Lyme disease (LD) is the most common tick-borne illness in the USA, with an estimated 476,000 cases diagnosed and treated annually. Common signs, symptoms, and manifestations of LD are well described; however, there is limited qualitative understanding of the signs and symptoms patients experience during their illness and the associated impacts patients endure along the way. Thus, we aimed to explore the patient journey and experience with LD, including patient-reported signs and symptoms and impacts to health-related quality of life (HRQOL). No a priori hypotheses were evaluated. In-depth, one-on-one, semi-structured interviews were conducted with US adults aged ≥ 18years who had physician-diagnosed LD in 2023 to explore their experience with LD diagnosis, management, and treatment. The EQ-5D (a standardised HRQOL measure) was administered, and a patient journey map was developed. Interview transcripts were analysed via inductive and deductive coding, using an experiential, realist approach. Twenty-five participants with LD were interviewed (female, 13/25, 52%; male, 12/25, 48%), including those classified as having localised (10/25, 40%), disseminated (10/25, 40%), and indeterminate (5/25, 20%) LD. Participants reported various impacts at diagnosis, such as fear and anxiety, difficulty exercising, needing time off work, and spending increased time indoors. Most participants (19/25, 76%) stated that their symptoms resolved after antibiotic therapy; however, nearly a quarter (6/25, 24%) reported persistent symptoms. Most (15/25, 60%) reported continued emotional impacts after treatment, including fear of future LD infection, fear of the outdoors, and LD-related anxiety. As reported, all EQ-5D domains were worst at diagnosis, but most participants returned to their pre-LD score by the time of the interview. The patient journey with LD is highly varied and individualised, and this study highlights the range of signs, symptoms, physical and emotional impacts that many individuals with LD experience throughout their journey.

The realist approach seeks to understand underlying mechanisms that explain how and why complex interventions, programmes, and policies work in specific contexts, making it particularly valuable in health policy and systems research (HPSR). We draw on reflexive practice of realist evaluations from several realist evaluation practitioners and on insights from an organized session at the Eighth Health Systems Research Symposium in Nagasaki, Japan, in 2024, where we engaged a diverse group of practitioners and researchers on how to use realist approaches in HPSR. Examples from our studies, while situated in distinct contexts, highlight common challenges in applying realist methodologies including identifying and refining context-mechanism-outcome configurations. Building on these examples, we illustrate how realist evaluations, if conducted rigorously and with the purpose of advancing justice in health systems, could do so through exposing structural barriers to health justice, amplifying local voices and fostering epistemic justice in knowledge production.

The influence of Türkiye’s foreign strategy far exceeds what its national size would normally predict, making it a particularly notable manifestation of strategic autonomy in twenty-first-century international politics. Türkiye has put this strategic autonomy into practice in several ways: by pursuing transactional diplomacy to recalibrate relations with its traditional Western allies; applying realist approaches to deepen its involvement in the Syrian crisis; engaging in parallel strategic bargaining with the USA, Europe, and Russia in the Black Sea region; and projecting both hard and soft power beyond the Western world. This paper argues that as the structural factors and systemic environment shaping Türkiye’s practice of strategic autonomy undergo accelerated change, its foreign strategy will further illuminate how middle powers influence global governance and international politics. More broadly, it points towards a longer-term trajectory marked by the decentralisation of power both internationally and regionally, together with a renewed prominence of realism.

