This review is set out in seven distinct steps; it is acknowledged that realist reviews incorporate iterative cycles within the steps outlined below as well as engagement with the literature and stakeholders with relevant knowledge. The review flow diagram is illustrated in Fig 1.
Step 1: Define the review scope and locate existing theories.
A small-scale study was conducted to understand the views and experiences of implementing ISC approaches from the implementor’s point of view in Assam, India and compare that with the globally available literature to better understand ISC (Aivalli et al., 2023, under review). The findings from this study were used as a base to elicit the Initial Programme Theory (IPT) for the review. The resulting IPTs are illustrated in Fig 2. Based on the findings, an initial scoping search was conducted to identify initial theories that explain and develop an understanding of power dynamics within ISC. This stage was crucial to make the underpinning assumptions explicit about why certain components and processes of ISC are required to achieve one or more desired outcomes (e.g., collaborated action, integrated care or a greater degree of engagement among the stakeholders, implementation success or failure). Following the realist review methodology (52), these theories will be explored in two main ways 1) by drawing on exploratory searches of relevant literature in continual cycles and 2) by consulting with key stakeholders.
The review will commence with the broad question: how do power dynamics between different stakeholders of different sectors influence the collaboration which can influence the implementation of intersectoral health interventions? More specific questions include what contextual factors facilitate or hinder the ISC and why? What mechanisms are triggered by these contextual factors, and how do these mechanisms lead to greater implementation or poor implementation? Consistent with best practices in realist reviews and significant findings from the qualitative study (Aivalli et al), five Initial Programme Theories (IPTs) were developed for testing in the realist review process. Comments and feedback received from the stakeholders will be incorporated to further refine and finalise the IPT. This IPT will serve as a framework for data collection and analysis during the review process. Relevant substantive theories from the literature related to organisation collaboration, leadership, and collaborative theories will be considered at this stage.
Stakeholder group input: Our stakeholder group will include (1) internationally-renowned ISC/ researchers, (2) middle-level programme implementors from a national nutrition programme; (3) and expert realist researchers. The stakeholder group will provide feedback on the IPT which will further narrow the scope of the review. We will consult with stakeholders regarding which CMOs to prioritise in the review and ask for additional evidence in accordance with our available time and resources (53). For the purpose of this review, power dynamics in ISC refers to the mechanism that facilitates or hinders the collaboration between and among the stakeholders of different sectors involved in implementing intersectoral health programmes (54,55).
Step 2: Literature search and case study to identify & develop Candidate IPTs
The extant literature searches will be guided by the initial programme theory developed in Step 1. A systematic search of peer-reviewed literature will be conducted in four databases: Medline, Embase, CINAHL, and Web of Science. Searches will also be performed in Google and Google Scholar to identify additional relevant resources. Search results from 01 January 2012 to 31 May 2023 published in English will be included for the review (see Table 1).
Table 1 Initial search terms
Concept 1: Power dynamics
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Decision mak* OR power dynamic* OR Power relation OR communication OR Hierarch* OR trust OR respect OR Dominance OR interpersonal relation* OR Recognition OR Role Clarity OR Role Appreciation OR Role Conflict OR Authorit* OR communication OR Hierarch* OR Power OR Decision effective* OR Decision Comprehensiv*
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AND
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Concept 2: Intersectoral
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Intersect* OR multisect*l OR Multi-sectoral OR Cross sect* OR Cross-sectoral OR Intersectoral action OR Multisectoral action OR interdepartmental OR interministerial OR multiparty OR public-private OR intergovernmental OR integrated governance OR integrated governance OR interorgani*
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AND
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Concept 3: collaboration
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Collaborat* OR Harmonisation OR Cooperat* OR Coherence OR Partnership* OR Coordinat* OR Coalition OR Convergence OR Alliance OR Linkage*
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A search of the bibliographies and citations of retrieved peer-reviewed articles will also be conducted to identify other pertinent studies that were not found through the initial database searches (56). Based on the extensiveness and depth of the identified literature in our searches, the research team (in consultation with the stakeholder group) will determine if additional searches are required (e.g., with modified search terms and/or additional databases.) The search process in a realist review is iterative, and any subsequent alterations in focus, search terms, or strategy will be documented as they occur (49,56-58). Additional searches will be aimed at identifying the specific elements of contexts, mechanisms, outcomes and their interactions in our initial programme theory, to provide more detailed and specific explanations of the developing CMOs.
