Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol

Climate Change and Sustainability in Health... | HRB Open Research dataLayer = dataLayer || []; // Standard GTM initialization - Google Consent Mode handles consent automatically (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src= 'https://www.googletagmanager.com/gtm.js?id='+i+dl+ '>m_auth=hzk0Vc3qFsQYhCrIoHz68A>m_preview=env-1>m_cookies_win=x';f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-MWFK8L5J'); ;window.NREUM||(NREUM={});NREUM.init={distributed_tracing:{enabled:true},privacy:{cookies_enabled:true},ajax:{deny_list:["bam.nr-data.net"]}}; ;NREUM.loader_config={accountID:"438030",trustKey:"438030",agentID:"772317073",licenseKey:"97f8f67f26",applicationID:"772317073"} ;NREUM.info={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net",licenseKey:"97f8f67f26",applicationID:"772317073",sa:1} ;/*! For license information please see nr-loader-spa-1.236.0.min.js.LICENSE.txt */ (()=>{"use strict";var e,t,r={5763:(e,t,r)=>{r.d(t,{P_:()=>l,Mt:()=>g,C5:()=>s,DL:()=>v,OP:()=>T,lF:()=>D,Yu:()=>y,Dg:()=>h,CX:()=>c,GE:()=>b,sU:()=>_});var n=r(8632),i=r(9567);const o={beacon:n.ce.beacon,errorBeacon:n.ce.errorBeacon,licenseKey:void 0,applicationID:void 0,sa:void 0,queueTime:void 0,applicationTime:void 0,ttGuid:void 0,user:void 0,account:void 0,product:void 0,extra:void 0,jsAttributes:{},userAttributes:void 0,atts:void 0,transactionName:void 0,tNamePlain:void 0},a={};function s(e){if(!e)throw new Error("All info objects require an agent identifier!");if(!a[e])throw new Error("Info for ".concat(e," was never set"));return a[e]}function c(e,t){if(!e)throw new Error("All info objects require an agent identifier!");a[e]=(0,i.D)(t,o),(0,n.Qy)(e,a[e],"info")}var u=r(7056);const d=()=>{const e={blockSelector:"[data-nr-block]",maskInputOptions:{password:!0}};return{allow_bfcache:!0,privacy:{cookies_enabled:!0},ajax:{deny_list:void 0,enabled:!0,harvestTimeSeconds:10},distributed_tracing:{enabled:void 0,exclude_newrelic_header:void 0,cors_use_newrelic_header:void 0,cors_use_tracecontext_headers:void 0,allowed_origins:void 0},session:{domain:void 0,expiresMs:u.oD,inactiveMs:u.Hb},ssl:void 0,obfuscate:void 0,jserrors:{enabled:!0,harvestTimeSeconds:10},metrics:{enabled:!0},page_action:{enabled:!0,harvestTimeSeconds:30},page_view_event:{enabled:!0},page_view_timing:{enabled:!0,harvestTimeSeconds:30,long_task:!1},session_trace:{enabled:!0,harvestTimeSeconds:10},harvest:{tooManyRequestsDelay:60},session_replay:{enabled:!1,harvestTimeSeconds:60,sampleRate:.1,errorSampleRate:.1,maskTextSelector:"*",maskAllInputs:!0,get blockClass(){return"nr-block"},get ignoreClass(){return"nr-ignore"},get maskTextClass(){return"nr-mask"},get blockSelector(){return e.blockSelector},set blockSelector(t){e.blockSelector+=",".concat(t)},get maskInputOptions(){return e.maskInputOptions},set maskInputOptions(t){e.maskInputOptions={...t,password:!0}}},spa:{enabled:!0,harvestTimeSeconds:10}}},f={};function l(e){if(!e)throw new Error("All configuration objects require an agent identifier!");if(!f[e])throw new Error("Configuration for ".concat(e," was never set"));return f[e]}function h(e,t){if(!e)throw new Error("All configuration objects require an agent identifier!");f[e]=(0,i.D)(t,d()),(0,n.Qy)(e,f[e],"config")}function g(e,t){if(!e)throw new Error("All configuration objects require an agent identifier!");var r=l(e);if(r){for(var n=t.split("."),i=0;i {r.d(t,{D:()=>i});var n=r(50);function i(e,t){try{if(!e||"object"!=typeof e)return(0,n.Z)("Setting a Configurable requires an object as input");if(!t||"object"!=typeof t)return(0,n.Z)("Setting a Configurable requires a model to set its initial properties");const r=Object.create(Object.getPrototypeOf(t),Object.getOwnPropertyDescriptors(t)),o=0===Object.keys(r).length?e:r;for(let a in o)if(void 0!==e[a])try{"object"==typeof e[a]&&"object"==typeof t[a]?r[a]=i(e[a],t[a]):r[a]=e[a]}catch(e){(0,n.Z)("An error occurred while setting a property of a Configurable",e)}return r}catch(e){(0,n.Z)("An error occured while setting a Configurable",e)}}},6818:(e,t,r)=>{r.d(t,{Re:()=>i,gF:()=>o,q4:()=>n});const n="1.236.0",i="PROD",o="CDN"},385:(e,t,r)=>{r.d(t,{FN:()=>a,IF:()=>u,Nk:()=>f,Tt:()=>s,_A:()=>o,il:()=>n,pL:()=>c,v6:()=>i,w1:()=>d});const n="undefined"!=typeof window&&!!window.document,i="undefined"!=typeof WorkerGlobalScope&&("undefined"!=typeof self&&self instanceof WorkerGlobalScope&&self.navigator instanceof WorkerNavigator||"undefined"!=typeof globalThis&&globalThis instanceof WorkerGlobalScope&&globalThis.navigator instanceof WorkerNavigator),o=n?window:"undefined"!=typeof WorkerGlobalScope&&("undefined"!=typeof self&&self instanceof WorkerGlobalScope&&self||"undefined"!=typeof globalThis&&globalThis instanceof WorkerGlobalScope&&globalThis),a=""+o?.location,s=/iPad|iPhone|iPod/.test(navigator.userAgent),c=s&&"undefined"==typeof SharedWorker,u=(()=>{const e=navigator.userAgent.match(/Firefox[/\s](\d+\.\d+)/);return Array.isArray(e)&&e.length>=2?+e[1]:0})(),d=Boolean(n&&window.document.documentMode),f=!!navigator.sendBeacon},1117:(e,t,r)=>{r.d(t,{w:()=>o});var n=r(50);const i={agentIdentifier:"",ee:void 0};class o{constructor(e){try{if("object"!=typeof e)return(0,n.Z)("shared context requires an object as input");this.sharedContext={},Object.assign(this.sharedContext,i),Object.entries(e).forEach((e=>{let[t,r]=e;Object.keys(i).includes(t)&&(this.sharedContext[t]=r)}))}catch(e){(0,n.Z)("An error occured while setting SharedContext",e)}}}},8e3:(e,t,r)=>{r.d(t,{L:()=>d,R:()=>c});var n=r(2177),i=r(1284),o=r(4322),a=r(3325);const s={};function c(e,t){const r={staged:!1,priority:a.p[t]||0};u(e),s[e].get(t)||s[e].set(t,r)}function u(e){e&&(s[e]||(s[e]=new Map))}function d(){let e=arguments.length>0&&void 0!==arguments[0]?arguments[0]:"",t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:"feature";if(u(e),!e||!s[e].get(t))return a(t);s[e].get(t).staged=!0;const r=[...s[e]];function a(t){const r=e?n.ee.get(e):n.ee,a=o.X.handlers;if(r.backlog&&a){var s=r.backlog[t],c=a[t];if(c){for(var u=0;s&&u {let[t,r]=e;return r.staged}))&&(r.sort(((e,t)=>e[1].priority-t[1].priority)),r.forEach((e=>{let[t]=e;a(t)})))}function f(e,t){var r=e[1];(0,i.D)(t[r],(function(t,r){var n=e[0];if(r[0]===n){var i=r[1],o=e[3],a=e[2];i.apply(o,a)}}))}},2177:(e,t,r)=>{r.d(t,{c:()=>f,ee:()=>u});var n=r(8632),i=r(2210),o=r(1284),a=r(5763),s="nr@context";let c=(0,n.fP)();var u;function d(){}function f(e){return(0,i.X)(e,s,l)}function l(){return new d}function h(){u.aborted=!0,u.backlog={}}c.ee?u=c.ee:(u=function e(t,r){var n={},c={},f={},g=!1;try{g=16===r.length&&(0,a.OP)(r).isolatedBacklog}catch(e){}var p={on:b,addEventListener:b,removeEventListener:y,emit:v,get:x,listeners:w,context:m,buffer:A,abort:h,aborted:!1,isBuffering:E,debugId:r,backlog:g?{}:t&&"object"==typeof t.backlog?t.backlog:{}};return p;function m(e){return e&&e instanceof d?e:e?(0,i.X)(e,s,l):l()}function v(e,r,n,i,o){if(!1!==o&&(o=!0),!u.aborted||i){t&&o&&t.emit(e,r,n);for(var a=m(n),s=w(e),d=s.length,f=0;fn,p:()=>i});var n=r(2177).ee.get("handle");function i(e,t,r,i,o){o?(o.buffer([e],i),o.emit(e,t,r)):(n.buffer([e],i),n.emit(e,t,r))}},4322:(e,t,r)=>{r.d(t,{X:()=>o});var n=r(5546);o.on=a;var i=o.handlers={};function o(e,t,r,o){a(o||n.E,i,e,t,r)}function a(e,t,r,i,o){o||(o="feature"),e||(e=n.E);var a=t[o]=t[o]||{};(a[r]=a[r]||[]).push([e,i])}},3239:(e,t,r)=>{r.d(t,{bP:()=>s,iz:()=>c,m$:()=>a});var n=r(385);let i=!1,o=!1;try{const e={get passive(){return i=!0,!1},get signal(){return o=!0,!1}};n._A.addEventListener("test",null,e),n._A.removeEventListener("test",null,e)}catch(e){}function a(e,t){return i||o?{capture:!!e,passive:i,signal:t}:!!e}function s(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2],n=arguments.length>3?arguments[3]:void 0;window.addEventListener(e,t,a(r,n))}function c(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2],n=arguments.length>3?arguments[3]:void 0;document.addEventListener(e,t,a(r,n))}},4402:(e,t,r)=>{r.d(t,{Ht:()=>u,M:()=>c,Rl:()=>a,ky:()=>s});var n=r(385);const i="xxxxxxxx-xxxx-4xxx-yxxx-xxxxxxxxxxxx";function o(e,t){return e?15&e[t]:16*Math.random()|0}function a(){const e=n._A?.crypto||n._A?.msCrypto;let t,r=0;return e&&e.getRandomValues&&(t=e.getRandomValues(new Uint8Array(31))),i.split("").map((e=>"x"===e?o(t,++r).toString(16):"y"===e?(3&o()|8).toString(16):e)).join("")}function s(e){const t=n._A?.crypto||n._A?.msCrypto;let r,i=0;t&&t.getRandomValues&&(r=t.getRandomValues(new Uint8Array(31)));const a=[];for(var s=0;s {r.d(t,{Bq:()=>n,Hb:()=>o,oD:()=>i});const n="NRBA",i=144e5,o=18e5},7894:(e,t,r)=>{function n(){return Math.round(performance.now())}r.d(t,{z:()=>n})},7243:(e,t,r)=>{r.d(t,{e:()=>o});var n=r(385),i={};function o(e){if(e in i)return i[e];if(0===(e||"").indexOf("data:"))return{protocol:"data"};let t;var r=n._A?.location,o={};if(n.il)t=document.createElement("a"),t.href=e;else try{t=new URL(e,r.href)}catch(e){return o}o.port=t.port;var a=t.href.split("://");!o.port&&a[1]&&(o.port=a[1].split("/")[0].split("@").pop().split(":")[1]),o.port&&"0"!==o.port||(o.port="https"===a[0]?"443":"80"),o.hostname=t.hostname||r.hostname,o.pathname=t.pathname,o.protocol=a[0],"/"!==o.pathname.charAt(0)&&(o.pathname="/"+o.pathname);var s=!t.protocol||":"===t.protocol||t.protocol===r.protocol,c=t.hostname===r.hostname&&t.port===r.port;return o.sameOrigin=s&&(!t.hostname||c),"/"===o.pathname&&(i[e]=o),o}},50:(e,t,r)=>{function n(e,t){"function"==typeof console.warn&&(console.warn("New Relic: ".concat(e)),t&&console.warn(t))}r.d(t,{Z:()=>n})},2587:(e,t,r)=>{r.d(t,{N:()=>c,T:()=>u});var n=r(2177),i=r(5546),o=r(8e3),a=r(3325);const s={stn:[a.D.sessionTrace],err:[a.D.jserrors,a.D.metrics],ins:[a.D.pageAction],spa:[a.D.spa],sr:[a.D.sessionReplay,a.D.sessionTrace]};function c(e,t){const r=n.ee.get(t);e&&"object"==typeof e&&(Object.entries(e).forEach((e=>{let[t,n]=e;void 0===u[t]&&(s[t]?s[t].forEach((e=>{n?(0,i.p)("feat-"+t,[],void 0,e,r):(0,i.p)("block-"+t,[],void 0,e,r),(0,i.p)("rumresp-"+t,[Boolean(n)],void 0,e,r)})):n&&(0,i.p)("feat-"+t,[],void 0,void 0,r),u[t]=Boolean(n))})),Object.keys(s).forEach((e=>{void 0===u[e]&&(s[e]?.forEach((t=>(0,i.p)("rumresp-"+e,[!1],void 0,t,r))),u[e]=!1)})),(0,o.L)(t,a.D.pageViewEvent))}const u={}},2210:(e,t,r)=>{r.d(t,{X:()=>i});var n=Object.prototype.hasOwnProperty;function i(e,t,r){if(n.call(e,t))return e[t];var i=r();if(Object.defineProperty&&Object.keys)try{return Object.defineProperty(e,t,{value:i,writable:!0,enumerable:!1}),i}catch(e){}return e[t]=i,i}},1284:(e,t,r)=>{r.d(t,{D:()=>n});const n=(e,t)=>Object.entries(e||{}).map((e=>{let[r,n]=e;return t(r,n)}))},4351:(e,t,r)=>{r.d(t,{P:()=>o});var n=r(2177);const i=()=>{const e=new WeakSet;return(t,r)=>{if("object"==typeof r&&null!==r){if(e.has(r))return;e.add(r)}return r}};function o(e){try{return JSON.stringify(e,i())}catch(e){try{n.ee.emit("internal-error",[e])}catch(e){}}}},3960:(e,t,r)=>{r.d(t,{K:()=>a,b:()=>o});var n=r(3239);function i(){return"undefined"==typeof document||"complete"===document.readyState}function o(e,t){if(i())return e();(0,n.bP)("load",e,t)}function a(e){if(i())return e();(0,n.iz)("DOMContentLoaded",e)}},8632:(e,t,r)=>{r.d(t,{EZ:()=>u,Qy:()=>c,ce:()=>o,fP:()=>a,gG:()=>d,mF:()=>s});var n=r(7894),i=r(385);const o={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net"};function a(){return i._A.NREUM||(i._A.NREUM={}),void 0===i._A.newrelic&&(i._A.newrelic=i._A.NREUM),i._A.NREUM}function s(){let e=a();return e.o||(e.o={ST:i._A.setTimeout,SI:i._A.setImmediate,CT:i._A.clearTimeout,XHR:i._A.XMLHttpRequest,REQ:i._A.Request,EV:i._A.Event,PR:i._A.Promise,MO:i._A.MutationObserver,FETCH:i._A.fetch}),e}function c(e,t,r){let i=a();const o=i.initializedAgents||{},s=o[e]||{};return Object.keys(s).length||(s.initializedAt={ms:(0,n.z)(),date:new Date}),i.initializedAgents={...o,[e]:{...s,[r]:t}},i}function u(e,t){a()[e]=t}function d(){return function(){let e=a();const t=e.info||{};e.info={beacon:o.beacon,errorBeacon:o.errorBeacon,...t}}(),function(){let e=a();const t=e.init||{};e.init={...t}}(),s(),function(){let e=a();const t=e.loader_config||{};e.loader_config={...t}}(),a()}},7956:(e,t,r)=>{r.d(t,{N:()=>i});var n=r(3239);function i(e){let t=arguments.length>1&&void 0!==arguments[1]&&arguments[1],r=arguments.length>2?arguments[2]:void 0,i=arguments.length>3?arguments[3]:void 0;return void(0,n.iz)("visibilitychange",(function(){if(t)return void("hidden"==document.visibilityState&&e());e(document.visibilityState)}),r,i)}},1214:(e,t,r)=>{r.d(t,{em:()=>v,u5:()=>N,QU:()=>S,_L:()=>I,Gm:()=>L,Lg:()=>M,gy:()=>U,BV:()=>Q,Kf:()=>ee});var n=r(2177);const i="nr@original";var o=Object.prototype.hasOwnProperty,a=!1;function s(e,t){return e||(e=n.ee),r.inPlace=function(e,t,n,i,o){n||(n="");var a,s,c,u="-"===n.charAt(0);for(c=0;c 2?n-2:0),o=2;o {r(A[T],e,w),r(E[T],e,w)})),r(l._A,"fetch",y),t.on(y+"end",(function(e,r){var n=this;if(r){var i=r.headers.get("content-length");null!==i&&(n.rxSize=i),t.emit(y+"done",[null,r],n)}else t.emit(y+"done",[e],n)})),t}const O={},j=["pushState","replaceState"];function S(e){const t=function(e){return(e||n.ee).get("history")}(e);return!l.il||O[t.debugId]++||(O[t.debugId]=1,s(t).inPlace(window.history,j,"-")),t}var P=r(3239);const C={},R=["appendChild","insertBefore","replaceChild"];function I(e){const t=function(e){return(e||n.ee).get("jsonp")}(e);if(!l.il||C[t.debugId])return t;C[t.debugId]=!0;var r=s(t),i=/[?&](?:callback|cb)=([^&#]+)/,o=/(.*)\.([^.]+)/,a=/^(\w+)(\.|$)(.*)$/;function c(e,t){var r=e.match(a),n=r[1],i=r[3];return i?c(i,t[n]):t[n]}return r.inPlace(Node.prototype,R,"dom-"),t.on("dom-start",(function(e){!function(e){if(!e||"string"!=typeof e.nodeName||"script"!==e.nodeName.toLowerCase())return;if("function"!=typeof e.addEventListener)return;var n=(a=e.src,s=a.match(i),s?s[1]:null);var a,s;if(!n)return;var u=function(e){var t=e.match(o);if(t&&t.length>=3)return{key:t[2],parent:c(t[1],window)};return{key:e,parent:window}}(n);if("function"!=typeof u.parent[u.key])return;var d={};function f(){t.emit("jsonp-end",[],d),e.removeEventListener("load",f,(0,P.m$)(!1)),e.removeEventListener("error",l,(0,P.m$)(!1))}function l(){t.emit("jsonp-error",[],d),t.emit("jsonp-end",[],d),e.removeEventListener("load",f,(0,P.m$)(!1)),e.removeEventListener("error",l,(0,P.m$)(!1))}r.inPlace(u.parent,[u.key],"cb-",d),e.addEventListener("load",f,(0,P.m$)(!1)),e.addEventListener("error",l,(0,P.m$)(!1)),t.emit("new-jsonp",[e.src],d)}(e[0])})),t}var k=r(5763);const H={};function L(e){const t=function(e){return(e||n.ee).get("mutation")}(e);if(!l.il||H[t.debugId])return t;H[t.debugId]=!0;var r=s(t),i=k.Yu.MO;return i&&(window.MutationObserver=function(e){return this instanceof i?new i(r(e,"fn-")):i.apply(this,arguments)},MutationObserver.prototype=i.prototype),t}const z={};function M(e){const t=function(e){return(e||n.ee).get("promise")}(e);if(z[t.debugId])return t;z[t.debugId]=!0;var r=n.c,o=s(t),a=k.Yu.PR;return a&&function(){function e(r){var n=t.context(),i=o(r,"executor-",n,null,!1);const s=Reflect.construct(a,[i],e);return t.context(s).getCtx=function(){return n},s}l._A.Promise=e,Object.defineProperty(e,"name",{value:"Promise"}),e.toString=function(){return a.toString()},Object.setPrototypeOf(e,a),["all","race"].forEach((function(r){const n=a[r];e[r]=function(e){let i=!1;[...e||[]].forEach((e=>{this.resolve(e).then(a("all"===r),a(!1))}));const o=n.apply(this,arguments);return o;function a(e){return function(){t.emit("propagate",[null,!i],o,!1,!1),i=i||!e}}}})),["resolve","reject"].forEach((function(r){const n=a[r];e[r]=function(e){const r=n.apply(this,arguments);return e!==r&&t.emit("propagate",[e,!0],r,!1,!1),r}})),e.prototype=a.prototype;const n=a.prototype.then;a.prototype.then=function(){var e=this,i=r(e);i.promise=e;for(var a=arguments.length,s=new Array(a),c=0;c e())),t};function m(e,t){i.inPlace(t,["onreadystatechange"],"fn-",E)}function b(){var e=this,t=r.context(e);e.readyState>3&&!t.resolved&&(t.resolved=!0,r.emit("xhr-resolved",[],e)),i.inPlace(e,f,"fn-",E)}if(function(e,t){for(var r in e)t[r]=e[r]}(o,p),p.prototype=o.prototype,i.inPlace(p.prototype,J,"-xhr-",E),r.on("send-xhr-start",(function(e,t){m(e,t),function(e){h.push(e),a&&(y?y.then(A):u?u(A):(w=-w,x.data=w))}(t)})),r.on("open-xhr-start",m),a){var y=c&&c.resolve();if(!u&&!c){var w=1,x=document.createTextNode(w);new a(A).observe(x,{characterData:!0})}}else t.on("fn-end",(function(e){e[0]&&e[0].type===d||A()}));function A(){for(var e=0;e {r.d(t,{t:()=>n});const n=r(3325).D.ajax},6660:(e,t,r)=>{r.d(t,{A:()=>i,t:()=>n});const n=r(3325).D.jserrors,i="nr@seenError"},3081:(e,t,r)=>{r.d(t,{gF:()=>o,mY:()=>i,t9:()=>n,vz:()=>s,xS:()=>a});const n=r(3325).D.metrics,i="sm",o="cm",a="storeSupportabilityMetrics",s="storeEventMetrics"},4649:(e,t,r)=>{r.d(t,{t:()=>n});const n=r(3325).D.pageAction},7633:(e,t,r)=>{r.d(t,{Dz:()=>i,OJ:()=>a,qw:()=>o,t9:()=>n});const n=r(3325).D.pageViewEvent,i="firstbyte",o="domcontent",a="windowload"},9251:(e,t,r)=>{r.d(t,{t:()=>n});const n=r(3325).D.pageViewTiming},3614:(e,t,r)=>{r.d(t,{BST_RESOURCE:()=>i,END:()=>s,FEATURE_NAME:()=>n,FN_END:()=>u,FN_START:()=>c,PUSH_STATE:()=>d,RESOURCE:()=>o,START:()=>a});const n=r(3325).D.sessionTrace,i="bstResource",o="resource",a="-start",s="-end",c="fn"+a,u="fn"+s,d="pushState"},7836:(e,t,r)=>{r.d(t,{BODY:()=>A,CB_END:()=>E,CB_START:()=>u,END:()=>x,FEATURE_NAME:()=>i,FETCH:()=>_,FETCH_BODY:()=>v,FETCH_DONE:()=>m,FETCH_START:()=>p,FN_END:()=>c,FN_START:()=>s,INTERACTION:()=>l,INTERACTION_API:()=>d,INTERACTION_EVENTS:()=>o,JSONP_END:()=>b,JSONP_NODE:()=>g,JS_TIME:()=>T,MAX_TIMER_BUDGET:()=>a,REMAINING:()=>f,SPA_NODE:()=>h,START:()=>w,originalSetTimeout:()=>y});var n=r(5763);const i=r(3325).D.spa,o=["click","submit","keypress","keydown","keyup","change"],a=999,s="fn-start",c="fn-end",u="cb-start",d="api-ixn-",f="remaining",l="interaction",h="spaNode",g="jsonpNode",p="fetch-start",m="fetch-done",v="fetch-body-",b="jsonp-end",y=n.Yu.ST,w="-start",x="-end",A="-body",E="cb"+x,T="jsTime",_="fetch"},5938:(e,t,r)=>{r.d(t,{W:()=>o});var n=r(5763),i=r(2177);class o{constructor(e,t,r){this.agentIdentifier=e,this.aggregator=t,this.ee=i.ee.get(e,(0,n.OP)(this.agentIdentifier).isolatedBacklog),this.featureName=r,this.blocked=!1}}},9144:(e,t,r)=>{r.d(t,{j:()=>m});var n=r(3325),i=r(5763),o=r(5546),a=r(2177),s=r(7894),c=r(8e3),u=r(3960),d=r(385),f=r(50),l=r(3081),h=r(8632);function g(){const e=(0,h.gG)();["setErrorHandler","finished","addToTrace","inlineHit","addRelease","addPageAction","setCurrentRouteName","setPageViewName","setCustomAttribute","interaction","noticeError","setUserId"].forEach((t=>{e[t]=function(){for(var r=arguments.length,n=new Array(r),i=0;i 1?r-1:0),i=1;i {e.exposed&&e.api[t]&&o.push(e.api[t](...n))})),o.length>1?o:o[0]}(t,...n)}}))}var p=r(2587);function m(e){let t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:{},m=arguments.length>2?arguments[2]:void 0,v=arguments.length>3?arguments[3]:void 0,{init:b,info:y,loader_config:w,runtime:x={loaderType:m},exposed:A=!0}=t;const E=(0,h.gG)();y||(b=E.init,y=E.info,w=E.loader_config),(0,i.Dg)(e,b||{}),(0,i.GE)(e,w||{}),(0,i.sU)(e,x),y.jsAttributes??