Existing evidence demonstrates the benefits of integrated palliative care for people with cancer and their carers, for improved symptom burden, quality of life and appropriate healthcare resource use. The integration of palliative care and oncology has the potential to improve the quality of life and is recommended by international guidelines. However, it is not yet consistent practice. There are many approaches to integration, but it is unclear what works, for whom and in what contexts to achieve the best possible outcomes for people with cancer, carers and healthcare systems. To conduct a realist synthesis to develop a programme theory of how integrated palliative care in cancer works, for whom and in what contexts to achieve improved symptom management and increased quality of life for people with cancer and their carers. To use the programme theory to coproduce, with stakeholders (e.g. patient and public involvement representatives, local, national, international content experts and multidisciplinary practitioners), guidance to inform delivery of best practice and guide future research. Realist review, conducted in accordance with Realist and Meta-narrative Evidence Synthesis: Evolving Standards. Evidence was identified through systematically searching academic databases and through stakeholder engagement. Data were extracted from included articles and were synthesised using a realist logic of analysis to develop explanations of how and why integrated palliative care in oncology works, for whom and in what contexts. One hundred and sixty-four papers from 33 countries were included in the review. Integrated palliative care and oncology could improve people with cancer's outcomes, increase the goal-concordance of care and support workforce well-being. Interventions to support integration should be tailored to the context in which they are delivered. Ensuring the timely delivery of palliative care for people with cancer requires integration that overcomes siloes between oncology, specialist palliative care and primary and community care. The motivation to prioritise the integration of palliative care relies upon all stakeholders first understanding its value. Enriched interdisciplinary collaboration involves developing confidence in their own and their colleagues' skillsets, facilitating co-ordination between care settings and supporting communication within and between teams. Supportive leadership could promote an institutional culture of acceptance of the value of integrating palliative care into oncology management. The realist approach to analysis means that findings are based on our interpretation of the data. To manage the high volume of studies, we limited inclusion to documents published since 2010, using qualitative, mixed or economic methods; therefore, we may have excluded relevant documents. The success of integration is influenced by the ways in which palliative care is understood, prioritised, operationalised and measured within oncology. Through the synthesis of international evidence, this project draws on implementation science to contribute clarity on how integrated palliative care and cancer care can be achieved in practice. Future work should use the implications and recommendations to initiate and optimise palliative care in oncology management. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR152115.

Palliative care is required for all life-threatening diagnoses, aiming to prevent and reduce patients' experienced total pain, hence improving the quality of life for both patients and their relatives. Providing palliative care at home and facilitating home deaths is challenging. Norwegian authorities recognise insufficient competence among healthcare professionals as a factor within this area. To elucidate how healthcare professionals experience their utilisation of individual competencies when providing palliative end-of-life care at home. A qualitative study was performed in the Norwegian home care service. Ten individual semi-structured interviews with healthcare professionals were conducted. Data were analysed using reflexive thematic analysis, employing a critical realist approach. Three themes were developed: (1) Being the right person for the job, (2) The patient is more than a diagnosis and (3) Supporting relatives along the journey. Healthcare professionals' individual competencies made them well-suited to provide palliative care, enabled them to recognise patients as unique individuals, and facilitated essential support and empowerment of their relatives. Important individual competencies among healthcare professionals were personal intuition, compassion, attentiveness, respect, flexibility and open-mindedness. The right healthcare professionals for providing palliative end-of-life care at home must utilise their individual competencies to seamlessly unite the art of caring with the science of palliative medicine. By doing this, healthcare professionals can better fulfil the aims of palliative care and provide high-quality care for patients.

Sexual minority adolescents experience elevated rates of psychological distress, influenced by societal stigma and heteronormativity. Psychological therapists can play a key role in supporting identity development and advocating for systemic change. This study explored therapists' lived experiences of working with sexual minority adolescents, attending to both reported experiences and deeper social mechanisms. A qualitative study using a critical realist approach to thematic analysis that integrated inductive coding with abductive and retroductive theorising. Seven UK-based psychological therapists participated in semi-structured interviews conducted between January and March 2024. Analysis examined both dispositional and inferential themes, exploring both surface experiences and deeper social mechanisms shaping participants' experiences. Three dispositional themes were generated: (1) therapists' experiences of socio-environmental forces shaping adolescent sexuality; (2) the striving to offer attuned, responsive therapy; and (3) the influence of socio-political tensions on navigating identity-related work. The analysis suggests that the therapeutic process functions as a relational shield against conflicting structural forces. By centring this relational process to navigate developmental fluidity, effective practice relied on agential striving to protect the adolescent's narrative from external agendas. This involved fundamental clinical skills: creating a non-judgemental space, using compassionate curiosity, and maintaining awareness of relational pulls and assumptions. Socio-political structures are often enacted within the therapy room, presenting both challenges and opportunities for therapeutic work. The findings suggest that therapy functions as a mediating space, shielding adolescents' developing identities from polarisation and stigma. This highlights the ethical necessity of maintaining a protected process in a politicised climate.