Step 3: Article selection, screening, relevancy, rigour and richness
The identified articles will be exported to Covidence (59), an online tool for managing literature reviews where duplicate articles will be removed. Two reviewers will conduct title and abstract, and full-text screening for the identified resources. In realist reviews, the unit of analysis is not the entirety of a study but the evidentiary fragments in the study (53). While the rigour of data in a traditional systematic review is often based on the plausibility of the methods through which the data were generated (60,61), in realist reviews, data can be drawn from any part of a paper, not just the results section (62). The most important decision to be made about data quality is the contribution each paper can make to building and refining the programme theory, usually stemming from the ‘pieces’ of data and not the entire body of the paper (63). Rigour in realist reviews refers to the credibility, plausibility and trustworthiness of the methods used to generate data or a theory and depends on two criteria: trustworthiness (how much the methods used to obtain data are plausible and can be trusted) and coherence (whether the data are consistent and logical with explanatory breadth) (63,64). However, to ensure the relevance and rigour of the studies, studies will be classified into primary contributors and secondary contributors based on the amount of relevant information available after the screening. The following steps will be followed for screening:
- The screening by title and abstracts and then by full text will be undertaken by the lead author and a second researcher in Covidence (59).
- Any disagreements will be resolved by discussion between the researchers. Unresolved disagreements will be decided by a third member of the research team.
- Assessment of relevance, richness and rigour will focus on the extent to which sources provide a detailed description of their methods and how generalisable and trustworthy their findings are based on those methods (65).
- Each paper’s characteristics will be recorded in Covidence during data extraction, including (1) bibliographic details: title, author, journal and year of publication; (2) study type and design; and (3) target population, intervention and type of programme, as well as generative causation in the form of Cs, Ms and Os and notes/observations on the paper.
Formal criteria for classifying the potential relevancy of sources are by ascending order of relevancy.
Primary contributors
- The source which contributes to the study aim and is conducted in the LMICs context
- Sources insufficiently explain ISC, but the power dynamics (a mechanism) causing an effect on the ISC will be considered.
Secondary contributors
- Sources which contribute to study aims and can clearly help to identify mechanisms which could plausibly operate in the context of LMICs
- Sources which contribute to the study aims and are conducted in a non-hospital-based setting with a similar context
Primary relevance papers will be prioritised as per the above criteria. These sources will then be sorted into the above categories in Covidence and assessed for their ability to inform the refinement of programme theories (theoretical relevancy and conceptual richness). If there is insufficient data to develop and refine aspects of programme theory from primary relevant sources, secondary relevancy criteria will be considered to draw sufficient data to develop IPT.
Inclusion criteria:
- Peer-reviewed articles (empirical research) relevant to understanding one or more aspects of power dynamics (including but not limited to power relations, hierarchy, psychological safety, communication, interpersonal relations, recognition, role clarity, role conflict, interpersonal influence and dominance) will be considered for review.
- Articles must contain sufficient information relevant to the elucidation of CMO configurations (i.e., information about context, mechanism and outcome and their interaction).
- Outcome measures: both intended and unintended outcomes of power dynamics in ISC will be explored.
Exclusion criteria:
- Research not related to intersectoral or cross-departmental collaboration.
- Research articles have only briefly mentioned ISC but with no further details on how dimensions of power influenced the ISC.
- The research focused only on one sector, not explaining the interaction with another sector.
- Studies set in non-LMIC contexts.
- Previous systematic, literature, narrative, and realist reviews will be excluded.