={},d.v6&&(y.jsAttributes.isWorker=!0),(0,i.CX)(e,y),g();const T=function(e,t){t||(0,c.R)(e,"api");const h={};var g=a.ee.get(e),p=g.get("tracer"),m="api-",v=m+"ixn-";function b(t,r,n,o){const a=(0,i.C5)(e);return null===r?delete a.jsAttributes[t]:(0,i.CX)(e,{...a,jsAttributes:{...a.jsAttributes,[t]:r}}),x(m,n,!0,o||null===r?"session":void 0)(t,r)}function y(){}["setErrorHandler","finished","addToTrace","inlineHit","addRelease"].forEach((e=>h[e]=x(m,e,!0,"api"))),h.addPageAction=x(m,"addPageAction",!0,n.D.pageAction),h.setCurrentRouteName=x(m,"routeName",!0,n.D.spa),h.setPageViewName=function(t,r){if("string"==typeof t)return"/"!==t.charAt(0)&&(t="/"+t),(0,i.OP)(e).customTransaction=(r||"http://custom.transaction")+t,x(m,"setPageViewName",!0)()},h.setCustomAttribute=function(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2];if("string"==typeof e){if(["string","number"].includes(typeof t)||null===t)return b(e,t,"setCustomAttribute",r);(0,f.Z)("Failed to execute setCustomAttribute.\nNon-null value must be a string or number type, but a type of was provided."))}else(0,f.Z)("Failed to execute setCustomAttribute.\nName must be a string type, but a type of was provided."))},h.setUserId=function(e){if("string"==typeof e||null===e)return b("enduser.id",e,"setUserId",!0);(0,f.Z)("Failed to execute setUserId.\nNon-null value must be a string type, but a type of was provided."))},h.interaction=function(){return(new y).get()};var w=y.prototype={createTracer:function(e,t){var r={},i=this,a="function"==typeof t;return(0,o.p)(v+"tracer",[(0,s.z)(),e,r],i,n.D.spa,g),function(){if(p.emit((a?"":"no-")+"fn-start",[(0,s.z)(),i,a],r),a)try{return t.apply(this,arguments)}catch(e){throw p.emit("fn-err",[arguments,this,"string"==typeof e?new Error(e):e],r),e}finally{p.emit("fn-end",[(0,s.z)()],r)}}}};function x(e,t,r,i){return function(){return(0,o.p)(l.xS,["API/"+t+"/called"],void 0,n.D.metrics,g),i&&(0,o.p)(e+t,[(0,s.z)(),...arguments],r?null:this,i,g),r?void 0:this}}function A(){r.e(439).then(r.bind(r,7438)).then((t=>{let{setAPI:r}=t;r(e),(0,c.L)(e,"api")})).catch((()=>(0,f.Z)("Downloading runtime APIs failed...")))}return["actionText","setName","setAttribute","save","ignore","onEnd","getContext","end","get"].forEach((e=>{w[e]=x(v,e,void 0,n.D.spa)})),h.noticeError=function(e,t){"string"==typeof e&&(e=new Error(e)),(0,o.p)(l.xS,["API/noticeError/called"],void 0,n.D.metrics,g),(0,o.p)("err",[e,(0,s.z)(),!1,t],void 0,n.D.jserrors,g)},d.il?(0,u.b)((()=>A()),!0):A(),h}(e,v);return(0,h.Qy)(e,T,"api"),(0,h.Qy)(e,A,"exposed"),(0,h.EZ)("activatedFeatures",p.T),T}},3325:(e,t,r)=>{r.d(t,{D:()=>n,p:()=>i});const n={ajax:"ajax",jserrors:"jserrors",metrics:"metrics",pageAction:"page_action",pageViewEvent:"page_view_event",pageViewTiming:"page_view_timing",sessionReplay:"session_replay",sessionTrace:"session_trace",spa:"spa"},i={[n.pageViewEvent]:1,[n.pageViewTiming]:2,[n.metrics]:3,[n.jserrors]:4,[n.ajax]:5,[n.sessionTrace]:6,[n.pageAction]:7,[n.spa]:8,[n.sessionReplay]:9}}},n={};function i(e){var t=n[e];if(void 0!==t)return t.exports;var o=n[e]={exports:{}};return r[e](o,o.exports,i),o.exports}i.m=r,i.d=(e,t)=>{for(var r in t)i.o(t,r)&&!i.o(e,r)&&Object.defineProperty(e,r,{enumerable:!0,get:t[r]})},i.f={},i.e=e=>Promise.all(Object.keys(i.f).reduce(((t,r)=>(i.f[r](e,t),t)),[])),i.u=e=>(({78:"page_action-aggregate",147:"metrics-aggregate",242:"session-manager",317:"jserrors-aggregate",348:"page_view_timing-aggregate",412:"lazy-feature-loader",439:"async-api",538:"recorder",590:"session_replay-aggregate",675:"compressor",733:"session_trace-aggregate",786:"page_view_event-aggregate",873:"spa-aggregate",898:"ajax-aggregate"}[e]||e)+"."+{78:"ac76d497",147:"3dc53903",148:"1a20d5fe",242:"2a64278a",317:"49e41428",348:"bd6de33a",412:"2f55ce66",439:"30bd804e",538:"1b18459f",590:"cf0efb30",675:"ae9f91a8",733:"83105561",786:"06482edd",860:"03a8b7a5",873:"e6b09d52",898:"998ef92b"}[e]+"-1.236.0.min.js"),i.o=(e,t)=>Object.prototype.hasOwnProperty.call(e,t),e={},t="NRBA:",i.l=(r,n,o,a)=>{if(e[r])e[r].push(n);else{var s,c;if(void 0!==o)for(var u=document.getElementsByTagName("script"),d=0;d {s.onerror=s.onload=null,clearTimeout(h);var i=e[r];if(delete e[r],s.parentNode&&s.parentNode.removeChild(s),i&&i.forEach((e=>e(n))),t)return t(n)},h=setTimeout(l.bind(null,void 0,{type:"timeout",target:s}),12e4);s.onerror=l.bind(null,s.onerror),s.onload=l.bind(null,s.onload),c&&document.head.appendChild(s)}},i.r=e=>{"undefined"!=typeof Symbol&&Symbol.toStringTag&&Object.defineProperty(e,Symbol.toStringTag,{value:"Module"}),Object.defineProperty(e,"__esModule",{value:!0})},i.j=364,i.p="https://js-agent.newrelic.com/",(()=>{var e={364:0,953:0};i.f.j=(t,r)=>{var n=i.o(e,t)?e[t]:void 0;if(0!==n)if(n)r.push(n[2]);else{var o=new Promise(((r,i)=>n=e[t]=[r,i]));r.push(n[2]=o);var a=i.p+i.u(t),s=new Error;i.l(a,(r=>{if(i.o(e,t)&&(0!==(n=e[t])&&(e[t]=void 0),n)){var o=r&&("load"===r.type?"missing":r.type),a=r&&r.target&&r.target.src;s.message="Loading chunk "+t+" failed.\n("+o+": "+a+")",s.name="ChunkLoadError",s.type=o,s.request=a,n[1](s)}}),"chunk-"+t,t)}};var t=(t,r)=>{var n,o,[a,s,c]=r,u=0;if(a.some((t=>0!==e[t]))){for(n in s)i.o(s,n)&&(i.m[n]=s[n]);if(c)c(i)}for(t&&t(r);u {i.r(o);var e=i(3325),t=i(5763);const r=Object.values(e.D);function n(e){const n={};return r.forEach((r=>{n[r]=function(e,r){return!1!==(0,t.Mt)(r,"".concat(e,".enabled"))}(r,e)})),n}var a=i(9144);var s=i(5546),c=i(385),u=i(8e3),d=i(5938),f=i(3960),l=i(50);class h extends d.W{constructor(e,t,r){let n=!(arguments.length>3&&void 0!==arguments[3])||arguments[3];super(e,t,r),this.auto=n,this.abortHandler,this.featAggregate,this.onAggregateImported,n&&(0,u.R)(e,r)}importAggregator(){let e=arguments.length>0&&void 0!==arguments[0]?arguments[0]:{};if(this.featAggregate||!this.auto)return;const r=c.il&&!0===(0,t.Mt)(this.agentIdentifier,"privacy.cookies_enabled");let n;this.onAggregateImported=new Promise((e=>{n=e}));const o=async()=>{let t;try{if(r){const{setupAgentSession:e}=await Promise.all([i.e(860),i.e(242)]).then(i.bind(i,3228));t=e(this.agentIdentifier)}}catch(e){(0,l.Z)("A problem occurred when starting up session manager. This page will not start or extend any session.",e)}try{if(!this.shouldImportAgg(this.featureName,t))return void(0,u.L)(this.agentIdentifier,this.featureName);const{lazyFeatureLoader:r}=await i.e(412).then(i.bind(i,8582)),{Aggregate:o}=await r(this.featureName,"aggregate");this.featAggregate=new o(this.agentIdentifier,this.aggregator,e),n(!0)}catch(e){(0,l.Z)("Downloading and initializing ".concat(this.featureName," failed..."),e),this.abortHandler?.(),n(!1)}};c.il?(0,f.b)((()=>o()),!0):o()}shouldImportAgg(r,n){return r!==e.D.sessionReplay||!1!==(0,t.Mt)(this.agentIdentifier,"session_trace.enabled")&&(!!n?.isNew||!!n?.state.sessionReplay)}}var g=i(7633),p=i(7894);class m extends h{static featureName=g.t9;constructor(r,n){let i=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];if(super(r,n,g.t9,i),("undefined"==typeof PerformanceNavigationTiming||c.Tt)&&"undefined"!=typeof PerformanceTiming){const n=(0,t.OP)(r);n[g.Dz]=Math.max(Date.now()-n.offset,0),(0,f.K)((()=>n[g.qw]=Math.max((0,p.z)()-n[g.Dz],0))),(0,f.b)((()=>{const t=(0,p.z)();n[g.OJ]=Math.max(t-n[g.Dz],0),(0,s.p)("timing",["load",t],void 0,e.D.pageViewTiming,this.ee)}))}this.importAggregator()}}var v=i(1117),b=i(1284);class y extends v.w{constructor(e){super(e),this.aggregatedData={}}store(e,t,r,n,i){var o=this.getBucket(e,t,r,i);return o.metrics=function(e,t){t||(t={count:0});return t.count+=1,(0,b.D)(e,(function(e,r){t[e]=w(r,t[e])})),t}(n,o.metrics),o}merge(e,t,r,n,i){var o=this.getBucket(e,t,n,i);if(o.metrics){var a=o.metrics;a.count+=r.count,(0,b.D)(r,(function(e,t){if("count"!==e){var n=a[e],i=r[e];i&&!i.c?a[e]=w(i.t,n):a[e]=function(e,t){if(!t)return e;t.c||(t=x(t.t));return t.min=Math.min(e.min,t.min),t.max=Math.max(e.max,t.max),t.t+=e.t,t.sos+=e.sos,t.c+=e.c,t}(i,a[e])}}))}else o.metrics=r}storeMetric(e,t,r,n){var i=this.getBucket(e,t,r);return i.stats=w(n,i.stats),i}getBucket(e,t,r,n){this.aggregatedData[e]||(this.aggregatedData[e]={});var i=this.aggregatedData[e][t];return i||(i=this.aggregatedData[e][t]={params:r||{}},n&&(i.custom=n)),i}get(e,t){return t?this.aggregatedData[e]&&this.aggregatedData[e][t]:this.aggregatedData[e]}take(e){for(var t={},r="",n=!1,i=0;i t.max&&(t.max=e),e 2&&void 0!==arguments[2])||arguments[2];super(e,r,j.t,n),c.il&&((0,t.OP)(e).initHidden=Boolean("hidden"===document.visibilityState),(0,N.N)((()=>(0,s.p)("docHidden",[(0,p.z)()],void 0,j.t,this.ee)),!0),(0,O.bP)("pagehide",(()=>(0,s.p)("winPagehide",[(0,p.z)()],void 0,j.t,this.ee))),this.importAggregator())}}var P=i(3081);class C extends h{static featureName=P.t9;constructor(e,t){let r=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];super(e,t,P.t9,r),this.importAggregator()}}var R,I=i(2210),k=i(1214),H=i(2177),L={};try{R=localStorage.getItem("__nr_flags").split(","),console&&"function"==typeof console.log&&(L.console=!0,-1!==R.indexOf("dev")&&(L.dev=!0),-1!==R.indexOf("nr_dev")&&(L.nrDev=!0))}catch(e){}function z(e){try{L.console&&z(e)}catch(e){}}L.nrDev&&H.ee.on("internal-error",(function(e){z(e.stack)})),L.dev&&H.ee.on("fn-err",(function(e,t,r){z(r.stack)})),L.dev&&(z("NR AGENT IN DEVELOPMENT MODE"),z("flags: "+(0,b.D)(L,(function(e,t){return e})).join(", ")));var M=i(6660);class B extends h{static featureName=M.t;constructor(r,n){let i=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];super(r,n,M.t,i),this.skipNext=0;try{this.removeOnAbort=new AbortController}catch(e){}const o=this;o.ee.on("fn-start",(function(e,t,r){o.abortHandler&&(o.skipNext+=1)})),o.ee.on("fn-err",(function(t,r,n){o.abortHandler&&!n[M.A]&&((0,I.X)(n,M.A,(function(){return!0})),this.thrown=!0,(0,s.p)("err",[n,(0,p.z)()],void 0,e.D.jserrors,o.ee))})),o.ee.on("fn-end",(function(){o.abortHandler&&!this.thrown&&o.skipNext>0&&(o.skipNext-=1)})),o.ee.on("internal-error",(function(t){(0,s.p)("ierr",[t,(0,p.z)(),!0],void 0,e.D.jserrors,o.ee)})),this.origOnerror=c._A.onerror,c._A.onerror=this.onerrorHandler.bind(this),c._A.addEventListener("unhandledrejection",(t=>{const r=function(e){let t="Unhandled Promise Rejection: ";if(e instanceof Error)try{return e.message=t+e.message,e}catch(t){return e}if(void 0===e)return new Error(t);try{return new Error(t+(0,D.P)(e))}catch(e){return new Error(t)}}(t.reason);(0,s.p)("err",[r,(0,p.z)(),!1,{unhandledPromiseRejection:1}],void 0,e.D.jserrors,this.ee)}),(0,O.m$)(!1,this.removeOnAbort?.signal)),(0,k.gy)(this.ee),(0,k.BV)(this.ee),(0,k.em)(this.ee),(0,t.OP)(r).xhrWrappable&&(0,k.Kf)(this.ee),this.abortHandler=this.#e,this.importAggregator()}#e(){this.removeOnAbort?.abort(),this.abortHandler=void 0}onerrorHandler(t,r,n,i,o){"function"==typeof this.origOnerror&&this.origOnerror(...arguments);try{this.skipNext?this.skipNext-=1:(0,s.p)("err",[o||new F(t,r,n),(0,p.z)()],void 0,e.D.jserrors,this.ee)}catch(t){try{(0,s.p)("ierr",[t,(0,p.z)(),!0],void 0,e.D.jserrors,this.ee)}catch(e){}}return!1}}function F(e,t,r){this.message=e||"Uncaught error with no additional information",this.sourceURL=t,this.line=r}let U=1;const q="nr@id";function G(e){const t=typeof e;return!e||"object"!==t&&"function"!==t?-1:e===c._A?0:(0,I.X)(e,q,(function(){return U++}))}function V(e){if("string"==typeof e&&e.length)return e.length;if("object"==typeof e){if("undefined"!=typeof ArrayBuffer&&e instanceof ArrayBuffer&&e.byteLength)return e.byteLength;if("undefined"!=typeof Blob&&e instanceof Blob&&e.size)return e.size;if(!("undefined"!=typeof FormData&&e instanceof FormData))try{return(0,D.P)(e).length}catch(e){return}}}var X=i(7243);class W{constructor(e){this.agentIdentifier=e,this.generateTracePayload=this.generateTracePayload.bind(this),this.shouldGenerateTrace=this.shouldGenerateTrace.bind(this)}generateTracePayload(e){if(!this.shouldGenerateTrace(e))return null;var r=(0,t.DL)(this.agentIdentifier);if(!r)return null;var n=(r.accountID||"").toString()||null,i=(r.agentID||"").toString()||null,o=(r.trustKey||"").toString()||null;if(!n||!i)return null;var a=(0,_.M)(),s=(0,_.Ht)(),c=Date.now(),u={spanId:a,traceId:s,timestamp:c};return(e.sameOrigin||this.isAllowedOrigin(e)&&this.useTraceContextHeadersForCors())&&(u.traceContextParentHeader=this.generateTraceContextParentHeader(a,s),u.traceContextStateHeader=this.generateTraceContextStateHeader(a,c,n,i,o)),(e.sameOrigin&&!this.excludeNewrelicHeader()||!e.sameOrigin&&this.isAllowedOrigin(e)&&this.useNewrelicHeaderForCors())&&(u.newrelicHeader=this.generateTraceHeader(a,s,c,n,i,o)),u}generateTraceContextParentHeader(e,t){return"00-"+t+"-"+e+"-01"}generateTraceContextStateHeader(e,t,r,n,i){return i+"@nr=0-1-"+r+"-"+n+"-"+e+"----"+t}generateTraceHeader(e,t,r,n,i,o){if(!("function"==typeof c._A?.btoa))return null;var a={v:[0,1],d:{ty:"Browser",ac:n,ap:i,id:e,tr:t,ti:r}};return o&&n!==o&&(a.d.tk=o),btoa((0,D.P)(a))}shouldGenerateTrace(e){return this.isDtEnabled()&&this.isAllowedOrigin(e)}isAllowedOrigin(e){var r=!1,n={};if((0,t.Mt)(this.agentIdentifier,"distributed_tracing")&&(n=(0,t.P_)(this.agentIdentifier).distributed_tracing),e.sameOrigin)r=!0;else if(n.allowed_origins instanceof Array)for(var i=0;i 2&&void 0!==arguments[2])||arguments[2];super(r,n,Z.t,i),(0,t.OP)(r).xhrWrappable&&(this.dt=new W(r),this.handler=(e,t,r,n)=>(0,s.p)(e,t,r,n,this.ee),(0,k.u5)(this.ee),(0,k.Kf)(this.ee),function(r,n,i,o){function a(e){var t=this;t.totalCbs=0,t.called=0,t.cbTime=0,t.end=E,t.ended=!1,t.xhrGuids={},t.lastSize=null,t.loadCaptureCalled=!1,t.params=this.params||{},t.metrics=this.metrics||{},e.addEventListener("load",(function(r){_(t,e)}),(0,O.m$)(!1)),c.IF||e.addEventListener("progress",(function(e){t.lastSize=e.loaded}),(0,O.m$)(!1))}function s(e){this.params={method:e[0]},T(this,e[1]),this.metrics={}}function u(e,n){var i=(0,t.DL)(r);i.xpid&&this.sameOrigin&&n.setRequestHeader("X-NewRelic-ID",i.xpid);var a=o.generateTracePayload(this.parsedOrigin);if(a){var s=!1;a.newrelicHeader&&(n.setRequestHeader("newrelic",a.newrelicHeader),s=!0),a.traceContextParentHeader&&(n.setRequestHeader("traceparent",a.traceContextParentHeader),a.traceContextStateHeader&&n.setRequestHeader("tracestate",a.traceContextStateHeader),s=!0),s&&(this.dt=a)}}function d(e,t){var r=this.metrics,i=e[0],o=this;if(r&&i){var a=V(i);a&&(r.txSize=a)}this.startTime=(0,p.z)(),this.listener=function(e){try{"abort"!==e.type||o.loadCaptureCalled||(o.params.aborted=!0),("load"!==e.type||o.called===o.totalCbs&&(o.onloadCalled||"function"!=typeof t.onload)&&"function"==typeof o.end)&&o.end(t)}catch(e){try{n.emit("internal-error",[e])}catch(e){}}};for(var s=0;s 1?e[1]=i:e.push(i)}else e[0]&&e[0].headers&&s(e[0].headers,n)&&(this.dt=n);function s(e,t){var r=!1;return t.newrelicHeader&&(e.set("newrelic",t.newrelicHeader),r=!0),t.traceContextParentHeader&&(e.set("traceparent",t.traceContextParentHeader),t.traceContextStateHeader&&e.set("tracestate",t.traceContextStateHeader),r=!0),r}}function x(e,t){this.params={},this.metrics={},this.startTime=(0,p.z)(),this.dt=t,e.length>=1&&(this.target=e[0]),e.length>=2&&(this.opts=e[1]);var r,n=this.opts||{},i=this.target;"string"==typeof i?r=i:"object"==typeof i&&i instanceof Y?r=i.url:c._A?.URL&&"object"==typeof i&&i instanceof URL&&(r=i.href),T(this,r);var o=(""+(i&&i instanceof Y&&i.method||n.method||"GET")).toUpperCase();this.params.method=o,this.txSize=V(n.body)||0}function A(t,r){var n;this.endTime=(0,p.z)(),this.params||(this.params={}),this.params.status=r?r.status:0,"string"==typeof this.rxSize&&this.rxSize.length>0&&(n=+this.rxSize);var o={txSize:this.txSize,rxSize:n,duration:(0,p.z)()-this.startTime};i("xhr",[this.params,o,this.startTime,this.endTime,"fetch"],this,e.D.ajax)}function E(t){var r=this.params,n=this.metrics;if(!this.ended){this.ended=!0;for(var o=0;o 2&&void 0!==arguments[2])||arguments[2];super(e,t,we.t,r),this.importAggregator()}}new class{constructor(e){let t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:(0,_.ky)(16);c._A?(this.agentIdentifier=t,this.sharedAggregator=new y({agentIdentifier:this.agentIdentifier}),this.features={},this.desiredFeatures=new Set(e.features||[]),this.desiredFeatures.add(m),Object.assign(this,(0,a.j)(this.agentIdentifier,e,e.loaderType||"agent")),this.start()):(0,l.Z)("Failed to initial the agent. Could not determine the runtime environment.")}get config(){return{info:(0,t.C5)(this.agentIdentifier),init:(0,t.P_)(this.agentIdentifier),loader_config:(0,t.DL)(this.agentIdentifier),runtime:(0,t.OP)(this.agentIdentifier)}}start(){const t="features";try{const r=n(this.agentIdentifier),i=[...this.desiredFeatures];i.sort(((t,r)=>e.p[t.featureName]-e.p[r.featureName])),i.forEach((t=>{if(r[t.featureName]||t.featureName===e.D.pageViewEvent){const n=function(t){switch(t){case e.D.ajax:return[e.D.jserrors];case e.D.sessionTrace:return[e.D.ajax,e.D.pageViewEvent];case e.D.sessionReplay:return[e.D.sessionTrace];case e.D.pageViewTiming:return[e.D.pageViewEvent];default:return[]}}(t.featureName);n.every((e=>r[e]))||(0,l.Z)("".concat(t.featureName," is enabled but one or more dependent features has been disabled (").concat((0,D.P)(n),"). This may cause unintended consequences or missing data...")),this.features[t.featureName]=new t(this.agentIdentifier,this.sharedAggregator)}})),(0,T.Qy)(this.agentIdentifier,this.features,t)}catch(e){(0,l.Z)("Failed to initialize all enabled instrument classes (agent aborted) -",e);for(const e in this.features)this.features[e].abortHandler?.();const r=(0,T.fP)();return delete r.initializedAgents[this.agentIdentifier]?.api,delete r.initializedAgents[this.agentIdentifier]?.[t],delete this.sharedAggregator,r.ee?.abort(),delete r.ee?.get(this.agentIdentifier),!1}}}({features:[J,m,S,class extends h{static featureName=oe;constructor(t,r){if(super(t,r,oe,!(arguments.length>2&&void 0!==arguments[2])||arguments[2]),!c.il)return;const n=this.ee;let i;(0,k.QU)(n),this.eventsEE=(0,k.em)(n),this.eventsEE.on(se,(function(e,t){this.bstStart=(0,p.z)()})),this.eventsEE.on(ae,(function(t,r){(0,s.p)("bst",[t[0],r,this.bstStart,(0,p.z)()],void 0,e.D.sessionTrace,n)})),n.on(ce+ne,(function(e){this.time=(0,p.z)(),this.startPath=location.pathname+location.hash})),n.on(ce+ie,(function(t){(0,s.p)("bstHist",[location.pathname+location.hash,this.startPath,this.time],void 0,e.D.sessionTrace,n)}));try{i=new PerformanceObserver((t=>{const r=t.getEntries();(0,s.p)(te,[r],void 0,e.D.sessionTrace,n)})),i.observe({type:re,buffered:!0})}catch(e){}this.importAggregator({resourceObserver:i})}},C,xe,B,class extends h{static featureName=de;constructor(e,r){if(super(e,r,de,!(arguments.length>2&&void 0!==arguments[2])||arguments[2]),!c.il)return;if(!(0,t.OP)(e).xhrWrappable)return;try{this.removeOnAbort=new AbortController}catch(e){}let n,i=0;const o=this.ee.get("tracer"),a=(0,k._L)(this.ee),s=(0,k.Lg)(this.ee),u=(0,k.BV)(this.ee),d=(0,k.Kf)(this.ee),f=this.ee.get("events"),l=(0,k.u5)(this.ee),h=(0,k.QU)(this.ee),g=(0,k.Gm)(this.ee);function m(e,t){h.emit("newURL",[""+window.location,t])}function v(){i++,n=window.location.hash,this[ve]=(0,p.z)()}function b(){i--,window.location.hash!