The World Health Organization's Framework on Integrated, People-Centred Health Services (IPCHS) proposes five interdependent strategies to guide health system transformation. In low- and middle-income countries (LMICs), implementation of IPCHS is often fragmented due to limited understanding of how its strategies interact in practice. Community Health Workers (CHWs), situated between households and formal health systems, offer a unique lens to examine these dynamics. This study used a multi-phase realist approach, integrating a realist synthesis and two realist evaluations in KwaZulu-Natal, South Africa. Findings from each phase contributed to refining an initial programme theory into a dynamic, mechanism-sensitive model that captures how IPCHS strategies function interdependently. Findings were analysed using context-mechanism-outcome (CMO) configurations. Systems thinking tools, including causal loop diagrams, were used to visualise mechanism chaining and feedback loops across system levels and strategies. Three cross-cutting meta-mechanisms: trust, motivation, and professional legitimacy (with institutional support) were found to underpin CHW performance across all five IPCHS strategies. These mechanisms interacted recursively, meaning activation or erosion of one affected others. People-centred care is not the outcome of any single strategy but rather emerges from the alignment and interaction of mechanisms triggered by multiple strategies in different contexts. When mechanisms align, they reinforce CHW performance and advance IPCHS; when misaligned, they contribute to system fragility and poor outcomes. People-centred care is an emergent property of aligned, interacting IPCHS strategies, as opposed to isolated interventions. Further research should test and refine the proposed mechanism-sensitive approach to implementing the IPCHS framework.

ABSTRACT In this article, I aim to make a theoretical and conceptual contribution to greening international relations theory by rethinking the relationship between nature, society, and the international through a critical realist approach. I conceptualize the international as a distinctive socio-material form of being that emerges from the historically constituted mutual conditioning between natural processes and social relations of production, which cannot, however, be reduced either to natural processes or to soc ial relations of production taken in isolation. Bringing critical realism into dialogue with historical materialism, I draw on metabolic rift theory as an analytical framework that reveals the historically specific social origins of ecological destruction. I do so in three interconnected ways: (1) defining the international in terms of socio-ecological diversity, (2) uncovering the socio-ecological origins of the international, and (3) clarifying how historically specific intersocietal relations generate ecological destruction and condition the possibilities for transformative praxis.

BackgroundExercise programmes are an important component of comprehensive cardiac rehabilitation (CR). High Intensity Interval Training (HIIT) has been proposed as an alternative to conventional moderate intensity steady state (MISS) exercise. In the ‘HIIT or MISS UK’ trial, low-volume HIIT was safe, and clinically and cost effective. However, there is a lack of insight into the lived experiences of those who engage in non-conventional approaches to CR exercise training. The aim of this research was to explore the benefits and challenges associated with HIIT and MISS in CR.Materials and methodsA qualitative descriptive methodology was adopted to document participant lived experiences. Participants were purposefully recruited from two ‘HIIT or MISS UK’ trial CR centres. After consent, participants took part in semi-structured interviews conducted via Voice over Internet Protocol (VoIP) technologies (e.g., Microsoft Teams (MT), Skype or Zoom). A critical realist approach to inductive thematic analysis was used to analyse the data.Findings19 people took part (8 MISS and 11 HIIT; male 18 [95%]; age 59.6 years [SD 10.4]). Analysis revealed a range of perceived psychosocial (e.g., enjoyment, confidence, purpose) and physiological (e.g., weight loss, increased fitness) benefits that were present across both groups (i.e., HIIT and MISS). Participants in both groups identified challenges, for example, a need for exercise to continue beyond what was offered in the trial. There were notable differences across the groups, namely HIIT participants enjoyed feeling challenged, yet grappled with feelings of monotony, whilst MISS participants experienced increased social interaction.ConclusionHIIT in CR offered a range of perceived psychosocial and physiological benefits. Integrating more opportunities for social interaction into the HIIT program could enhance participant experience. Practitioners could investigate the feasibility of support for patients after CR has finished.