Step 4: Data Extraction and Analysis
A data extraction form will be developed based on the IPTs and the aims of the review. This will be reviewed and refined throughout the review process as necessary. The following data will be extracted from the studies and cases identified for inclusion: setting and mentioning of power aspect in intersectoral collaboration and its impact on the implementation of ISC health policies, any models or theoretical frameworks that informed the power dynamics, and the CMOCs of the impact of power on ISC. Data providing evidence to confirm, refute, or refine the IPTs will be documented as well as notes on this decision-making process and any potential knock-on effects or linkages to other IPTs/relevant findings. Two reviewers will independently extract an initial sample of documents and compare them. A small sample of data extraction forms will also be shared with the stakeholder committee for feedback and refinement. We will use NVivo V.12 software to support qualitative data analysis (66,67). Relevant sections of texts that have been extracted as related to contexts, mechanisms and/or their relationships to outcomes will be coded and organised in NVivo V.12. Coding will be both inductive (codes created to categorise data reported in included sources) and deductive (codes created in advance of data extraction and analysis as informed by the initial programme theory). Each new element of relevant data will be used to test and refine aspects of the programme theory. As it is refined, included sources will be re-examined to search for data relevant to the revised programme theory that may have been missed initially. This is consistent with the iterative and retroductive approach to analysis within the realist approach (68,69). The goal of the review will be to reach theoretical saturation in relation to the objectives rather than to aggregate every single study in the area. Using the coding and analysis process, the literature considered to make a ‘primary’, the most relevant contribution to the research questions will be considered to start building and refining our programme theory. Articles categorised as providing ‘secondary’ contributions will be held back and analysed if no ‘primary’ study sheds light on certain aspects of the programme theory. All study-related decisions will be documented and recorded to increase transparency and ensure consistency and rigour.
Step 5: Synthesis, forming CMOs & programme theory
The data analysis process will involve finding generative causation along with identifying elements of context, mechanism, outcome and their inter-relationships in the data fragments (70). Data will be interrogated at team, sector, organisational or policy levels to establish their relationships. Both quantitative and qualitative data will be used to identify any of these elements (71). For instance, to identify mechanisms, qualitative data obtained from interviews can be a pathway to identifying participants’ reasoning. At the same time, a multiple-choice question in a questionnaire survey can be used for the same purpose (70,71). Outcomes can be identified through quantitative data, while in certain cases, such as identifying unintended outcomes, qualitative data might prove useful (70,71) For example, the participants’ reasoning occurs in their minds and might not be explicit in the selected data. Therefore, the identification of mechanisms can be made by using ‘retroduction’ method, an analytic technique to uncover hidden causal factors lying behind the identified patterns. (72) Retroduction encompasses induction (developing theories from empirical evidence), deduction (testing theories against the evidence) and abduction (creative thinking). (69,72) Identifying the interactions between the elements of context, mechanism and outcome is imperative in realist reviews and has been emphasised by realist researchers (73). The identified CMOs will be used to test and refine the IPT. Relevant formal theories supporting these CMOs will be sought to advance our realist programme theory at the middle-range level, allowing our findings to be transferable to similar contexts (74,75).
Step 6: Testing and refining theory and dissemination
The stakeholder group will be consulted regarding the final programme theory/theories; their feedback will be sought to further improve and finalise the realist programme theory. At this stage, any or all of the review steps may be revisited as necessary to refine the programme theory and attain ‘theoretical saturation’. The threshold for ‘theoretical saturation’ will be determined according to Pawson’s ‘test of saturation’ (52,63). After each cycle of review steps, the research team will determine whether the latest cycle has provided additional information about the intervention to answer the research questions and test the programme theory. The stopping point for the review will be determined when ‘theoretical saturation’ is reached when the addition of documents and repetition of steps are not adding further knowledge (52). Following this, recommendations will be made to policymakers, programme managers, and implementors on how to address the power imbalances in ISC approaches for better intersectoral action and sustainability, including reference to evidence-based strategies elucidated in the review.
Ethics declarations
This study is a review and synthesis of the literature. No patients or the public will be directly involved in this study. A stakeholder committee will be engaged to provide feedback and guidance based on their relevant experience and expertise but no data will be collected from them. Hence, institutional ethics approval is not required for this review.