==n&&m(0,!0);var e=(0,p.z)();this[pe]=~~this[pe]+e-this[ve],this[ye]=e}function y(e,t){e.on(t,(function(){this[t]=(0,p.z)()}))}this.ee.on(ve,v),s.on(be,v),a.on(be,v),this.ee.on(ye,b),s.on(ge,b),a.on(ge,b),this.ee.buffer([ve,ye,"xhr-resolved"],this.featureName),f.buffer([ve],this.featureName),u.buffer(["setTimeout"+le,"clearTimeout"+fe,ve],this.featureName),d.buffer([ve,"new-xhr","send-xhr"+fe],this.featureName),l.buffer([me+fe,me+"-done",me+he+fe,me+he+le],this.featureName),h.buffer(["newURL"],this.featureName),g.buffer([ve],this.featureName),s.buffer(["propagate",be,ge,"executor-err","resolve"+fe],this.featureName),o.buffer([ve,"no-"+ve],this.featureName),a.buffer(["new-jsonp","cb-start","jsonp-error","jsonp-end"],this.featureName),y(l,me+fe),y(l,me+"-done"),y(a,"new-jsonp"),y(a,"jsonp-end"),y(a,"cb-start"),h.on("pushState-end",m),h.on("replaceState-end",m),window.addEventListener("hashchange",m,(0,O.m$)(!0,this.removeOnAbort?.signal)),window.addEventListener("load",m,(0,O.m$)(!0,this.removeOnAbort?.signal)),window.addEventListener("popstate",(function(){m(0,i>1)}),(0,O.m$)(!0,this.removeOnAbort?.signal)),this.abortHandler=this.#e,this.importAggregator()}#e(){this.removeOnAbort?.abort(),this.abortHandler=void 0}}],loaderType:"spa"})})(),window.NRBA=o})(); const cookieDomain = window.location.hostname; const tld = buildTLD(); function buildTLD() { const domainParts = cookieDomain.split('.'); while (domainParts.length > 2) { domainParts.shift(); } return domainParts.join('.'); } function deleteCookie(cookieName) { if (!cookieName) { return; } const cookiePath = (cookieName.startsWith('retraction_warning_') || cookieName.startsWith('version_warning_')) ? '/articles/' + cookieName : '/'; // Yes, these three slightly different ways to try and remove cookies are necessary document.cookie = cookieName + '=; path=' + cookiePath + '; domain=' + cookieDomain + '; expires=Thu, 01 Jan 1970 00:00:01 GMT;'; document.cookie = cookieName + '=; path=' + cookiePath + '; domain=.' + tld + '; expires=Thu, 01 Jan 1970 00:00:01 GMT;'; document.cookie = cookieName + '=; path=' + cookiePath + '; expires=Thu, 01 Jan 1970 00:00:01 GMT;'; } function deleteGroupCookies(group) { if (!group) { return; } const domainData = OneTrust.GetDomainData(), cookies = domainData.Groups.filter(cookieGroup => cookieGroup.OptanonGroupId === group)[0].Cookies; cookies.forEach(cookie => deleteCookie(cookie.Name)); } function OptanonWrapper() { const cookieConsentGroups = []; for (group of OneTrust.GetDomainData().Groups) { cookieConsentGroups.push(group.OptanonGroupId); } OneTrust.OnConsentChanged(function(e) { const cookieConsentActiveGroups = OnetrustActiveGroups.split(',').filter(activeGroup => activeGroup); cookieConsentGroups.forEach(group => { if (!cookieConsentActiveGroups.includes(group)) { deleteGroupCookies(group); }; }); }); } window.jQuery || document.write(' ') CKEDITOR_BASEPATH='https://hrbopenresearch.org/js/vendor/ckeditor/' window.reactTheme = 'HRB'; window.MathJax = { CommonHTML: { linebreaks: { automatic: true } }, 'HTML-CSS': { linebreaks: { automatic: true } }, SVG: { linebreaks: { automatic: true } }, AuthorInit: function() { MathJax.Hub.Register.MessageHook('End Process', function () { let timeout = false; // holder for timeout id const delay = 250; // delay after event is "complete" to run callback const reflowMath = function() { const dispFormulas = document.querySelectorAll('.disp-formula.panel'); if (!dispFormulas) { return; } for (const dispFormula of dispFormulas) { const child = dispFormula.querySelector('.MathJax_Preview').nextSibling.firstChild; const isMultiline = MathJax.Hub.getAllJax(dispFormula)[0].root.isMultiline; if (dispFormula.offsetWidth < child.offsetWidth || isMultiline) { MathJax.Hub.Queue(['Rerender', MathJax.Hub, dispFormula]); } } }; window.addEventListener('resize', function() { clearTimeout(timeout); // clear the timeout timeout = setTimeout(reflowMath, delay); // start timing for event "completion" }); }); }, }; if (window.location.hash == '#_=_'){ window.location = window.location.href.split('#')[0] } !function(f,b,e,v,n,t,s){if(f.fbq)return;n=f.fbq=function() {n.callMethod? n.callMethod.apply(n,arguments):n.queue.push(arguments)} ;if(!f._fbq)f._fbq=n; n.push=n;n.loaded=!0;n.version='2.0';n.queue=[];t=b.createElement(e);t.async=!0; t.src=v;s=b.getElementsByTagName(e)[0];s.parentNode.insertBefore(t,s)}(window, document,'script','https://connect.facebook.net/en_US/fbevents.js'); fbq('init', '1641728616063202'); fbq('track', "PixelInitialized", {}); Skip to content HRB Open Research file_upload Submit your research search clear search menu close clear Search Browse Gateways & Collections How to Publish Submit your Research My Submissions Article Guidelines Article Guidelines (New Versions) Data Guidelines Prepublication Checks Production Process Article Processing Charges Finding Article Reviewers About How it Works For Reviewers National Steering Group Policies Glossary FAQs Contact Blog My Account Submissions Content and Tracking Alerts My Details Sign In file_upload Submit your research { "@context": "https://schema.org", "@type": "ScholarlyArticle", "mainEntityOfPage": { "@type": "WebPage", "@id": "https://hrbopenresearch.org/articles/8-122" }, "headline": "Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol", "datePublished": "2025-11-18T15:50:38", "dateModified": "2026-02-02T09:43:06", "author": [ { "@type": "Person", "name": "Marah Elfghi" }, { "@type": "Person", "name": "Emer Galvin" }, { "@type": "Person", "name": "Deirdre Bennett" }, { "@type": "Person", "name": "Niamh Coakley" }, { "@type": "Person", "name": "Deborah Heaphy" }, { "@type": "Person", "name": "Rory Mulcaire" }, { "@type": "Person", "name": "Caoimhe O'Brien" }, { "@type": "Person", "name": "Claudia Osborne" }, { "@type": "Person", "name": "Anél Wiese" } ], "publisher": { "@type": "Organization", "name": "HRB Open Research", "logo": { "@type": "ImageObject", "url": "https://hrbopenresearch.org/img/AMP/HRB_image.png", "height": 566, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://hrbopenresearch.org/img/AMP/HRB_image.png", "height": 1200, "width": 127 }, "description": " Background Climate change poses a critical global health challenge, affecting public health, healthcare systems, and health professions education (HPE). While healthcare professionals play a key role in addressing climate-related health risks and promoting sustainable practices, formal training in climate change and sustainability (CC&S) remains limited and CC&S education is inconsistently implemented due to challenges such as curriculum constraints and lack of faculty expertise. Existing systematic and scoping reviews provide an overview of CC&S interventions but do not sufficiently explore the mechanisms driving their success or failure. A realist review is needed to understand what works, for whom, and under what conditions in CC&S education. Methods This realist review will follow the RAMESES publication standards and use a structured, iterative approach to synthesise evidence. A comprehensive search strategy will be conducted across academic databases and grey literature sources to identify CC&S education interventions in undergraduate, postgraduate, and continuing professional education across healthcare disciplines. Data will be extracted using a Context-Mechanism-Outcome (CMO) framework to analyse key contextual factors, mechanisms, and outcomes influencing intervention effectiveness. Regular team discussions will ensure consensus in identifying CMOs and refining the initial programme theory. Findings will be reported through narrative synthesis, summary tables, and a graphical representation of the final programme theory. Discussion This review will provide practical insights for stakeholders on how to effectively integrate CC&S education into HPE curricula. By unpacking mechanisms and contextual factors, it will go beyond traditional systematic reviews to explain why and how these interventions succeed or fail. The findings will inform curriculum development, faculty training, and policy recommendations, ensuring that future healthcare professionals are equipped to address climate-related health challenges and advance sustainable healthcare practices. Ultimately, this review will contribute to the global effort to embed sustainability within HPE, preparing the healthcare workforce for a changing climate. Systematic review registration: Open Science Framework (OSF) " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://hrbopenresearch.org/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://hrbopenresearch.org/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://hrbopenresearch.org/articles/8-122/v1", "name": "Climate Change and Sustainability in Health Professions Education:..." } } ] } Home Browse Climate Change and Sustainability in Health Professions Education:... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Elfghi M, Galvin E, Bennett D et al. Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :122 ( https://doi.org/10.12688/hrbopenres.14282.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] Marah Elfghi https://orcid.org/0000-0003-1383-5683 1 , Emer Galvin https://orcid.org/0000-0001-8047-5599 1 , Deirdre Bennett 1 , [...] Niamh Coakley 1 , Deborah Heaphy 1 , Rory Mulcaire 1 , Caoimhe O'Brien https://orcid.org/0009-0008-1647-4346 1 , Claudia Osborne 1 , Anél Wiese 1 Marah Elfghi https://orcid.org/0000-0003-1383-5683 1 , Emer Galvin https://orcid.org/0000-0001-8047-5599 1 , [...] Deirdre Bennett 1 , Niamh Coakley 1 , Deborah Heaphy 1 , Rory Mulcaire 1 , Caoimhe O'Brien https://orcid.org/0009-0008-1647-4346 1 , Claudia Osborne 1 , Anél Wiese 1 PUBLISHED 18 Nov 2025 Author details Author details 1 Medical Education Unit, University College Cork School of Medicine, Cork, County Cork, T12 AK54, Ireland Marah Elfghi Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Emer Galvin Roles: Writing – Review & Editing Deirdre Bennett Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Writing – Review & Editing Niamh Coakley Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Writing – Review & Editing Deborah Heaphy Roles: Writing – Review & Editing Rory Mulcaire Roles: Writing – Review & Editing Caoimhe O'Brien Roles: Writing – Review & Editing Claudia Osborne Roles: Writing – Review & Editing Anél Wiese Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Climate change poses a critical global health challenge, affecting public health, healthcare systems, and health professions education (HPE). While healthcare professionals play a key role in addressing climate-related health risks and promoting sustainable practices, formal training in climate change and sustainability (CC&S) remains limited and CC&S education is inconsistently implemented due to challenges such as curriculum constraints and lack of faculty expertise. Existing systematic and scoping reviews provide an overview of CC&S interventions but do not sufficiently explore the mechanisms driving their success or failure. A realist review is needed to understand what works, for whom, and under what conditions in CC&S education. Methods This realist review will follow the RAMESES publication standards and use a structured, iterative approach to synthesise evidence. A comprehensive search strategy will be conducted across academic databases and grey literature sources to identify CC&S education interventions in undergraduate, postgraduate, and continuing professional education across healthcare disciplines. Data will be extracted using a Context-Mechanism-Outcome (CMO) framework to analyse key contextual factors, mechanisms, and outcomes influencing intervention effectiveness. Regular team discussions will ensure consensus in identifying CMOs and refining the initial programme theory. Findings will be reported through narrative synthesis, summary tables, and a graphical representation of the final programme theory. Discussion This review will provide practical insights for stakeholders on how to effectively integrate CC&S education into HPE curricula. By unpacking mechanisms and contextual factors, it will go beyond traditional systematic reviews to explain why and how these interventions succeed or fail. The findings will inform curriculum development, faculty training, and policy recommendations, ensuring that future healthcare professionals are equipped to address climate-related health challenges and advance sustainable healthcare practices. Ultimately, this review will contribute to the global effort to embed sustainability within HPE, preparing the healthcare workforce for a changing climate. Systematic review registration: Open Science Framework (OSF) READ ALL READ LESS Keywords Climate change, sustainability, planetary health, health professions education, realist review Corresponding Author(s) Marah Elfghi ( [email protected] ) Close Corresponding author: Marah Elfghi Competing interests: No competing interests were disclosed. Grant information: Health Research Board [2023-004]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Elfghi M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Elfghi M, Galvin E, Bennett D et al. Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :122 ( https://doi.org/10.12688/hrbopenres.14282.1 ) First published: 18 Nov 2025, 8 :122 ( https://doi.org/10.12688/hrbopenres.14282.1 ) Latest published: 02 Feb 2026, 8 :122 ( https://doi.org/10.12688/hrbopenres.14282.2 )  There is a newer version of this article available. Suppress this message for one day. Background Climate change is a critical global health challenge with profound implications for public health, healthcare systems, and health professions education (HPE) 1 . Rising temperatures, extreme weather, shifting disease patterns, and ecosystem disruptions are worsening disease burdens and increasing health risks worldwide 2 . Beyond impacting public health, climate change also threatens healthcare system accessibility and sustainability 3 . Moreover, the healthcare sector contributes 4–5% of global greenhouse gas emissions through energy use, waste, and the carbon footprint of medical supply chains 4 . This underscores the urgent need to integrate sustainability into healthcare delivery and education to mitigate climate change impacts while ensuring high-quality, resilient healthcare systems. Healthcare professionals play a critical role in addressing the health consequences of climate change and promoting sustainable healthcare practices 5 . As frontline providers, they must be equipped with the knowledge, skills, and attitudes to recognise climate-related health impacts and integrate sustainability into clinical practice that support both environmental and human health 6 , 7 . However, despite growing recognition of these responsibilities, formal training in CC&S remains limited in HPE 8 – 10 . Surveys among healthcare students and practitioners indicate that while interest in CC&S education is high, opportunities for structured learning remain limited 9 , 11 – 15 . This gap has led to calls for the systematic integration of CC&S education into HPE programmes globally 16 – 19 . International organisations, professional bodies, policymakers and educational institutions have advocated for embedding CC&S education into HPE. The Lancet Countdown on Health and Climate Change 20 , the Global Consortium on Climate and Health Education 21 , and Health Care Without Harm 22 emphasise the urgent need to equip healthcare professionals with climate and sustainability competencies to enhance preparedness and response efforts. Similarly, national accreditation bodies—such as the UK General Medical Council 23 , the Association of American Medical Colleges 24 , and The Royal College of Physicians and Surgeons of Canada 25 — stress the health sector’s responsibility in climate adaptation and mitigation. The Global Climate and Health Alliance 26 further reinforces the need for targeted education programmes, while the International Federation of Medical Students’ Associations 27 has played a key role in student-led advocacy for climate-conscious medical curricula. Together, these initiatives highlight the critical need for CC&S education in HPE to ensure that future healthcare professionals are adequately prepared to address the challenges posed by climate change. Despite this growing recognition of CC&S education, implementation remains inconsistent across different health professions, educational institutions, and geographic regions 16 , 28 . Several barriers have hindered the systematic integration of CC&S into HPE curricula. Many educators lack formal training or expertise in CC&S, making it difficult to incorporate these topics into exiting curricula 29 , 30 . Health professions programmes are densely packed with clinical, biomedical, and technical content, making it challenging to introduce additional CC&S topics without restructuring existing curricula 29 – 31 . Without clear curriculum guidelines or accreditation requirements, CC&S education remain optional rather than an essential competency 10 , 32 . While various teaching approaches (e.g., case-based learning, online modules, simulations, workshops) have been used to introduce CC&S education, there is insufficient research on which methods are most effective across different learning contexts 28 . Many CC&S initiatives in HPE rely on short-term funding or voluntary efforts limiting their scalability and long-term impact. Three recent scoping reviews highlight the current landscape of CC&S education in HPE. The first review explored nursing students' perspectives and evaluated various teaching strategies for integrating CC&S into nursing curricula 33 . The second review examined interprofessional education on climate change and health, identifying a limited number of studies with diverse intervention designs, underscoring the need for further research and standardised approaches to interprofessional CC&S education 34 . A third scoping review mapped the global integration CC&S content in undergraduate medical education found that most implementations began between 2020 and 2021, using stand-alone modules, electives, and curriculum modifications, with student-led initiatives playing a key role 31 . A systematic review on sustainable healthcare education in HPE found that various interventions, including workshops and clinical skills sessions, effectively improved learners' knowledge, attitudes, and skills, though no single approach was superior, and challenges such as limited curriculum time and faculty expertise hindered broader implementation 28 . Systematic reviews often focus on the effectiveness of interventions without considering the mechanisms underlying their success or failure. Whereas scoping review methods provide descriptive overviews. These methods rarely consider contextual variations – such as institutional policies, faculty engagement, or student motivation – that shape the effectiveness of education. In contrast, realist reviews aim to unpack the underlying mechanisms and contextual factors that shape outcomes, offering a deeper understanding of why and how CC&S education programmes succeed or fail 35 . Realist reviews have been successfully applied in HPE