Older people from ethnic minority communities are disproportionately affected by the risks of polypharmacy due to higher levels of multiple long-term conditions, unequal access to care, and communication barriers. Medicine optimisation is a key approach to improving prescribing and outcomes, but how it works for older people from ethnic minority communities in primary care remains poorly understood. To explore how, why, and under what circumstances medicine optimisation works or does not work for older people from ethnic minority communities with polypharmacy, from the perspective of primary care practitioners. A realist evaluation using semi-structured realist interviews with primary care practitioners in England and Wales. We conducted seventeen interviews with GPs, clinical pharmacists, community pharmacists, and practice nurses. We analysed the data using a realist approach to refine and extend an initial programme theory developed through a prior realist review. Seventeen primary care practitioners participated, representing diverse professional roles, ethnic backgrounds, and levels of experience. Analysis identified 18 context-mechanism-outcome configurations, organised into five areas: practitioner strategies, patient beliefs and stigma, communication and language support, informal carer involvement, and system constraints (especially time pressure and remote consultations). Medicine optimisation worked well when practitioners showed respect, adapted communication to cultural and language contexts, and negotiated family involvement. Barriers included stigma, deference to authority, reliance on herbal beliefs, language limitations, and informal carer burden. Improving medicine optimisation for older people from ethnic minority communities requires relationship-based, context-sensitive care. These findings offer theory-based insights for UK primary care.

Mindfulness-based programs (MBPs) are a promising approach to enhancing elite athlete wellbeing, yet little is known about the mechanisms through which they exert their effects. Guided by a critical realist approach, we qualitatively explored mechanisms of change during an 8-week MBP (the Mindfulness for Wellbeing program) delivered to 13 elite athletes (8 females, 5 males; M age = 22.23). Data were drawn from participants’ stated intentions, practice notes, and semistructured interviews, and analyzed using reflexive thematic analysis. We generated four themes: (1) Wellbeing intentions guide wellbeing outcomes; (2) Developing moment-to-moment awareness to improve positive affect and autonomy; (3) Attending to bodily and sensory experience to support emotional regulation and disengagement from thoughts; and (4) Cultivating self-compassion to enhance growth in sport and personal life. These findings provide contextual insight into further refinement of MBPs to better promote and protect mental wellbeing in elite athletes or other athlete populations.

Purpose Context is increasingly recognised as a central determinant of whether integrated care interventions succeed or fail. Yet the proliferation of contextual analysis frameworks with different epistemological perspectives and empirical applications has created uncertainty about how to make sense of context in complex health and social care systems. This paper critically compares thirteen influential frameworks to examine how they conceptualise, assess and operationalise context for integrated care implementation. Design/methodology/approach A structured and theory-informed comparative analysis was undertaken. Frameworks were purposively selected based on relevance to health and social care, conceptual clarity, empirical use and applicability to complex or multi-level settings. Each framework was examined across five analytical dimensions: epistemological foundations, conceptual structure, methodological guidance, empirical application and relevance to integrated care. An interpretive synthesis approach enabled cross-framework comparison without collapsing diverse paradigms into a single model. Findings Frameworks varied substantially in their assumptions about knowledge, causality, and system behaviour. While tools such as CFIR and Theoretical Domains Framework offer structured and widely used taxonomies, newer frameworks; including ICON, CICI, NASSS and the Context Coding Framework, better reflect the dynamic, relational and cross-boundary nature of integrated care. Participatory and realist approaches add value through attention to mechanisms, reflexivity and power, but often lack procedural guidance. No single framework fully captures the multi-level and emergent properties of integrated care systems highlighting the need for purposeful combination rather than substitution. Practical implications The analysis highlights the need for hybrid and adaptive approaches to contextual analysis, supported by greater epistemological awareness and attention to power, equity and inter-organisational dynamics. The paper offers guidance for selecting and combining frameworks depending on purpose, stage of implementation and system context. Originality/value To our knowledge, this is the first study to systematically compare contextual frameworks through the lens of integrated care. It provides conceptual orientation and practical sensemaking to support more context-sensitive, adaptive and relational approaches to integrated care implementation.

