, and administration and management, that influenced variation through 20 interlinked demand- and supply-side mechanisms. The refined theory for Thailand added eight mechanisms and discarded six mechanisms irrelevant to the local context. Our middle range and refined theories provide information about health insurance features associated with health care variation. We encourage policymakers and researchers to test the CMOc in their specific contexts. Appropriately validated, it can help design interventions in health insurance schemes to prevent or mitigate the detrimental effects of unwarranted health care variation.

Integrated care system leadership: a rapid realist review

PurposeGiven the complex nature of integrated care systems (ICSs), the geographical spread and the large number of organisations involved in partnership delivery, the importance of leadership cannot be overstated. This paper aims to present novel findings from a rapid realist review of ICS leadership in England. The overall review question was: how does leadership in ICSs work, for whom and in what circumstances?Design/methodology/approachDevelopment of initial programme theories and associated context–mechanism–outcome configurations (CMOCs) were supported by the theory-gleaning activities of a review of ICS strategies and guidance documents, a scoping review of the literature and interviews with key informants. A refined programme theory was then developed by testing these CMOCs against empirical data published in academic literature. Following screening and testing, six CMOCs were extracted from 18 documents. The study design, conduct and reporting were informed by the Realist And Metanarrative Evidence Syntheses: Evolving Standards (RAMESES) training materials (Wong et al., 2013).FindingsThe review informed four programme theories explaining that leadership in ICSs works when ICS leaders hold themselves and others to account for improving population health, a sense of purpose is fostered through a clear vision, partners across the system are engaged in problem ownership and relationships are built at all levels of the system.Research limitations/implicationsDespite being a rigorous and comprehensive investigation, stakeholder input was limited to one ICS, potentially restricting insights from varied geographical contexts. In addition, the recent establishment of ICSs meant limited literature availability, with few empirical studies conducted. Although this emphasises the importance and originality of the research, this scarcity posed challenges in extracting and applying certain programme theory elements, particularly context.Originality/valueThis review will be of relevance to academics and health-care leaders within ICSs in England, offering critical insights into ICS leadership, integrating diverse evidence to develop new evidence-based recommendations, filling a gap in the current literature and informing leadership practice and health-care systems.

Keeping Girls in Sport: A Two-Part Evaluation of an E-Learning Program for Coaches and Activity Leaders

The purpose of this study was twofold: first, to identify who engaged with the Keeping Girls in Sport e-learning program and, second, to evaluate coach and activity leaders’ perceptions of the program and their perceived learnings gained from completing the program. An explanatory sequential mixed-method design was adopted. First, an online survey was distributed to all individuals who had participated in the program. In total, 511 (33% response rate) completed the survey. Quantitative survey data were analysed using descriptive statistics. Subsequently, interviews were conducted with 20 survey respondents. A realist logic of analysis was applied to the qualitative data, and context–mechanism–outcome configurations were formed. Overall, survey findings indicated that most participants identified as women (56%), coaches (69%), and were between 40 and 49 years of age (37%). In general, participants had positive perceptions of the program. Participants perceived that the accessibility and flexibility of the program increased opportunities to engage with content and, thus, their learning. They described improvements in knowledge and perspective regarding working with female athletes. This increase in knowledge provided participants with confidence to establish trusting and positive relationships with others, specifically parents. Nevertheless, participants highlighted a need for more tailored but also more expansive programs.

A Protocol for a Rapid Realist Review of Literature Examining Co-Production in Youth Mental Health Services

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. The proposed rapid realist review aims to develop a theory about how and why co-production methods in youth mental health services work (or do not work), for whom, in which contexts, and through what mechanisms. Relevant evidence will be synthesised to develop context–mechanism–outcome (CMO) configurations that can inform policy and practice. Stakeholders will be iteratively involved in the development of these theories (CMO configurations) by engaging an expert panel and youth advisory group. The review results will be reported according to the RAMESES guidelines and are intended to be published in an academic journal. Additionally, a plain English summary will be produced with the support of the youth advisory group.