to examine diverse areas, including workplace learning 36 , online medical education 37 , and remediation programmes 38 . However, to our knowledge, no realist review has systematically examined the implementation and effectiveness of CC&S education interventions for healthcare professionals across different contexts. The guiding research question for this review is: "What works, for whom, and under what circumstances in climate change and sustainability education in health professions education?" This review will examine CC&S education interventions across undergraduate, postgraduate, and continuing professional education, identifying the key contextual factors, mechanisms, and outcomes that shape their effectiveness. It will consider both formal curriculum-based interventions and extracurricular or professional development initiatives, offering a comprehensive understanding of best practices in CC&S education. The scope will span diverse healthcare disciplines, including medicine, nursing, and allied health professions. Guided by learning 39 , 40 , behavioural 41 , 42 , and implementation science theories 43 , this review will identify the mechanisms driving CC&S education interventions. A core outcome of this realist review will be the development of a programme theory, providing a structured, theoretical framework to enhance the understanding and implementation of CC&S education in HPE. By synthesising evidence through a realist lens, we aim to generate practical insights that can guide the design and implementation of impactful and sustainable educational strategies. This protocol outlines the methodology for our realist review, detailing the scope, objectives, and approach to data collection and analysis. Ultimately, our findings will contribute to the growing body of knowledge on sustainability education and support the integration of climate-conscious practices in HPE. Methods A realist review will be conducted, following the RAMESES Publication Standards for Realist Syntheses 44 and associated training materials 45 . Realist principles will be integrated into all stages of the review process. This review protocol follows the guidelines outlined in PRISMA-P checklist 46 , Appendix 1 . This realist review will follow a structured process to analyse CC&S education interventions by examining context, mechanisms, and outcomes. First, we will refine the research question and establish the review scope. Next, we will develop an initial programme theory, outlining how CC&S education is expected to work. A comprehensive literature search will then be conducted across relevant databases and grey literature sources. Identified studies will undergo systematic screening and selection based on detailed selection criteria. The analysis and synthesis phase will apply realist principles to extract and identify patterns in CMO configurations, refining the programme theory iteratively. Finally, the refined programme theory will be presented in narrative, tabular, and graphical formats, providing actionable insights for educators, policymakers, and institutions to support the effective integration of CC&S education in health professions curricula. Defining the scope of the review This realist review will focus on CC&S education interventions across various formats—including online, in-person, workplace, classroom, and group-based settings—targeting healthcare professionals and students from disciplines such as medicine, nursing, dentistry, pharmacy, and allied health. By including studies from undergraduate, postgraduate, and continuing professional development contexts, the review aims to capture a comprehensive picture of how CC&S education is being implemented and evaluated globally. The scope is further defined to incorporate empirical research—both published journal articles and relevant grey literature—that assesses intervention effectiveness, using quantitative, qualitative, or mixed-method approaches. This focus and these boundaries ensure that the review concentrates on interventions directly impacting educational practices and outcomes, while excluding non-empirical work, studies outside healthcare, non-educational interventions, and theoretical papers without practical implementation. This deliberate framing facilitates a nuanced understanding of what works, for whom, and under what conditions in CC&S education within HPE, thereby providing actionable insights for curriculum design and policy development. Initial Programme Theory The Initial Programme Theory (IPT) for this realist review was developed through an iterative process, integrating existing literature, curricular documents, and theoretical frameworks. The IPT serves as the starting framework for the review, outlining how CC&S education interventions are expected to work, for whom, and under what conditions. A structured theoretical approach guided the development of the IPT, focusing on three key dimensions necessary for embedding CC&S education: (1) behavioural change, (2) effective learning, and (3) institutional integration. To address behavioural change, the COM-B Model was selected for its focus on how Capability, Opportunity, and Motivation interact to shape learners' ability to engage with CC&S practices 42 . Additionally, the Theory of Planned Behaviour explains how attitudes, social norms, and perceived behavioural control influence whether learners adopt CC&S behaviours in their professional practice 41 . For effective learning, multiple theories were incorporated. Social Constructivist Learning Theory emphasises collaborative learning, experiential knowledge-building, and social interactions, all of which are critical for CC&S education. Transformative Learning Theory highlights how learners undergo perspective shifts through critical reflection and real-world engagement 40 , that could lead to long-term commitment to CC&S principles. Sociocultural Learning Theory emphasise learning takes place through engagement within a social context, encompassing both formal education (structured, intentional instruction) and informal learning (implicit understanding of norms and practices within a given setting) 39 . It underscores that individuals are part of a larger social whole, where learning occurs through active participation in meaningful activities. In CC&S education, this means not just acquiring knowledge but continuously shaping and being shaped by one’s professional and environmental context. For institutional integration, Normalisation Process Theory 43 can be used to examine how CC&S education can become embedded in healthcare curricula and professional practices, focusing on processes of adoption, implementation, and sustainability. The Consolidated Framework for Implementation Research 47 provides a structured way to assess barriers and facilitators at multiple levels, including organisational culture, leadership engagement, and policy alignment. A key step in developing the IPT involved reviewing curricular documents from HPE to identify intended learning outcomes, pedagogical approaches, and competency frameworks related to CC&S education 48 . This helped establish potential contexts for CC&S education, such as interprofessional learning environments, problem-based learning approaches, and experiential simulations. Additionally, it outlined anticipated outcomes, including enhanced sustainability literacy, clinical decision-making informed by planetary health principles, and advocacy for sustainable healthcare practices. This refined IPT will guide the analysis of evidence, ensuring that CMO configurations are systematically explored to understand what works, for whom, and under what conditions in CC&S education. Search strategy For this review, an initial comprehensive electronic literature search will be conducted across relevant databases, including Academic Search Complete, Australian Education Index, British Education Index, Business Source Complete, CINAHL, Embase, ERIC, PsycINFO, PubMed, Scopus, and SocINDEX, as well as grey literature sources. The search will target literature discussing climate change and sustainability interventions aimed at enhancing health professions education. The systematic search strategy is built around three keyword groups: (1) healthcare professionals, (2) climate change and sustainability, and (3) education interventions, linked using Boolean operators (OR and AND). Wherever possible, a combination of free-text terms and Medical Subject Headings (MeSH) terms will be used to optimise search sensitivity. The final search strategy is detailed in Appendix 2 , with adaptations made for different databases to ensure transparency and reproducibility. Searches will be restricted to titles and abstracts, and the process may involve multiple rounds of searching to refine and investigate specific areas of interest in greater detail. Additionally, backward and forward citation tracking will be employed to enhance the comprehensiveness of the review. Backward citation tracking will be done by checking reference lists of selected articles and forward citation tracking will be done by using citation indexes such as Scopus and Web of Science to identify more recent studies that have cited key articles, ensuring the inclusion of the latest research developments in CC&S education in HPE. Selection criteria Inclusion criteria: • Studies reporting on CC&S educational interventions in any format, e.g. online, in-person, workplace, classroom, small group, large group, any duration, etc., • Studies reporting on health professionals and students from a range of health disciplines, such as medical doctors, nurses, dentists, pharmacists, dietitians, dispensing opticians, medical scientists, occupational therapists, optometrists, physical therapists, physiotherapists, podiatrists, chiropodists, radiographers, radiation therapists, speech and language therapists and clinical biochemists. Various levels of training (e.g., undergraduate, postgraduate, CPD) will be included, • Studies reporting on evaluation of the intervention, • Studies that are empirical journal articles or grey literature containing empirical data, • Quantitative, qualitative, and mixed-method studies, • Studies published between January 2014 and October 2024, • Studies published in English. Exclusion criteria: • Non-empirical studies including commentaries, letters, editorials, and reviews, • Studies not related to healthcare students or professionals. • Non-educational interventions (e.g., clinical interventions, policy interventions) • Papers reporting on educational frameworks or curriculums without implementing an intervention. Selection process Studies identified through the database search will be exported to Covidence for screening. Duplicate records will be removed automatically by Covidence and manually verified by one reviewer. The title and abstract screening will be conducted independently by two reviewers, who will regularly meet with the research team to discuss progress and resolve any uncertainties. If disagreements arise, a third reviewer will be consulted to make a final decision. Articles will be excluded if they do not meet the inclusion criteria. During screening, reviewers will have access to bibliographic fields, including title, abstract, authors, journal name, and year of publication, and will not be blinded to these details. For full-text screening, the research team will first conduct a pilot screening with a sample of studies to ensure consistency. Full-text screening will also be performed by two independent reviewers, who will be blinded to each other’s decisions. If full-text access is unavailable, the research team will attempt to contact the corresponding authors via email. These communications will remain confidential, and no metadata will be shared. However, efforts to obtain full texts will be documented, including the number of authors contacted and the outcomes of these requests. This screening process balances methodological rigour with researcher resources, ensuring a systematic and transparent selection of studies while maintaining consistency and reliability in the inclusion process. Data extraction A structured data extraction process will be implemented to systematically collect study characteristics, intervention details, evaluation methods, and Context-Mechanism-Outcome (CMO) configurations. Data extraction will be conducted using two tools: a Microsoft Excel spreadsheet to document general study characteristics and a CMO Data Extraction Template specifically designed to identify and record CMO configurations. The Excel spreadsheet will capture key study characteristics, including title, author(s), year of publication, study type, a description of the intervention (including format, duration, and delivery method), details on how the intervention was evaluated, and the population involved (e.g., healthcare discipline, student or professional level). In parallel, the CMO Data Extraction Template will focus on identifying mechanisms and contextual factors influencing the effectiveness of CC&S education interventions. This template consists of two primary components: a Contextual Information Table, which captures key details such as the target population and educational format used (e.g., online, in-person, workshop, integrated curriculum), and a CMO Table, where explicitly stated or inferred CMO configurations are recorded, providing insight into how specific contexts influence mechanisms to produce particular outcomes. Additionally, the template includes a quality and relevance assessment section, where reviewers will evaluate the strengths and limitations of each study, assess its richness in identifying CMO configurations, and determine its usefulness in refining the programme theory. To ensure rigour and reliability, two independent reviewers will extract data from each study. Regular team discussions will be conducted to review and refine the CMOs, resolve any disagreements regarding what constitutes a CMO, and ensure a systematic approach to data extraction. This iterative process will help refine the programme theory, ensuring that the evidence collected contributes meaningfully to understanding what works, for whom, and under what conditions in CC&S education interventions. Analyses and synthesis The analysis and synthesis process will involve systematically reviewing all Context-Mechanism-Outcome configurations extracted from individual studies to identify patterns and regularities across the dataset and to identify common mechanisms, the contexts in which they operate, and the outcomes they produce. This process will be iterative, allowing for continuous refinement of the initial programme theory as new insights emerge. The refined programme theory will be developed based on the evidence, integrating key findings from the literature to enhance its explanatory power. Results will be reported in a narrative synthesis, supported by summarised data in table format to present key contextual information, mechanisms, and outcomes in a structured manner. Additionally, a graphic representation of the final programme theory will be created to visually illustrate the relationships between contexts, mechanisms, and outcomes, providing a clear and accessible framework for understanding the findings. Study status At the time of publication, the review is undergoing full-text screening. Discussion This realist review protocol outlines a structured approach to examining CC&S education in HPE. Given the growing recognition of climate change as a global health crisis and the need for sustainability education in healthcare, this review aims to bridge the gap between existing interventions and their effectiveness across different contexts. By systematically extracting and synthesising Context-Mechanism-Outcome configurations, this review will contribute to evidence-based curriculum development, guiding educators, policymakers, and institutions in designing effective and sustainable CC&S education strategies. The findings will support the integration of sustainability principles into healthcare education, ensuring that future healthcare professionals are equipped to address climate-related health challenges and advocate for environmentally responsible practices. Ultimately, this realist review will provide actionable insights for embedding CC&S education into HPE curricula globally, strengthening the healthcare sector’s capacity to contribute to climate adaptation and mitigation efforts. List of abbreviations CC&S Climate change and sustainability CMO Context-Mechanism-Outcome HPE Health professions education IPT Initial Programme Theory MeSH Medical Subject Headings Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Availability of data and materials Extended data Open Science Framework. Climate Change and Sustainability Interventions in Health Professions Education: A realist review protocol. https://osf.io/4u97s/ 49 . This project contains the following underlying data: Realist review protocol extended data.pdf (Includes the PRISMA-P Checklist and the Final Search Strategy as supplementary materials supporting the realist review protocol). Data is available under the terms of the Creative Commons Attribution 4.0 International Public License. Acknowledgements Not applicable Faculty Opinions recommended References 1. Romanello M, McGushin A, Napoli CD, et al. : The 2021 report of the Lancet countdown on health and climate change: code red for a healthy future. Lancet. 2021; 398 (10311): 1619–62. PubMed Abstract | Publisher Full Text | Free Full Text 2. WHO guidance for climate-resilient and environmentally sustainable health care facilities. 1st ed. Geneva: World Health Organization, 2020; 1. Reference Source 3. Romanello M, Di Napoli C, Drummond P, et al. : The 2022 report of the Lancet countdown on health and climate change: health at the mercy of fossil fuels. Lancet. 2022; 400 (10363): 1619–54. PubMed Abstract | Publisher Full Text | Free Full Text 4. Lenzen M, Malik A, Li M, et al. : The environmental footprint of health care: a global assessment. Lancet Planet Health. 2020; 4 (7): e271–e279. PubMed Abstract | Publisher Full Text 5. Ihsan FR, Bloomfield JG, Monrouxe LV: Triple planetary crisis: why healthcare professionals should care. Front Med (Lausanne). 2024; 11 : 1465662. PubMed Abstract | Publisher Full Text | Free Full Text 6. Mortimer F, Isherwood J, Wilkinson A, et al. : Sustainability in quality improvement: redefining value. Future Healthc J. 2018; 5 (2): 88–93. PubMed Abstract | Publisher Full Text | Free Full Text 7. Stanford V, Barna S, Gupta D, et al. : Teaching skills for sustainable health care. Lancet Planet Health. 2023; 7 (1): e64–7. PubMed Abstract | Publisher Full Text 8. Ccami-Bernal F, Barriga-Chambi F, Quispe-Vicuña C, et al. : Health science students’ preparedness for climate change: a scoping review on knowledge, attitudes, and practices. BMC Med Educ. 2024; 24 (1): 648. PubMed Abstract | Publisher Full Text | Free Full Text 9. Cogen JD, Perkins A, Mockler B, et al. : Pediatric resident and program director views on climate change and health curricula: a multi-Institution study. Acad Med. 2024; 99 (6): 654–62. PubMed Abstract | Publisher Full Text 10. Bevan J, Blyth R, Russell B, et al. : Planetary health and sustainability teaching in UK medical education: a review of medical school curricula. Med Teach. 