Women GPs experience higher rates of burnout, anxiety, depression, and slower career progression than men GPs. Women GPs are sought out by patients for specific conditions, which may increase consultation length. This can be a source of job satisfaction for some. However it can also contribute to additional exhaustion and affects career progression, meaning women GPs are at higher risk of leaving the profession. There is an urgent need to identify solutions to retain and support them. This review brings together a wide range of evidence to identify the conditions in which women GPs can thrive, to better support them at work. An international realist review of academic and grey literature across eight databases and Google Scholar. Following a realist approach, supported by stakeholder and patient involvement, a range of published documents were analysed using a realist logic to identify how, why, for whom and in what circumstances women GPs thrive at work. A total of 72 documents are included in this review. Sixteen configurations describe the conditions in which women GPs can thrive. Results cover three concepts: 'Patient-facing work'; 'Navigating competing roles'; and 'Sustainable careers, leadership and success'. However, literature also places heavy reliance on encouraging women GPs to 'fix' their own circumstances. This review provides evidence-based recommendations which may be of interest to those responsible for organisational culture within general practices, including (but not limited to) GP partners, and women GPs, who can utilise the recommendations to influence change.

Global trends indicate an increasing number of women training as doctors. However this is not a group who appear to be thriving at work. Women GPs are at high risk of leaving the profession, experience higher rates of burnout, anxiety and depression and slower career progression than male counterparts. Existing research shows that patients value being seen by women GPs, and this staff group focus more on an individual's care needs while spending longer with them. This may contribute to their burnout and intention to leave the profession. Women GPs are also more likely to work part-time, affecting their career progression. This has implications for women GPs, employers, and patient care including quality and safety. This review brings together a wide range of evidence to identify the conditions in which women GPs can thrive at work to better recruit, support and retain them. Taking a realist approach to reviewing existing evidence, a range of published documents on the topic have been analysed using a realist logic to identify how, why, for whom and in what contexts women GPs thrive at work. A total of 54 documents were included in this review. Eighteen statements (CMOCs) describe a range of conditions in which women GPs both thrive and don't. Results span across three core concepts including Navigating competing roles; Patient facing work; and Sustainable careers, leadership and success. These findings are likely to interest GPs, including GP partners and those responsible for organisational culture within general practices.

Background The optimal performance of doctors is critical to delivering high-quality, safe healthcare. However, 6–12% of doctors may experience challenges that impact their work performance. In many countries, including the UK, there is variation in the practice and quality of professional support services between different types of organisations. The aims of our study were (1) to identify why, how, in what contexts and for whom professional support works, (2) to develop a guide for healthcare organisations to use to optimise professional support. Methods We carried out a realist evaluation consistent with Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) II standards. 45 interviews were conducted with professional support staff and doctors who had undertaken professional support across seven sites in England. Interviews were analysed using a realist logic. To develop the guide, six workshops were held with the same groups plus a patient and public involvement group. Results We identified six principles of effective professional support, based on 47 context-mechanism-outcome configurations. (1) Work-place culture influences support-seeking behaviour. (2) Trust and psychological safety are central to enable candid conversations and engagement. (3) Doctors can then develop self-awareness and situational awareness, reframe challenges, accept responsibility where appropriate and recognise structural factors underpinning their difficulties. (4) Doctors are more likely to feel motivated to engage through positive framing. (5) Personal and professional growth occurs when doctors are empowered to make changes to their practice. (6) Cultures that stigmatise help-seeking undermine support, while those that model vulnerability and normalise support enhance the likelihood of positive outcomes. Conclusions Our guide provides step-by-step advice to identify key actions for those delivering professional support . Since the realist approach identifies principles and causal explanations, the findings are likely transferable to other settings/countries.