Mitigating risks of online engagement; considering the contexts and mechanisms of cybercrime among older adults

AbstractBackgroundThis talk will explore how benefits of remote interventions can be realised for older people with cognitive impairments alongside risk mitigation, drawing on a realist review of how and in what circumstances older people become victims of cybercrime. We aimed to identify factors leading to older adults' victimisation, and review theory and evidence for interventions to reduce victimisation risks.MethodWe conducted a realist review synthesising published literature and gathering stakeholder experiences via an online workshop to understand how, why and in what circumstances older adults are at risk of financial cybercrime victimisation. We used the evidence to develop a programme theory and Context, Mechanism, Outcome Configurations (CMOCs) to explain the mechanisms by which older adults become victims of financial cybercrime in different contexts, and to inform the development of interventions to produce desired outcomes of reducing and preventing cybercrime.ResultWe analysed 52 primary and secondary data sources and consulted with 21 stakeholders from across health, social, legal, and financial sectors. Our programme theory comprised 16 CMOCs describing how social isolation, cognitive decline, physical and mental health problems; wealth status, limited cyber security skills or awareness, societal attitudes and content of scams led to increased risk of victimisation. Only evidence for interventions to enhance cyber security awareness and skills of potential older victims was identified. Targeting offender motivation, redesign of security software to increase usability by older people and training programmes for professionals and family members are rational, yet untested interventions. A shift in societal attitudes, conveying positive messages, of older people’s rights to be safely active online, is needed too.ConclusionProtection from cybercrime is instrumental to supporting ageing in a digital world. Incorporating cyber security awareness into future interventions that promote social connectedness, cognition and healthy lifestyles, alongside legal structural protections, and measures to improve societal attitudes towards financial cybercrime victimisation will help older adults navigate online spaces safely. Training programmes targeting older adults, or their supporters should be deliverable by a range of professionals for greatest reach; and be co‐designed with end users to ensure that if they are useful, they are acceptable and used.

Sleep disturbance in people living with dementia or mild cognitive impairment: a realist review of general practice.

Sleep disturbance is a prevalent condition among people living with dementia (PLwD) or mild cognitive impairment (MCI). Its assessment and management within primary care is complex because of the comorbidities, older age, and cognitive impairment typical of this patient group. To explore how primary care clinicians assess, understand, and manage sleep disturbance for PLwD or MCI; if and why such initiatives work; and how people and their carers experience sleep disturbance and its treatment. A realist review of existing literature conducted in 2022. Six bibliographic databases were searched. Context-mechanism-outcome configurations (CMOCs) were developed and refined. In total, 60 records were included from 1869 retrieved hits and 19 CMOCs were developed. Low awareness of and confidence in the treatment of sleep disturbance among primary care clinicians and patients, combined with time and resource constraints, meant that identifying sleep disturbance was difficult and not prioritised. Medication was perceived by clinicians and patients as the primary management tool, resulting in inappropriate or long-term prescription. Rigid nursing routines in care homes were reportedly not conducive to good-quality sleep. In primary care, sleep disturbance among PLwD or MCI is not adequately addressed. Over-reliance on medication, underutilisation of non-pharmacological strategies, and inflexible care home routines were reported as a result of low confidence in sleep management and resource constraints. This does not constitute effective and person-centred care. Future work should consider ways to tailor the assessment and management of sleep disturbance to the needs of individuals and their informal carers without overstretching services.

Focusing a realist evaluation of peer support for paediatric mental health

ObjectiveMental health problems are a leading and increasing cause of health-related burden in children across the world. Peer support interventions are increasingly used to meet this need using the lived experience of people with a history of mental health problems. However, much of the research underpinning this work has focused on adults, leaving a gap in knowledge about how these complex interventions may work for different children in different circumstances. Realist research may help us to understand how such complex interventions may trigger different mechanisms to produce different outcomes in children. This paper reports on an important first step in realist research, namely the construction of an embryonic initial programme theory to help ‘focus’ realist evaluation exploring how children’s peer support services work in different contexts to produce different outcomes in the West Midlands (UK).MethodsA survey and preliminary semi-structured realist interviews were conducted with 10 people involved in the delivery of peer support services. Realist analysis was carried out to produce context-mechanism-outcome configurations (CMOC).ResultsAnalysis produced an initial programme theory of peer support for children’s mental health. This included 12 CMOCs. Important outcomes identified by peer support staff included hope, service engagement, wellbeing, resilience, and confidence; each generated by different mechanisms including contextualisation of psychoeducation, navigating barriers to accessing services, validation, skill development, therapeutic relationship, empowerment, and reducing stigma.ConclusionThese data lay the groundwork for designing youth mental health realist research to evaluate with nuance the complexities of what components of peer support work for whom in varying circumstances.