2023; 45 (6): 623–632. PubMed Abstract | Publisher Full Text 11. Lé tourneau S, Roshan A, Kitching GT, et al. : Climate change and health in medical school curricula: a national survey of medical students’ experiences, attitudes and interests. J Clim Chang Health. 2023; 11 : 100226. Publisher Full Text 12. Aronsson J, Nichols A, Warwick P, et al. : Nursing students’ and educators’ perspectives on sustainability and climate change: an integrative review. J Adva Nurs. 2024; 80 (8): 3072–85. PubMed Abstract | Publisher Full Text 13. Gupta D, Shantharam L, MacDonald BK: Sustainable healthcare in medical education: survey of the student perspectives at a UK medical school. BMC Med Educ. 2022; 22 (1): 689. PubMed Abstract | Publisher Full Text | Free Full Text 14. Huang A, Cooke SM, Garsden C, et al. : Transitioning to sustainable, climate-resilient healthcare: insights from a health service staff survey in Australia. BMC Health Serv Res. 2024; 24 (1): 475. PubMed Abstract | Publisher Full Text | Free Full Text 15. Kotcher J, Maibach E, Miller J, et al. : Views of health professionals on climate change and health: a multinational survey study. Lancet Planet Health. 2021; 5 (5): e316–23. PubMed Abstract | Publisher Full Text | Free Full Text 16. Visser EH, Oosterveld B, Slootweg IA, et al. : The development and characteristics of planetary health in medical education: a scoping review. Acad Med. 2024; 99 (10): 1155–66. PubMed Abstract | Publisher Full Text 17. McLean M: ‘We argue that … one simply cannot claim to be a “ health” care professional without advocating forcefully for the planet’: planetary health needs to be included in health professions’ education. In: Routledge Handbook of Climate Change and Health System Sustainability . 2024; 215–32. Reference Source 18. Irlam JH, Scheerens C, Mash B: Planetary Health and environmental sustainability in African health professions education. Afr J Prim Health Care Fam Med. 2023; 15 (1): e1–e3. PubMed Abstract | Publisher Full Text | Free Full Text 19. Shaw E, Walpole S, McLean M, et al. : AMEE consensus statement: planetary health and education for sustainable healthcare. Med Teach. 2021; 43 (3): 272–86. PubMed Abstract | Publisher Full Text 20. Romanello M, Walawender M, Hsu SC, et al. : The 2024 report of the Lancet countdown on health and climate change: facing record-breaking threats from delayed action. Lancet. 2024; 404 (10465): 1847–96. PubMed Abstract | Publisher Full Text | Free Full Text 21. Columbia University Mailman School of Public Health: Global Consortium on Climate and Health Education. 2017; [cited 2025 Feb 24]. Reference Source 22. Health Care Without Harm International strategic plan 2024–2028. 2024. Reference Source 23. Striving for sustainability. [cited 2025 Feb 24]. Reference Source 24. Association of American Medical Colleges (AAMC). National Academy of Medicine, [cited 2025 Feb 24]. Reference Source 25. Royal College of Physicians and Surgeons of Cananda: Strategic plan and themes 2023–2026. [cited 2025 Feb 24]. Reference Source 26. The Global Climate and Health Alliance: The Global Climate and Health Alliance mobilises the global health community on the climate crisis, health and equity. [cited 2025 Feb 24]. Reference Source 27. Advocacy priorities. IFMSA, [cited 2025 Feb 24]. Reference Source 28. Bray L, Meznikova K, Crampton P, et al. : Sustainable healthcare education: a systematic review of the evidence and barriers to inclusion. Med Teach. 2023; 45 (2): 157–66. PubMed Abstract | Publisher Full Text 29. Brady Bates O, Walsh A, Stanistreet D: Factors influencing the integration of planetary health topics into undergraduate medical education in Ireland: a qualitative study of medical educator perspectives. BMJ Open. 2023; 13 (1): e067544. PubMed Abstract | Publisher Full Text | Free Full Text 30. Dixon J, Field J, van Harten M, et al. : Environmental sustainability in oral health professional education: approaches, challenges, and drivers— ADEE special-interest group report. Eur J Dent Educ. 2024; 28 (4): 969–77. PubMed Abstract | Publisher Full Text 31. Maisoon B, Narayanan P, Shetty RS: Integration of climate change and health components in medical education worldwide- a scoping review. medRxiv. 2025; 2025.02.06.25321781. Publisher Full Text 32. Ragusa AT, Crampton A: Willingness to learn, yet no lessons available? Environmental sustainability training and policy in Australia and New Zealand. Sustainability (Switzerland). 2024; 16 (11): 4673. Publisher Full Text 33. Tiitta I, Cubelo F, McDermott-Levy R, et al. : Climate change integration in nursing education: a scoping review. Nurse Educ Today. 2024; 139 : 106210. PubMed Abstract | Publisher Full Text 34. Dalapati T, Nick SE, Chari TA, et al. : Interprofessional climate change curriculum in health professional programs: a scoping review. Educ Sci. 2023; 13 (9): 945. Publisher Full Text 35. Pawson R, Greenhalgh T, Harvey G, et al. : Realist review - a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy. 2005; 10 (1_suppl): 21–34. PubMed Abstract | Publisher Full Text 36. Wiese A, Kilty C, Bennett D: Supervised workplace learning in postgraduate training: a realist synthesis. Med Educ. 2018; 52 (9): 951–69. Publisher Full Text 37. Wong G, Greenhalgh T, Pawson R: Internet-based medical education: a realist review of what works, for whom and in what circumstances. BMC Med Educ. 2010; 10 : 12. PubMed Abstract | Publisher Full Text | Free Full Text 38. Price T, Wong G, Withers L, et al. : Optimising the delivery of remediation programmes for doctors: a realist review. Med Educ. 2021; 55 (9): 995–1010. PubMed Abstract | Publisher Full Text 39. Kahlke R, Bates J, Nimmon L: When I say … sociocultural learning theory. Med Educ. 2019; 53 (2): 117–8. PubMed Abstract | Publisher Full Text 40. Vipler B, Knehans A, Rausa D, et al. : Transformative learning in graduate medical education: a scoping review. J Grad Med Educ. 2021; 13 (6): 801–814. PubMed Abstract | Publisher Full Text | Free Full Text 41. Ajzen I: The theory of planned behavior. Organ Behav Hum Decis Process. 1991; 50 (2): 179–211. Publisher Full Text 42. Michie S, van Stralen MM, West R: The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011; 6 (1): 42. PubMed Abstract | Publisher Full Text | Free Full Text 43. Murray E, Treweek S, Pope C, et al. : Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med. 2010; 8 (1): 63. PubMed Abstract | Publisher Full Text | Free Full Text 44. Wong G, Greenhalgh T, Westhorp G, et al. : RAMESES publication standards: realist syntheses. BMC Med. 2013; 11 (1): 21. PubMed Abstract | Publisher Full Text | Free Full Text 45. Wong G, Westhorp G, Pawson R, et al. : RAMESES training materials: realist synthesis. 2013. Reference Source 46. Moher D, Shamseer L, Clarke M, et al. : Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. Syst Rev. 2015; 4 : 1. PubMed Abstract | Publisher Full Text | Free Full Text 47. Damschroder LJ, Reardon CM, Widerquist MAO, et al. : The updated consolidated framework for implementation research based on user feedback. Implement Sci. 2022; 17 (1): 75. PubMed Abstract | Publisher Full Text | Free Full Text 48. Walpole SC, Vyas A, Maxwell J, et al. : Building an environmentally accountable medical curriculum through international collaboration. Med Teach. 2017; 39 (10): 1040–50. PubMed Abstract | Publisher Full Text 49. Elfghi M, Galvin E, Bennett D, et al. : Climate change and sustainability interventions in health professions education: a realist review protocol. October 29, 2025. https://osf.io/4u97s/overview Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 18 Nov 2025 ADD YOUR COMMENT Comment Author details Author details 1 Medical Education Unit, University College Cork School of Medicine, Cork, County Cork, T12 AK54, Ireland Marah Elfghi Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Emer Galvin Roles: Writing – Review & Editing Deirdre Bennett Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Writing – Review & Editing Niamh Coakley Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Writing – Review & Editing Deborah Heaphy Roles: Writing – Review & Editing Rory Mulcaire Roles: Writing – Review & Editing Caoimhe O'Brien Roles: Writing – Review & Editing Claudia Osborne Roles: Writing – Review & Editing Anél Wiese Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information Health Research Board [2023-004]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) version 2 Revised Published: 02 Feb 2026, 8:122 https://doi.org/10.12688/hrbopenres.14282.2 version 1 Published: 18 Nov 2025, 8:122 https://doi.org/10.12688/hrbopenres.14282.1 Copyright © 2025 Elfghi M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics VIEWS $counts.viewCount downloads Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Elfghi M, Galvin E, Bennett D et al. Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :122 ( https://doi.org/10.12688/hrbopenres.14282.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 18 Nov 2025 Views 0 Cite How to cite this report: McLean M. Reviewer Report For: Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :122 ( https://doi.org/10.21956/hrbopenres.15713.r52299 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-122/v1#referee-response-52299 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 06 Jan 2026 Michelle McLean , Bond University, Gold Coast, Australia Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15713.r52299 The article is clearly written and for the most, I know what the authors want to achieve. I don't believe I had access to the two appendices. A few considerations: P3, second column, ... Continue reading READ ALL The article is clearly written and for the most, I know what the authors want to achieve. I don't believe I had access to the two appendices. A few considerations: P3, second column, Line 4. should read 'CC&S education remains..' (currently 'remain'). Same line 'an essential competency' should read 'a set oc competencies' as there are many competencies in different domains relating to CC&S. Same page and column, paragraph starting with "Systematic reviews... " The second 'sentence' starting "Whereas... " is not a sentence. Same paragraph, the sentence should read "To the best of our knowledge, no ...". Page 4, Column 1, paragraph beginning "Guided by learning.." near the top of the page, "programme theory" is used. I am not sure what to suggest as an alternative, but programme theory is not an informative term. A programme is usually the complete degree and all of its content and activities. Page 4, Column 1, paragraph beginning "This realist.." What is meant by 'mechanism'? For me, a mechanism involves 'how'. Is it a delivery methods, a format, an educational intervention? Selection criteria 1.Although other disciplines have been excluded, and including them will be impossible, it is probably worth including a note to acknowledge that, in terms of the interrelated triple planetary crisis of a changing climate, biodiversity loss and pollution, solutions are going to come from many different fields, not just health. 2. Much water has flowed under the bridge since October 2024 so the review will be outdated by the time it is published. I think that for the review to be current, the end date should be kept open until the article is about to be published. This has happened to me on three occasions this year. The review process has taken so long that I have had to add an addendum or replace references. For example, in June this year, a seventh planetary boundary was crossed (ocean acidification). Page 6, Column 1, Paragraph 2, starting "In parallel, ..", "educational format" includes what (i.e. activity, e.g. assignment, lecture, etc.) and how (in teams, face-to-face, etc.) . List of abbreviations CMO. Outcome. This could be short-term, e.g. learner satisfaction, which is the most common form of outcome as the longer-term outcomes such as competencies in the workplace, are difficult to measure. Longitudinal studies are required with multi-source feedback. Perhaps 'outcome' needs to be clarified. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Medical education, including evaluation and assessment, curriculum development and planetary health. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT McLean M. Reviewer Report For: Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :122 ( https://doi.org/10.21956/hrbopenres.15713.r52299 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-122/v1#referee-response-52299 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 02 Feb 2026 Marah Elfghi , Medical Education Unit, University College Cork School of Medicine, Cork, T12 AK54, Ireland 02 Feb 2026 Author Response Dear Reviewer, We would like to sincerely thank you for your careful reading of our manuscript and for your constructive and detailed feedback. We appreciate your positive assessment of ... Continue reading Dear Reviewer, We would like to sincerely thank you for your careful reading of our manuscript and for your constructive and detailed feedback. We appreciate your positive assessment of the clarity of the article and the helpful suggestions provided. Below, we respond to each of your comments and outline the revisions made to the manuscript. Access to Appendices 1.Comment: The appendices were not accessible. Response: Thank you for bringing this to our attention. The appendices are provided as supplementary material in Reference 49 Editorial and Language Corrections: 2.Comment: “CC&S education remain” should read “remains”. “An essential competency” should read “a set of competencies”. The sentence beginning “Whereas…” is incomplete. “To our knowledge” should read “To the best of our knowledge” Response: We thank the reviewer for noting these issues. All suggested grammatical and stylistic corrections have been implemented, including: Correction of verb agreement (“remains”) (pg.4) Revision to “a set of competencies” to reflect the multidimensional nature of CC&S competencies (pg.4) Correction of the incomplete sentence to ensure grammatical completeness (pg.5) Revision to “To the best of our knowledge” for academic precision (pg.5) Use of the Term “Programme Theory” 3.Comment: The term “programme theory” may be misleading, as “programme” is often interpreted as a full degree programme. Response: We appreciate this important conceptual clarification. We have revised the manuscript to explicitly define “programme theory” in the realist sense, clarifying that it refers to an explanatory theory of how educational interventions work, rather than an entire degree programme. Additional explanatory text has been added at first use to avoid ambiguity and support readers less familiar with realist methodology. (pg. 5) Clarification of “Mechanism” 4.Comment: The meaning of “mechanism” is unclear and may be confused with delivery methods or formats. Response: We agree with this observation. We have added a clear definition of “mechanism” consistent with realist methodology, explaining that mechanisms refer to the underlying processes (e.g. reasoning, motivation, engagement) triggered by an intervention within a specific context, rather than the intervention activities or delivery formats themselves. This clarification explicitly distinguishes mechanisms from teaching methods, formats, or educational activities. (pg. 6) Selection Criteria – Scope and Disciplinary Boundaries 5.Comment: Acknowledgement is needed that solutions to the triple planetary crisis extend beyond health disciplines. Response: Thank you for this valuable suggestion. We have added a statement acknowledging that addressing the interconnected challenges of climate change, biodiversity loss, and pollution requires contributions from multiple disciplines beyond health. We clarify that the present review focuses on health professions education while recognising the importance of broader interdisciplinary action. (pg. 9) Search End Date and Currency of the Review 6.Comment: The fixed end date (October 2024) risks the review being outdated by publication. Response: We appreciate this practical and important point. We have revised the protocol to state that the search will start from January 2024 onwards. (pg.9) Clarification of “Educational Format” 7.Comment: “Educational format” should clarify both the activity and mode of delivery. Response: Thank you for this suggestion. We have expanded the definition of “educational format” to explicitly include both the type of activity (e.g. lecture, assignment, workshop, simulation) and the mode of delivery (e.g. individual or team-based, face-to-face or online). (pg.10) Clarification of “Outcome” in CMO Framework 8.Comment: Outcomes can be short-term or long-term and should be clarified. Response: We agree with you. We have clarified this distinction in the protocol. Short-term outcomes (e.g., knowledge, attitudes, immediate skills acquisition) and long-term outcomes (e.g., sustained practice change, clinical outcomes) will be specified in our outcome definitions. We will include evaluation studies that measure outcomes at different timepoints, and what outcomes we extract will depend on how individual studies were designed and what they measured. Longitudinal studies will be particularly valuable for capturing long-term outcomes. We acknowledge this temporal distinction is important for understanding how mechanisms may operate differently over time. (pg.10) We thank the reviewer once again for their thoughtful and constructive feedback. The suggested revisions have significantly improved the precision, clarity, and methodological transparency of the manuscript. We believe the revised version addresses all concerns raised and strengthens the overall contribution of the protocol. We welcome any further guidance you may wish to provide. Kind regards, Marah Dear Reviewer, We would like to sincerely thank you for your careful reading of our manuscript and for your constructive and detailed feedback. We appreciate your positive assessment of the clarity of the article and the helpful suggestions provided. Below, we respond to each of your comments and outline the revisions made to the manuscript. Access to Appendices 1.Comment: The appendices were not accessible. Response: Thank you for bringing this to our attention. The appendices are provided as supplementary material in Reference 49 Editorial and Language Corrections: 2.Comment: “CC&S education remain” should read “remains”. “An essential competency” should read “a set of competencies”. The sentence beginning “Whereas…” is incomplete. “To our knowledge” should read “To the best of our knowledge” Response: We thank the reviewer for noting these issues. All suggested grammatical and stylistic corrections have been