As the pax Americana inevitably disintegrates, enemies probe along its frontier, and the frontier states must choose how to respond. Russia attacked the European perimeter’s Ukrainian buffer zone. Hungary, a small frontier state, has chosen to maintain friendly economic and diplomatic relations with Russia. One interpretation suggests that Hungary’s Russia policy is a product of Hungary’s history as a small nation surviving amidst hostile empires, and the Hungarian government’s realist approach to foreign affairs. An alternative interpretation suggests that Hungary’s Russia policy is a function of Russia’s capture of key Hungarian elites. This article presents Hungarian foreign policy experts’ views on Russia. The author interviewed these experts in the Summer of 2025.

BACKGROUND: We present the protocol for the AUDACE realist mixed methods evaluation of the BCM2.0 occupational therapy and assistive device programme. The BCM2.0 (“Bien chez moi 2.0”) programme provides occupational therapy sessions and assistive devices to support older people who want to age in place. We designed the AUDACE evaluation to improve understanding of the programme and its effectiveness, and to promote a favourable context for the professional empowerment of occupational therapists as primary care providers. METHODS: We involved home care occupational therapists at every stage of the protocol design to ensure that the tools, training, and organisational structures put in place for the evaluation could also form the basis of their routine practice, harmonising their practices, ethos and processes. We designed a realist mixed methods evaluation to answer the following question: "How, for whom and why do assistive devices, integrated with occupational therapy support, enable older people to remain at home, and under what conditions?" Interrelated components addressed different research sub-questions: (1a) To describe the evaluation population, interventions, and contexts: a descriptive quantitative study using baseline data from all BCM2.0 beneficiaries. (1b) To describe the frailty process in older people receiving the programme: a qualitative study using semi-structured individual interviews with a biographical dimension. (2) To explore the enrolment process: focus groups with occupational therapists, following a realist approach. (3) To assess effectiveness: a prospective cohort study with up to 12 months follow-up of all BCM2.0 beneficiaries. (4) To identify barriers and facilitators to implementation: multiple nested case study in five areas, using a realist approach. (5) To build a learning community to clarify ethical considerations: communities of practice meetings. DISCUSSION: The inclusion of occupational therapists in the design and implementation process ensured that the evaluation met their needs. This led to the development of a participatory action research protocol that improved the quality of the evaluation and supported the professional development of occupational therapists. TRIAL REGISTRATION: Primary Registry and Trial Identifying Number: https://clinicaltrials.gov/study/NCT06819982 Date of Registration in Primary Registry: February 11, 2025.

In 2022, the British Medical Ultrasound Society (BMUS) launched their Preceptorship and Capability Development Framework, the first document of its kind for sonographers and an important professional milestone. Since the framework's publication, its functionality in practice has not been evaluated. To address this gap, a preliminary realist evaluation was conducted. Its aim was to advance our understanding of why the framework 'works' (or not), how, for whom, in what context, and to what extent. As a preliminary realist enquiry, the central objective was to elicit initial programme theories (IPTs) about how the framework effects change (intended or otherwise) in different contexts. The IPTs were generated 'retroductively'. First, the incarnate theories embedded within the framework were inductively surfaced. Then, these were deductively tested in two semi-structured focus groups, comprising eight participants. Themes were surfaced using thematic analysis, from which IPTs emerged as 'context-mechanism-outcome' configurations (CMOCs). The analysis surfaced three core themes: structured, systems thinking approach; human factors; and boundary-spanning benefits. From these, thirty-five IPTs emerged in the form of CMOCs, capturing the causal pathways between contexts, mechanisms, and outcomes. Preceptorship should be a priority for the ultrasound workforce: it helps to future-proof the profession, solidify sonographer identity, elevate the professional profile, and demonstrate self-regulation. This study advances the preceptorship agenda by evaluating the framework and offering valuable insights into its 'real world' functionality. The surfacing of IPTs as functional units (CMOCs) narrows the knowledge-to-practice gap; because stakeholders can discern which outcomes are triggered in which circumstances, they can target their efforts accordingly. As such, the study has important implications for practice, as its design and outputs facilitate the development of holistic implementation strategies.