Racialised staff–patient relationships in inpatient mental health wards: a realist secondary qualitative analysis of patient experience data

BackgroundThe current study is a secondary analysis of qualitative data collected as part of EURIPIDES, a study which assessed how patient experience data were used to improve the quality of...

O.4.4-8 Promoting men’s health through sports clubs: a rapid realist review

Abstract Purpose Traditional health promotion interventions have failed to engage men. Sports clubs offer male-friendly environments that have been identified as an attractive setting for men’s health promotion, but little is known about implementable intervention strategies and subsequent effects. This rapid realist review (RRR) aims to close this gap by assessing context, mechanisms and effects of health promotion interventions targeting men by or in collaboration with sports clubs. Methods The RRR methodology was developed in collaboration with a panel of Danish practice and policy representatives and international academics. A systematic literature search was conducted in February 2023 for studies published after 2013 in MEDLINE, Embase, and SportDiscus databases. Included studies: 1) targeted men aged 18+ years, 2) reported health promotion outcomes, and 3) were delivered primarily by or in collaboration with sports clubs. A grey literature search of National Sports Associations and Federations and non-government men’s health organizations was also performed. Dalkin’s conceptualization of mechanisms in realist methodology was used to identify context- mechanism-outcome configurations (CMOc) and develop a program theory. The study follows Cochrane’s guidance for rapid reviews and is registered in Research Registry (ID: reviewregistry1556). Results We identified 2.720 studies after duplicates removal. Preliminary analyses indicate that interventions delivered through sports clubs show promise for engaging men and producing favorable health outcomes (e.g., weight loss, increased physical activity and improved social support). The realist synthesis suggests that health interventions delivered through sports clubs (resource mechanism) targeted at men who have high attachment to the sport or club (context), may align with their interests and identities (mechanism), to increase the potential for engagement and health behavior change (outcome). The analysis will be finalised by August. Conclusions Our study indicates that men’s health promotion through sports clubs is emergent. While great strides have been made to increase men’s involvement in health promoting activities by delivering interventions through sports clubs, research has predominantly focused on select behaviours (e.g., physical activity) and sub-groups (e.g., sports fans). Support/Funding Source This work was funded by the five Steno Diabetes Centers in Denmark, which are partly funded by the Novo Nordisk Foundation.

Understanding communication incommunity engagement formaternal andnewborn health programmes inlow- andmiddle-income countries: a realist review.

As community engagement (CE) is implemented for sustainable maternal and newborn health (MNH) programming, it is important to determine how these approaches work. Low- and middle-income countries (LMICs) have become a particular focus for MNH CE activities due to their high burden of maternal and neonatal deaths. MNH messaging and communication to engage communities are likely to differ by context, but how these approaches are actually developed and implemented within CE is not well understood. Understanding how communications in CE actually work is vital in the translation of learnings across programmes and to inform future projects. The purpose of this realist review is to describe how, why, to what extent and for whom communications in CE contribute to MNH programming in LMICs. After searching academic databases, grey literature and literature suggested by the expert advisory committee, documents were included if they described the CE communication processes/activities used for MNH programming in an LMIC. Relevant documents were assessed for richness (depth of insight) and rigor (trustworthiness and coherence of data/theories). Data were extracted as context-mechanism-outcome configurations (CMOCs) and synthesized into demi-regularities to contribute to theory refinement. After screening 416 records, 45 CMOCs were extracted from 11 documents. This informed five programme theories explaining that communications in CE for an MNH programme work when: communities are actively involved throughout the programme, the messaging and programme are acceptable, communication sources are trusted, the community has a reciprocal relationship with the programme and the community sees value in the programme. While these findings reflect what is often anecdotally known in CE or acknowledged in communications theory, they have implications for policy, practice and research by highlighting the importance of centring the community's needs and priorities throughout the stages of developing and implementing communications for CE in MNH.

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

Background: A robust Health Technology Assessment (HTA) mechanism is crucial to address the rising burden of healthcare costs and expenditures of patients. This research aims to describe the HTA methods and mechanisms for successful implementation of HTA in the WHO South-East Asia region, and contextualize the synthesized evidence relevant to Indian settings. Methods: 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. Conclusions: 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.