implemented, including: Correction of verb agreement (“remains”) (pg.4) Revision to “a set of competencies” to reflect the multidimensional nature of CC&S competencies (pg.4) Correction of the incomplete sentence to ensure grammatical completeness (pg.5) Revision to “To the best of our knowledge” for academic precision (pg.5) Use of the Term “Programme Theory” 3.Comment: The term “programme theory” may be misleading, as “programme” is often interpreted as a full degree programme. Response: We appreciate this important conceptual clarification. We have revised the manuscript to explicitly define “programme theory” in the realist sense, clarifying that it refers to an explanatory theory of how educational interventions work, rather than an entire degree programme. Additional explanatory text has been added at first use to avoid ambiguity and support readers less familiar with realist methodology. (pg. 5) Clarification of “Mechanism” 4.Comment: The meaning of “mechanism” is unclear and may be confused with delivery methods or formats. Response: We agree with this observation. We have added a clear definition of “mechanism” consistent with realist methodology, explaining that mechanisms refer to the underlying processes (e.g. reasoning, motivation, engagement) triggered by an intervention within a specific context, rather than the intervention activities or delivery formats themselves. This clarification explicitly distinguishes mechanisms from teaching methods, formats, or educational activities. (pg. 6) Selection Criteria – Scope and Disciplinary Boundaries 5.Comment: Acknowledgement is needed that solutions to the triple planetary crisis extend beyond health disciplines. Response: Thank you for this valuable suggestion. We have added a statement acknowledging that addressing the interconnected challenges of climate change, biodiversity loss, and pollution requires contributions from multiple disciplines beyond health. We clarify that the present review focuses on health professions education while recognising the importance of broader interdisciplinary action. (pg. 9) Search End Date and Currency of the Review 6.Comment: The fixed end date (October 2024) risks the review being outdated by publication. Response: We appreciate this practical and important point. We have revised the protocol to state that the search will start from January 2024 onwards. (pg.9) Clarification of “Educational Format” 7.Comment: “Educational format” should clarify both the activity and mode of delivery. Response: Thank you for this suggestion. We have expanded the definition of “educational format” to explicitly include both the type of activity (e.g. lecture, assignment, workshop, simulation) and the mode of delivery (e.g. individual or team-based, face-to-face or online). (pg.10) Clarification of “Outcome” in CMO Framework 8.Comment: Outcomes can be short-term or long-term and should be clarified. Response: We agree with you. We have clarified this distinction in the protocol. Short-term outcomes (e.g., knowledge, attitudes, immediate skills acquisition) and long-term outcomes (e.g., sustained practice change, clinical outcomes) will be specified in our outcome definitions. We will include evaluation studies that measure outcomes at different timepoints, and what outcomes we extract will depend on how individual studies were designed and what they measured. Longitudinal studies will be particularly valuable for capturing long-term outcomes. We acknowledge this temporal distinction is important for understanding how mechanisms may operate differently over time. (pg.10) We thank the reviewer once again for their thoughtful and constructive feedback. The suggested revisions have significantly improved the precision, clarity, and methodological transparency of the manuscript. We believe the revised version addresses all concerns raised and strengthens the overall contribution of the protocol. We welcome any further guidance you may wish to provide. Kind regards, Marah Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 02 Feb 2026 Marah Elfghi , Medical Education Unit, University College Cork School of Medicine, Cork, T12 AK54, Ireland 02 Feb 2026 Author Response Dear Reviewer, We would like to sincerely thank you for your careful reading of our manuscript and for your constructive and detailed feedback. We appreciate your positive assessment of ... Continue reading Dear Reviewer, We would like to sincerely thank you for your careful reading of our manuscript and for your constructive and detailed feedback. We appreciate your positive assessment of the clarity of the article and the helpful suggestions provided. Below, we respond to each of your comments and outline the revisions made to the manuscript. Access to Appendices 1.Comment: The appendices were not accessible. Response: Thank you for bringing this to our attention. The appendices are provided as supplementary material in Reference 49 Editorial and Language Corrections: 2.Comment: “CC&S education remain” should read “remains”. “An essential competency” should read “a set of competencies”. The sentence beginning “Whereas…” is incomplete. “To our knowledge” should read “To the best of our knowledge” Response: We thank the reviewer for noting these issues. All suggested grammatical and stylistic corrections have been implemented, including: Correction of verb agreement (“remains”) (pg.4) Revision to “a set of competencies” to reflect the multidimensional nature of CC&S competencies (pg.4) Correction of the incomplete sentence to ensure grammatical completeness (pg.5) Revision to “To the best of our knowledge” for academic precision (pg.5) Use of the Term “Programme Theory” 3.Comment: The term “programme theory” may be misleading, as “programme” is often interpreted as a full degree programme. Response: We appreciate this important conceptual clarification. We have revised the manuscript to explicitly define “programme theory” in the realist sense, clarifying that it refers to an explanatory theory of how educational interventions work, rather than an entire degree programme. Additional explanatory text has been added at first use to avoid ambiguity and support readers less familiar with realist methodology. (pg. 5) Clarification of “Mechanism” 4.Comment: The meaning of “mechanism” is unclear and may be confused with delivery methods or formats. Response: We agree with this observation. We have added a clear definition of “mechanism” consistent with realist methodology, explaining that mechanisms refer to the underlying processes (e.g. reasoning, motivation, engagement) triggered by an intervention within a specific context, rather than the intervention activities or delivery formats themselves. This clarification explicitly distinguishes mechanisms from teaching methods, formats, or educational activities. (pg. 6) Selection Criteria – Scope and Disciplinary Boundaries 5.Comment: Acknowledgement is needed that solutions to the triple planetary crisis extend beyond health disciplines. Response: Thank you for this valuable suggestion. We have added a statement acknowledging that addressing the interconnected challenges of climate change, biodiversity loss, and pollution requires contributions from multiple disciplines beyond health. We clarify that the present review focuses on health professions education while recognising the importance of broader interdisciplinary action. (pg. 9) Search End Date and Currency of the Review 6.Comment: The fixed end date (October 2024) risks the review being outdated by publication. Response: We appreciate this practical and important point. We have revised the protocol to state that the search will start from January 2024 onwards. (pg.9) Clarification of “Educational Format” 7.Comment: “Educational format” should clarify both the activity and mode of delivery. Response: Thank you for this suggestion. We have expanded the definition of “educational format” to explicitly include both the type of activity (e.g. lecture, assignment, workshop, simulation) and the mode of delivery (e.g. individual or team-based, face-to-face or online). (pg.10) Clarification of “Outcome” in CMO Framework 8.Comment: Outcomes can be short-term or long-term and should be clarified. Response: We agree with you. We have clarified this distinction in the protocol. Short-term outcomes (e.g., knowledge, attitudes, immediate skills acquisition) and long-term outcomes (e.g., sustained practice change, clinical outcomes) will be specified in our outcome definitions. We will include evaluation studies that measure outcomes at different timepoints, and what outcomes we extract will depend on how individual studies were designed and what they measured. Longitudinal studies will be particularly valuable for capturing long-term outcomes. We acknowledge this temporal distinction is important for understanding how mechanisms may operate differently over time. (pg.10) We thank the reviewer once again for their thoughtful and constructive feedback. The suggested revisions have significantly improved the precision, clarity, and methodological transparency of the manuscript. We believe the revised version addresses all concerns raised and strengthens the overall contribution of the protocol. We welcome any further guidance you may wish to provide. Kind regards, Marah Dear Reviewer, We would like to sincerely thank you for your careful reading of our manuscript and for your constructive and detailed feedback. We appreciate your positive assessment of the clarity of the article and the helpful suggestions provided. Below, we respond to each of your comments and outline the revisions made to the manuscript. Access to Appendices 1.Comment: The appendices were not accessible. Response: Thank you for bringing this to our attention. The appendices are provided as supplementary material in Reference 49 Editorial and Language Corrections: 2.Comment: “CC&S education remain” should read “remains”. “An essential competency” should read “a set of competencies”. The sentence beginning “Whereas…” is incomplete. “To our knowledge” should read “To the best of our knowledge” Response: We thank the reviewer for noting these issues. All suggested grammatical and stylistic corrections have been implemented, including: Correction of verb agreement (“remains”) (pg.4) Revision to “a set of competencies” to reflect the multidimensional nature of CC&S competencies (pg.4) Correction of the incomplete sentence to ensure grammatical completeness (pg.5) Revision to “To the best of our knowledge” for academic precision (pg.5) Use of the Term “Programme Theory” 3.Comment: The term “programme theory” may be misleading, as “programme” is often interpreted as a full degree programme. Response: We appreciate this important conceptual clarification. We have revised the manuscript to explicitly define “programme theory” in the realist sense, clarifying that it refers to an explanatory theory of how educational interventions work, rather than an entire degree programme. Additional explanatory text has been added at first use to avoid ambiguity and support readers less familiar with realist methodology. (pg. 5) Clarification of “Mechanism” 4.Comment: The meaning of “mechanism” is unclear and may be confused with delivery methods or formats. Response: We agree with this observation. We have added a clear definition of “mechanism” consistent with realist methodology, explaining that mechanisms refer to the underlying processes (e.g. reasoning, motivation, engagement) triggered by an intervention within a specific context, rather than the intervention activities or delivery formats themselves. This clarification explicitly distinguishes mechanisms from teaching methods, formats, or educational activities. (pg. 6) Selection Criteria – Scope and Disciplinary Boundaries 5.Comment: Acknowledgement is needed that solutions to the triple planetary crisis extend beyond health disciplines. Response: Thank you for this valuable suggestion. We have added a statement acknowledging that addressing the interconnected challenges of climate change, biodiversity loss, and pollution requires contributions from multiple disciplines beyond health. We clarify that the present review focuses on health professions education while recognising the importance of broader interdisciplinary action. (pg. 9) Search End Date and Currency of the Review 6.Comment: The fixed end date (October 2024) risks the review being outdated by publication. Response: We appreciate this practical and important point. We have revised the protocol to state that the search will start from January 2024 onwards. (pg.9) Clarification of “Educational Format” 7.Comment: “Educational format” should clarify both the activity and mode of delivery. Response: Thank you for this suggestion. We have expanded the definition of “educational format” to explicitly include both the type of activity (e.g. lecture, assignment, workshop, simulation) and the mode of delivery (e.g. individual or team-based, face-to-face or online). (pg.10) Clarification of “Outcome” in CMO Framework 8.Comment: Outcomes can be short-term or long-term and should be clarified. Response: We agree with you. We have clarified this distinction in the protocol. Short-term outcomes (e.g., knowledge, attitudes, immediate skills acquisition) and long-term outcomes (e.g., sustained practice change, clinical outcomes) will be specified in our outcome definitions. We will include evaluation studies that measure outcomes at different timepoints, and what outcomes we extract will depend on how individual studies were designed and what they measured. Longitudinal studies will be particularly valuable for capturing long-term outcomes. We acknowledge this temporal distinction is important for understanding how mechanisms may operate differently over time. (pg.10) We thank the reviewer once again for their thoughtful and constructive feedback. The suggested revisions have significantly improved the precision, clarity, and methodological transparency of the manuscript. We believe the revised version addresses all concerns raised and strengthens the overall contribution of the protocol. We welcome any further guidance you may wish to provide. Kind regards, Marah Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Anugwom EE. Reviewer Report For: Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :122 ( https://doi.org/10.21956/hrbopenres.15713.r51720 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-122/v1#referee-response-51720 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 02 Jan 2026 Edlyne Eze Anugwom , University of Nigeria, Nsukka, Nigeria Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15713.r51720 General Observations: The study is as timely as it is also seemingly overdue given the importance of climate change and its repercussions on all spheres of life in contemporary society. There is arguing the fact (despite the existence of ... Continue reading READ ALL General Observations: The study is as timely as it is also seemingly overdue given the importance of climate change and its repercussions on all spheres of life in contemporary society. There is arguing the fact (despite the existence of pockets of incurable nay-sayers) that climate change is perhaps the most remarkable challenge of life in contemporary society as we know it. It does really begs the question why health professions education has not mainstreamed climate change into its curricular and models of practice soon enough! In this sense, the present study is a timely and welcome intervention that would hopefully energize not only the discourse of climate change in HPE but the evolvement of workable strategies and theory that would guide education and practice. The above notwithstanding, the following observations may be pertinent: The study shows a very good knowledge of the extant literature in the area of focus and this commendable and portrays the fact that the authors are very capable of achieving the aims of the study. In addition to the above, the study uses available or extant literature to provide further insights for its goals/outcomes generally. In other words, the authors clearly demonstrate that the study is anchored on evident paucity in the extant literature especially gaps existing in available empirical studies or reviews in the literature. In addition, it also drew insights from advocacy and the standing of health policy bodies/accreditation agencies in underlining the overarching need for CCS in HPE. However, there are too many jargons and health-related concepts that can potentially limit the value of the study for non-health professionals. Given the nature of climate change as both inter and multi-disciplinary, there may be need to simplify these jargons and go for words/phrases that are within the easy comprehension of general readers. Despite the fact that it has become standard fare to talk about ‘realist’ review, the study needs to capture the essence of the so-called realist review i.e., is it different from systematic review or is it part of systematic review. This is important in the light of the fact that there seems some ambivalence in the extant literature regarding the real status of the so-called realist review. For instance, there is the perception of realist review as simply another form of systematic review (see, Pawson et al., 2025 Ref 1) or as the elongation of the usual systematic review to include the why and where questions often glossed over in traditional systematic reviews. Thus, the extant literature would seem to suggest that realist review is an elongation of the systematic review in the sense of going beyond what works to also include for whom and under what circumstances or why (see, Weiss and Bucuvalas, 1980 Ref 2; Pawson, 2006 Ref 3; Wong et al., 2012 Ref 4). There is mention of the Context-Mechanism-Outcome (CMO) framework and this seems quite interesting; however, there is need to make explicit what ‘mechanism’ means. In other words, there is need to properly conceptualize it along the lines of what was done with regards to ‘context’. Comments on Methods: The authors have done quite an impressive job of detailing and specifying the methods to be adopted in the study. However, I believe that the methods could be further strengthened by looking at the following minor issues: There is need to unravel or explain exactly some key phrases used in the protocol, e.g., ‘detailed selection criteria’ – what does this mean? Also, the idea of grey literature though an old practice in qualitative studies should be further elaborated – what is grey literature in this case? In addition to the above, the choice of studies or literature published between 2014 and 2024 in the inclusion criteria needs to be justified; why this period? Also, why the exclusion of non-empirical works/studies? This seems strange for a protocol focused on developing a new theory! There is the stated objective of the protocol to bridge the gap between existing interventions and their effectiveness across different contexts. As interesting