Background: YiPEE (Youth co-Production for sustainable Engagement and Empowerment in health) is a collaborative research initiative focusing on improving young people’s mental health through a co-designed multi-level school-based intervention, with inner, social, and environmental components, in urban settings in India (Chennai), Kenya (Nairobi), South Africa (Cape Town), and Sweden (Stockholm). Successful co-creation is known to generate highly contextualized, locally relevant and feasible solutions. However, little is known on how and why co-creation works, under which conditions and for whom. We aim to unravel these aspects by evaluating the co-design workshops organised across all four urban settings, in which the multi-component school-based intervention is collaboratively developed by adolescents, teachers, and stakeholders from the broader school environment. Approach: We adopt a realist approach to test an initial programme theory (IPT) based on the Normalization Process Theory (NPT) and Self-Determination Theory (SDT). The IPT will be tested and refined, for each site, using data from multiple workshop participants, including observers, facilitators, and participants in the workshops. Information from the different sources is triangulated and synthesized into the Intervention-Context-Actor-Mechanism-Outcome (ICAMO) configurational framework. Results: In the realist approach, the program theory consolidates causal explanations in the form of ICAMO configurations, which explain how interventions (I) within/and contexts (C) allow (or not) the emergence of mechanisms (M) in actors (A) that produce outcomes (O). The overarching goals of the workshop sessions were linked to the four constructs of the NPT: coherence (youth as interpreters), cognitive participation (youth as co-designers), collective action (youth as participants and implementers) and reflective monitoring (youth as researchers). We anticipate identifying multiple contextual factors (C) that facilitate engagement (O) of participants (A) by triggering NPT- and SDT-related mechanisms such as coherence (M), cognitive participation (M), collective action (M) and reflective monitoring (M), as well as perceived autonomy/agency (M), social connection/relatedness (M) and competence (M). Co-creation will be phased across the different study sites, allowing for iterative learning, theorizing on theory consolidation, and eventual scale-up. Implications: We expect this study to provide new understanding of how and why co-creation works, for whom, and under which real-world conditions. The study aims to offer fresh insights into the study of co-creation by integrating implementation science theory and realist evaluation.

Background: Chronic obstructive pulmonary disease (COPD) is the most common chronic medical condition leading to hospitalization and is also the most expensive at an estimated 30% higher cost than the next leading cause, with an estimated 1 in 10 people in Saskatchewan (SK) living with COPD. Approach: The SK Transforming Health with Integrated Care (THINC) implementation science team (IST) has undertaken this evaluation with the primary goal of providing insight to the Saskatchewan Health Authority (SHA) to optimize COPD care in SK through the use of provincial clinical networks (PCN) including an integrated care pathway (ICP), delivered by the SHA. The goal of PCNs is to provide effective coordination and integration of service delivery in a team-based care model to improve both patient and provider outcomes. The IST, co-led by patient partners and comprised of researchers, SHA policymakers and knowledge users, healthcare providers, and health system collaborators aims to provide a realist evaluation of the implementation of the COPD ICP delivery within PCNs. A realist approach allows for the evaluation of how, why, under what circumstances, and for whom the ICP works (or does not work). With 38 primary health networks in SK with diverse populations and demographics, and varying levels of maturity, this approach will provide timely and relevant information for the SHA to optimize delivery to a local context and ensure sustainability. Results: In the first phase of this evaluation project, the IST undertook realist training for all team members, including patient partners, taking the first step to increase capacity within the IST. Following initial training, the IST iteratively developed initial program theories for both patients and healthcare providers based on a realist literature review to explain how, why, under what circumstances, and for whom integrated clinical pathways work. In the current phase of this research, the initial program theories will be refined iteratively through discussions with the various groups impacted (patients, policy-makers and healthcare providers). These final program theories will be essential in the understanding of the pathway implementation and will provide valuable information for successful scaling and can also be translated to the implementation of PCNs for other domains in the future. Implications: Due to the early establishment of a team governance charter, and developing and fostering relational equity, the IST has successfully navigated a dynamic healthcare system while focusing on the primary goal of this research, to improve healthcare quality and outcomes for both patients and healthcare providers. Through the use of a realist methodology that is rooted in patient-centered care, the SHA is better poised to provide inclusive, responsive care in a sustainable, adaptable way. This research will serve as a template to address further chronic disease management in our province.