as the above sounds, the critical issue is how this goal can be achieved through the development of a new programme theory. In other words, there is need to further adumbrate or show in clear terms how a new programme theory would bridge this gap or at the minimum the envisaged properties of the theory that could tackle this gap. Observations on Goals/Outcomes: The goals/outcomes of the study seem at the same time laudable/impressive and over-ambitious. It would make sense for the researchers to have a clear focus on what is achievable and practicable and not enticed by the desire to solve all problems or cover all universe. Therefore, the following may be helpful: The goal of the review protocol to examine CCS in HPE at the undergraduate, postgraduate and even continuing professional education as well as in diverse health care disciplines seems over-ambitious and may lead to the generation or development of a protocol or guide too-unwieldy and over-reaching to provide realistic guidance. It would seem too-much like a one-size-fits-all approach and thus have limited effectiveness/impact. There is still need to relate the outcome of the study which is stated to be ‘the development of a programme theory’ to the methodology chosen. A review may yield evidence or results regarding paucity of existing theoretical orientations but how to transit from this paucity (or even gaps) to the evolvement/generation of a new theory needs further nuancing especially since no efforts addressing the critique and evaluation of existing theories were mentioned in the methods. All the same, one must acknowledge the impressive array of theories mentioned that would inform the Initial Programme Theory (IPT); however, these theories are so diverse in both focus and disciplinary orientations that the challenge of how to really and productively synthesize them emerge. And this was not creatively factored into the protocol. Thus, the validity of the envisaged Refined Programme Theory (RPT) may be limited especially as it is expected to apply to a diverse academic, practice and disciplinary worlds. Moreso, there is need to understand the pre-requisites of a good theory generally and the efforts towards critiquing or generating a new theory must abide with some of these major conventions (see, Okeibunor and Anugwom, 2002 Ref 5; Whetten, 1989 Ref 6; Guest, 2024 Ref 7; Lange et al., 2025 Ref 8). Also, the goal to provide actionable insights for embedding CC&S education into HPE curricula globally was mentioned – this seems too ambitious and clearly not feasible given structural, curricula and contextual differences in HPE across the globe. HPE curricular differs across nations and sometimes within countries and regions. Therefore, aiming for actionable insights applicable globally may in truth seem like an overreach. References: Guest, O. (2024). “What Makes a good Theory, and How Do We Make a Theory Good”? Computational Brain and Behaviour 7 (1). https://doi.org/10.1007/s42113-023-00193-2 Lange, J., Freyer, N., Musfeld, P., Schonbrodt, F., & Leising, D. (2025). “A Checklist for Incentivizing and Facilitating Good Theory Building”. Zeitschrift fur Psychologie 233 (4): 279 – 283. https://doi.org/10.1027/2151-2604/a000604 Okeibunor, J.C. & Anugwom, E.E. (2002). Sociological Theory: an insight into dominant viewpoints. Nsukka: Fulladu Pawson, R. (2006). Evidence Based Policy: A Realist Perspective . London: Sage. https://doi.org/10.1080/15588740802262039 Pawson, R., Greenhalgh, T., Harvey, G., & Walshe, K. (2025). “Realist Review: A New Method of Systematic Review Designed for Complex Policy Interventions”. Journal of Health Services Research and Policy 10 (1): 21 – 34. https://doi.org/10.1258/1355819054308530 Weiss, C.H., & Bucuvalas, M.J. (1980). Social Science Research and Decision Making . Newbury Park: Sage Whetten, D. (1989). “What Constitutes a Theoretical Contribution”? Academy of Management Review 14 (4): 490 – 495. https://doi.org/10.2307/258554 Wong, G., Greenhalgh, T., Westhorp G., Pawson, R. (2012). “Realist Methods in Medical Education Research: What are They and What can They Contribute”? Medical Education 46 (1):89–96. https://doi.org/10.111/j.1365-2923.2011.04045.x . Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable References 1. Pawson R, Greenhalgh T, Harvey G, Walshe K: Realist review - a new method of systematic review designed for complex policy interventions. Journal of Health Services Research & Policy . 2005; 10 (1_suppl): 21-34 Publisher Full Text 2. CH, Weiss MJ, Bucuvalas: Social Science Research and Decision Making. https://archive.org/details/socialscienceres0000weis . 1980. 3. Triana R: Evidence-Based Policy: A Realist Perspective, by Ray Pawson. Journal of Policy Practice . 2008; 7 (4): 321-323 Publisher Full Text 4. Wong G, Greenhalgh T, Westhorp G, Pawson R: Realist methods in medical education research: what are they and what can they contribute?. Medical Education . 2012; 46 (1): 89-96 Publisher Full Text 5. JC, Okeibunor EE, Anugwom: Sociological Theory: an insight into dominant viewpoints. 2002. 6. Whetten D: What Constitutes a Theoretical Contribution?. The Academy of Management Review . 1989; 14 (4). Publisher Full Text 7. Guest O: What Makes a Good Theory, and How Do We Make a Theory Good?. Computational Brain & Behavior . 2024; 7 (4): 508-522 Publisher Full Text 8. Lange J, Freyer N, Musfeld P, Schönbrodt F, et al.: A Checklist for Incentivizing and Facilitating Good Theory Building. Zeitschrift für Psychologie . 2025; 233 (4): 279-283 Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Social Dimensions of Climate Change; Development Studies; Political Economy; Public Health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Anugwom EE. Reviewer Report For: Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :122 ( https://doi.org/10.21956/hrbopenres.15713.r51720 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-122/v1#referee-response-51720 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 02 Feb 2026 Marah Elfghi , Medical Education Unit, University College Cork School of Medicine, Cork, T12 AK54, Ireland 02 Feb 2026 Author Response Dear Reviewer, We sincerely thank you for your thoughtful, generous, and constructive review of our realist review protocol. We greatly appreciate your recognition of the timeliness, relevance, and scholarly grounding ... Continue reading Dear Reviewer, We sincerely thank you for your thoughtful, generous, and constructive review of our realist review protocol. We greatly appreciate your recognition of the timeliness, relevance, and scholarly grounding of the study, as well as your detailed feedback, which has helped us strengthen the clarity, methodological rigour, and theoretical coherence of the protocol. Below, we respond to each of your comments in turn and outline the revisions made to the manuscript. General Observations: 1.Comment: The topic is timely and important, but the manuscript contains excessive jargon that may limit accessibility for non-health professionals. Response: We thank the reviewer for this thoughtful observation and agree that climate change is inherently interdisciplinary and of relevance beyond the health sector. The primary intended audience for this realist review, however, is educators, researchers, and policymakers working within health professions education. As such, the use of established terminology from health education, implementation science, and realist methodology is necessary to ensure conceptual precision and alignment with existing scholarly discourse in this field. That said, we have carefully reviewed the manuscript to ensure that key technical terms are used consistently and meaningfully, and that their application is appropriate to the aims of the study. Where specialist terminology is essential, it reflects commonly accepted language within health professions education and realist synthesis and is required to maintain methodological clarity and rigour. We believe that further simplification beyond this point would risk diluting important conceptual distinctions central to the realist approach. 2.Comment: The manuscript needs to more clearly explain what distinguishes a realist review from a systematic review. Response: Thank you for highlighting this important point. We have expanded the Background section to explicitly clarify the epistemological and methodological distinction between realist reviews and traditional systematic reviews. In particular, we now explain that realist reviews are theory-driven and focus on understanding how , why , for whom , and under what circumstances interventions work, rather than solely assessing effectiveness. We have added text positioning realist review as an extension beyond traditional systematic reviews, drawing on established realist literature to clarify this distinction and address ambivalence in the field. (pg. 5) 3.Comment: The Context–Mechanism–Outcome (CMO) framework is mentioned, but the concept of “mechanism” requires clearer conceptualisation. Response: We fully agree. We have added an explicit definition and conceptual explanation of “mechanism” within the realist tradition, distinguishing mechanisms from programme activities and outcomes. This clarification is now included in the Methods sections, ensuring consistency and conceptual transparency. (pg. 6) Comments on Methods 4.Comment: Key phrases such as “detailed selection criteria” and “grey literature” require clarification. Response: Thank you for your comment. We agree with you, we have defined detailed selection criteria: as the predefined inclusion and exclusion conditions used to decide which studies are eligible to be included. (pg.6) Additionally, we have expanded the description of grey literature, specifying what sources are included (e.g., policy reports, curricular documents, organisational reports) and explaining their relevance to realist theory development. (pg.8) 5.Comment: The inclusion of studies published between 2014 and 2024 requires justification, and the exclusion of non-empirical studies seems contradictory for theory development. Response: We appreciate this important critique. We have now justified the 2014 onwards timeframe, noting that most CC&S education initiatives in HPE emerged during this period alongside growing global policy and curricular momentum. (pg.9) Regarding non-empirical studies, we have clarified that while theoretical papers are excluded from formal inclusion, theory-informed insights are incorporated during the development of the Initial Programme Theory. Empirical studies are prioritised to ensure that theory refinement is grounded in observed contexts, mechanisms, and outcomes rather than abstract conceptualisation alone. (pg.9) 6.Comment: It is unclear how the development of a programme theory will bridge the gap between interventions and their effectiveness across contexts. Response: Thank you for your comment. Programme theory bridges this gap by explaining how and why interventions work differently across contexts. It identifies the mechanisms that are activated in particular contexts to produce outcomes, thereby explaining variation in effectiveness through context-mechanism-outcome configurations (as explained in pg.10) rather than simply documenting it. Observations on Goals and Outcomes 7.Comment: The goals of the study appear over-ambitious, particularly the inclusion of multiple educational levels and disciplines. Response: We acknowledge this concern and have revised the manuscript accordingly. We have refined the stated goals to emphasise theory-building rather than universal prescription, clarifying that the intent is not to propose a one-size-fits-all model but to develop an explanatory framework sensitive to contextual variation across educational levels and disciplines. (pg.5 and pg.11) 8.Comment: The relationship between theory development and the realist methodology requires clearer articulation. Response: We agree. We have strengthened the linkage between realist methodology and programme theory development, explicitly explaining how iterative CMO analysis leads to theory refinement. Furthermore, we have clarified how existing theories inform; but do not predetermine. These frameworks will be selectively refined the programme theory, and we have acknowledged the methodological challenge of synthesising diverse theoretical perspectives. (pg.8 and pg.11) 9.Comment: The ambition to generate globally applicable actionable insights is unrealistic given curricular and contextual variation. Response: We appreciate this important point. We have revised the language, we now emphasise that findings will offer transferable principles and context-sensitive insights, allowing educators and institutions to adapt recommendations to their local curricular, cultural, and policy environments. (pg.3 and pg.11) Once again, we sincerely thank you for your insightful and rigorous review. Your feedback has significantly strengthened the conceptual clarity, methodological transparency, and scholarly contribution of this protocol. We believe the revisions address your concerns and improve the overall quality and utility of the manuscript. We would be happy to address any further comments if required. Kind regards, Marah Dear Reviewer, We sincerely thank you for your thoughtful, generous, and constructive review of our realist review protocol. We greatly appreciate your recognition of the timeliness, relevance, and scholarly grounding of the study, as well as your detailed feedback, which has helped us strengthen the clarity, methodological rigour, and theoretical coherence of the protocol. Below, we respond to each of your comments in turn and outline the revisions made to the manuscript. General Observations: 1.Comment: The topic is timely and important, but the manuscript contains excessive jargon that may limit accessibility for non-health professionals. Response: We thank the reviewer for this thoughtful observation and agree that climate change is inherently interdisciplinary and of relevance beyond the health sector. The primary intended audience for this realist review, however, is educators, researchers, and policymakers working within health professions education. As such, the use of established terminology from health education, implementation science, and realist methodology is necessary to ensure conceptual precision and alignment with existing scholarly discourse in this field. That said, we have carefully reviewed the manuscript to ensure that key technical terms are used consistently and meaningfully, and that their application is appropriate to the aims of the study. Where specialist terminology is essential, it reflects commonly accepted language within health professions education and realist synthesis and is required to maintain methodological clarity and rigour. We believe that further simplification beyond this point would risk diluting important conceptual distinctions central to the realist approach. 2.Comment: The manuscript needs to more clearly explain what distinguishes a realist review from a systematic review. Response: Thank you for highlighting this important point. We have expanded the Background section to explicitly clarify the epistemological and methodological distinction between realist reviews and traditional systematic reviews. In particular, we now explain that realist reviews are theory-driven and focus on understanding how , why , for whom , and under what circumstances interventions work, rather than solely assessing effectiveness. We have added text positioning realist review as an extension beyond traditional systematic reviews, drawing on established realist literature to clarify this distinction and address ambivalence in the field. (pg. 5) 3.Comment: The Context–Mechanism–Outcome (CMO) framework is mentioned, but the concept of “mechanism” requires clearer conceptualisation. Response: We fully agree. We have added an explicit definition and conceptual explanation of “mechanism” within the realist tradition, distinguishing mechanisms from programme activities and outcomes. This clarification is now included in the Methods sections, ensuring consistency and conceptual transparency. (pg. 6) Comments on Methods 4.Comment: Key phrases such as “detailed selection criteria” and “grey literature” require clarification. Response: Thank you for your comment. We agree with you, we have defined detailed selection criteria: as the predefined inclusion and exclusion conditions used to decide which studies are eligible to be included. (pg.6) Additionally, we have expanded the description of grey literature, specifying what sources are included (e.g., policy reports, curricular documents, organisational reports) and explaining their relevance to realist theory development. (pg.8) 5.Comment: The inclusion of studies published between 2014 and 2024 requires justification, and the exclusion of non-empirical studies seems contradictory for theory development. Response: We appreciate this important critique. We have now justified the 2014 onwards timeframe, noting that most CC&S education initiatives in HPE emerged during this period alongside growing global policy and curricular momentum. (pg.9) Regarding non-empirical studies, we have clarified that while theoretical papers are excluded from formal inclusion, theory-informed insights are incorporated during the development of the Initial Programme Theory. Empirical studies are prioritised to ensure that theory refinement is grounded in observed contexts, mechanisms, and outcomes rather than abstract conceptualisation alone. (pg.9) 6.Comment: It is unclear how the development of a programme theory will bridge the gap between interventions and their effectiveness across contexts. Response: Thank you for your comment. Programme theory bridges this gap by explaining how and why interventions work differently across contexts. It identifies the mechanisms that are activated in particular contexts to produce outcomes, thereby explaining variation in effectiveness through context-mechanism-outcome configurations (as explained in pg.10) rather than simply documenting it. Observations on Goals and Outcomes 7.Comment: The goals of the study appear over-ambitious, particularly the inclusion of multiple educational levels and disciplines. Response: We acknowledge this concern and have revised the manuscript accordingly. We have refined the stated goals to emphasise theory-building rather than universal prescription, clarifying that the intent is not to propose a one-size-fits-all model but to develop an explanatory framework sensitive to contextual variation across educational levels and disciplines. (pg.5 and pg.11) 8.Comment: The relationship between theory development and the realist methodology requires clearer articulation. Response: We agree. We have strengthened the linkage between realist methodology and programme theory development, explicitly explaining how iterative CMO analysis leads to theory refinement. Furthermore, we have clarified how existing theories inform; but do not predetermine. These frameworks will be selectively refined the programme theory, and we have acknowledged the methodological challenge of synthesising diverse theoretical perspectives. (pg.8 and pg.11) 9.Comment: The ambition to generate globally applicable actionable insights is unrealistic given curricular and contextual variation. Response: We appreciate this important point. We have revised the language, we now emphasise that findings will offer transferable principles and context-sensitive insights, allowing educators and institutions to adapt recommendations to their local curricular, cultural, and policy environments. (pg.3 and pg.11) Once again, we sincerely thank you for your insightful and rigorous review. Your feedback has significantly strengthened the conceptual clarity, methodological transparency, and scholarly contribution of this protocol. We believe the revisions address your concerns and improve the overall quality and utility of the manuscript. We would be happy to address any further comments if required. Kind regards, Marah Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 02 Feb 2026 Marah Elfghi , Medical Education Unit, University College Cork School of Medicine, Cork, T12 AK54, Ireland 02 Feb 2026 Author Response Dear Reviewer, We sincerely thank you for your thoughtful, generous, and constructive review of our realist review protocol. We greatly appreciate your recognition of the timeliness, relevance, and scholarly grounding ... Continue reading Dear Reviewer, We sincerely thank you for your thoughtful, generous, and constructive review of our realist review protocol. We greatly appreciate your recognition of the timeliness, relevance, and scholarly grounding of the study, as well as your detailed feedback, which has helped us strengthen the clarity, methodological rigour, and theoretical coherence of the protocol. Below, we respond to each of your comments in turn and outline the revisions made to the manuscript. General Observations: 1.Comment: The topic is timely and important, but the manuscript contains excessive jargon that may limit accessibility for non-health professionals. Response: We thank the reviewer for this thoughtful observation and agree that climate change is inherently interdisciplinary and of relevance beyond the health sector. The primary intended audience for this realist review, however, is educators, researchers, and policymakers working within health professions education. As such, the use of established terminology from health education, implementation science, and realist methodology is necessary to ensure conceptual precision and alignment with existing scholarly discourse in this field. That said, we have carefully reviewed the manuscript to ensure that key technical terms are used consistently and meaningfully, and that their application is appropriate to the aims of the study. Where specialist terminology is essential, it reflects commonly accepted language within health professions education and realist synthesis and is required to maintain methodological clarity and rigour. We believe that further simplification beyond this point would risk diluting important conceptual distinctions central to the realist approach. 2.Comment: The manuscript needs to more clearly explain what distinguishes a realist review from a systematic review. Response: Thank you for highlighting this important point. We have expanded the Background section to explicitly clarify the epistemological and methodological distinction between realist reviews and traditional systematic reviews. In particular, we now explain that realist reviews are theory-driven and focus on understanding how , why , for whom , and under what circumstances interventions work, rather than solely assessing effectiveness. We have added text positioning realist review as an extension beyond traditional systematic reviews, drawing on established realist literature to clarify this distinction and address ambivalence in the field. (pg. 5) 3.Comment: The Context–Mechanism–Outcome (CMO) framework is mentioned, but the concept of “mechanism” requires clearer conceptualisation. Response: We fully agree. We have added an explicit definition and conceptual explanation of “mechanism” within the realist tradition, distinguishing mechanisms from programme activities and outcomes. This clarification is now included in the Methods sections, ensuring consistency and conceptual transparency. (pg. 6) Comments on Methods 4.Comment: Key phrases such as “detailed selection criteria” and “grey literature” require clarification. Response: Thank you for your comment. We agree with you, we have defined detailed selection criteria: as the predefined inclusion and exclusion conditions used to decide which studies are eligible to be included. (pg.6) Additionally, we have expanded the description of grey literature, specifying what sources are included (e.g., policy reports, curricular documents, organisational reports) and explaining their relevance to realist theory development. (pg.8) 5.Comment: The inclusion of studies published between 2014 and 2024 requires justification, and the exclusion of non-empirical studies seems contradictory for theory development. Response: We appreciate this important critique. We have now justified the 2014 onwards timeframe, noting that most CC&S education initiatives in HPE emerged during this period alongside growing global policy and curricular momentum. (pg.9) Regarding non-empirical studies, we have clarified that while theoretical papers are excluded from formal inclusion, theory-informed insights are incorporated during the development of the Initial Programme Theory. Empirical studies are prioritised to ensure that theory refinement is grounded in observed contexts, mechanisms, and outcomes rather than abstract conceptualisation alone. (pg.9) 6.Comment: It is unclear how the development of a programme theory will bridge the gap between interventions and their effectiveness across contexts. Response: Thank you for your comment. Programme theory bridges this gap by explaining how and why interventions work differently across contexts. It identifies the mechanisms that are activated in particular contexts to produce outcomes, thereby explaining variation in effectiveness through context-mechanism-outcome configurations (as explained in pg.10) rather than simply documenting it. Observations on Goals and Outcomes 7.Comment: The goals of the study appear over-ambitious, particularly the inclusion of multiple educational levels and disciplines. Response: We acknowledge this concern and have revised the manuscript accordingly. We have refined the stated goals to emphasise theory-building rather than universal prescription, clarifying that the intent is not to propose a one-size-fits-all model but to develop an explanatory framework sensitive to contextual variation across educational levels and disciplines. (pg.5 and pg.11) 8.Comment: The relationship between theory development and the realist methodology requires clearer articulation. Response: We agree. We have strengthened the linkage between realist methodology and programme theory development, explicitly explaining how iterative CMO analysis leads to theory refinement. Furthermore, we have clarified how existing theories inform; but do not predetermine. These frameworks will be selectively refined the programme theory, and we have acknowledged the methodological challenge of synthesising diverse theoretical perspectives. (pg.8 and pg.11) 9.Comment: The ambition to generate globally applicable actionable insights is unrealistic given curricular and contextual variation. Response: We appreciate this important point. We have revised the language, we now emphasise that findings will offer transferable principles and context-sensitive insights, allowing educators and institutions to adapt recommendations to their local curricular, cultural, and policy environments. (pg.3 and pg.11) Once again, we sincerely thank you for your insightful and rigorous review. Your feedback has significantly strengthened the conceptual clarity, methodological transparency, and scholarly contribution of this protocol. We believe the revisions address your concerns and improve the overall quality and utility of the manuscript. We would be happy to address any further comments if required. Kind regards, Marah Dear Reviewer, We sincerely thank you for your thoughtful, generous, and constructive review of our realist review protocol. We greatly appreciate your recognition of the timeliness, relevance, and scholarly grounding of the study, as well as your detailed feedback, which has helped us strengthen the clarity, methodological rigour, and theoretical coherence of the protocol. Below, we respond to each of your comments in turn and outline the revisions made to the manuscript. General Observations: 1.Comment: The topic is timely and important, but the manuscript contains excessive jargon that may limit accessibility for non-health professionals. Response: We thank the reviewer for this thoughtful observation and agree that climate change is inherently interdisciplinary and of relevance beyond the health sector. The primary intended audience for this realist review, however, is educators, researchers, and policymakers working within health professions education. As such, the use of established terminology from health education, implementation science, and realist methodology is necessary to ensure conceptual precision and alignment with existing scholarly discourse in this field. That said, we have carefully reviewed the manuscript to ensure that key technical terms are used consistently and meaningfully, and that their application is appropriate to the aims of the study. Where specialist terminology is essential, it reflects commonly accepted language within health professions education and realist synthesis and is required to maintain methodological clarity and rigour. We believe that further simplification beyond this point would risk diluting important conceptual distinctions central to the realist approach. 2.Comment: The manuscript needs to more clearly explain what distinguishes a realist review from a systematic review. Response: Thank you for highlighting this important point. We have expanded the Background section to explicitly clarify the epistemological and methodological distinction between realist reviews and traditional systematic reviews. In particular, we now explain that realist reviews are theory-driven and focus on understanding how , why , for whom , and under what circumstances interventions work, rather than solely assessing effectiveness. We have added text positioning realist review as an extension beyond traditional systematic reviews, drawing on established realist literature to clarify this distinction and address ambivalence in the field. (pg. 5) 3.Comment: The Context–Mechanism–Outcome (CMO) framework is mentioned, but the concept of “mechanism” requires clearer conceptualisation. Response: We fully agree. We have added an explicit definition and conceptual explanation of “mechanism” within the realist tradition, distinguishing mechanisms from programme activities and outcomes. This clarification is now included in the Methods sections, ensuring consistency and conceptual transparency. (pg. 6) Comments on Methods 4.Comment: Key phrases such as “detailed selection criteria” and “grey literature” require clarification. Response: Thank you for your comment. We agree with you, we have defined detailed selection criteria: as the predefined inclusion and exclusion conditions used to decide which studies are eligible to be included. (pg.6) Additionally, we have expanded the description of grey literature, specifying what sources are included (e.g., policy reports, curricular documents, organisational reports) and explaining their relevance to realist theory development. (pg.8) 5.Comment: The inclusion of studies published between 2014 and 2024 requires justification, and the exclusion of non-empirical studies seems contradictory for theory development. Response: We appreciate this important critique. We have now justified the 2014 onwards timeframe, noting that most CC&S education initiatives in HPE emerged during this period alongside growing global policy and curricular momentum. (pg.9) Regarding non-empirical studies, we have clarified that while theoretical papers are excluded from formal inclusion, theory-informed insights are incorporated during the development of the Initial Programme Theory. Empirical studies are prioritised to ensure that theory refinement is grounded in observed contexts, mechanisms, and outcomes rather than abstract conceptualisation alone. (pg.9) 6.Comment: It is unclear how the development of a programme theory will bridge the gap between interventions and their effectiveness across contexts. Response: Thank you for your comment. Programme theory bridges this gap by explaining how and why interventions work differently across contexts. It identifies the mechanisms that are activated in particular contexts to produce outcomes, thereby explaining variation in effectiveness through context-mechanism-outcome configurations (as explained in pg.10) rather than simply documenting it. Observations on Goals and Outcomes 7.Comment: The goals of the study appear over-ambitious, particularly the inclusion of multiple educational levels and disciplines. Response: We acknowledge this concern and have revised the manuscript accordingly. We have refined the stated goals to emphasise theory-building rather than universal prescription, clarifying that the intent is not to propose a one-size-fits-all model but to develop an explanatory framework sensitive to contextual variation across educational levels and disciplines. (pg.5 and pg.11) 8.Comment: The relationship between theory development and the realist methodology requires clearer articulation. Response: We agree. We have strengthened the linkage between realist methodology and programme theory development, explicitly explaining how iterative CMO analysis leads to theory refinement. Furthermore, we have clarified how existing theories inform; but do not predetermine. These frameworks will be selectively refined the programme theory, and we have acknowledged the methodological challenge of synthesising diverse theoretical perspectives. (pg.8 and pg.11) 9.Comment: The ambition to generate globally applicable actionable insights is unrealistic given curricular and contextual variation. Response: We appreciate this important point. We have revised the language, we now emphasise that findings will offer transferable principles and context-sensitive insights, allowing educators and institutions to adapt recommendations to their local curricular, cultural, and policy environments. (pg.3 and pg.11) Once again, we sincerely thank you for your insightful and rigorous review. Your feedback has significantly strengthened the conceptual clarity, methodological transparency, and scholarly contribution of this protocol. We believe the revisions address your concerns and improve the overall quality and utility of the manuscript. We would be happy to address any further comments if required. Kind regards, Marah Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 18 Nov 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 02 Feb 26 read Version 1 18 Nov 25 read read Edlyne Eze Anugwom , University of Nigeria, Nsukka, Nigeria Michelle McLean , Bond University, Gold Coast, Australia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Anugwom E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 10 Feb 2026 | for Version 2 Edlyne Eze Anugwom , University of Nigeria, Nsukka, Nigeria 0 Views copyright © 2026 Anugwom E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The review has taken care of the comments in my earlier submission. Therefore, the paper is now okay and acceptable. Competing Interests No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Anugwom EE. Peer Review Report For: Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :122 ( https://doi.org/10.21956/hrbopenres.15797.r53257) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-122/v2#referee-response-53257 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 McLean M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 06 Jan 2026 | for Version 1 Michelle McLean , Bond University, Gold Coast, Australia 0 Views copyright © 2026 McLean M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The article is clearly written and for the most, I know what the authors want to achieve. I don't believe I had access to the two appendices. A few considerations: P3, second column, Line 4. should read 'CC&S education remains..' (currently 'remain'). Same line 'an essential competency' should read 'a set oc competencies' as there are many competencies in different domains relating to CC&S. Same page and column, paragraph starting with "Systematic reviews... " The second 'sentence' starting "Whereas... " is not a sentence. Same paragraph, the sentence should read "To the best of our knowledge, no ...". Page 4, Column 1, paragraph beginning "Guided by learning.." near the top of the page, "programme theory" is used. I am not sure what to suggest as an alternative, but programme theory is not an informative term. A programme is usually the complete degree and all of its content and activities. Page 4, Column 1, paragraph beginning "This realist.." What is meant by 'mechanism'? For me, a mechanism involves 'how'. Is it a delivery methods, a format, an educational intervention? Selection criteria 1.Although other disciplines have been excluded, and including them will be impossible, it is probably worth including a note to acknowledge that, in terms of the interrelated triple planetary crisis of a changing climate, biodiversity loss and pollution, solutions are going to come from many different fields, not just health. 2. Much water has flowed under the bridge since October 2024 so the review will be outdated by the time it is published. I think that for the review to be current, the end date should be kept open until the article is about to be published. This has happened to me on three occasions this year. The review process has taken so long that I have had to add an addendum or replace references. For example, in June this year, a seventh planetary boundary was crossed (ocean acidification). Page 6, Column 1, Paragraph 2, starting "In parallel, ..", "educational format" includes what (i.e. activity, e.g. assignment, lecture, etc.) and how (in teams, face-to-face, etc.) . List of abbreviations CMO. Outcome. This could be short-term, e.g. learner satisfaction, which is the most common form of outcome as the longer-term outcomes such as competencies in the workplace, are difficult to measure. Longitudinal studies are required with multi-source feedback. Perhaps 'outcome' needs to be clarified. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise Medical education, including evaluation and assessment, curriculum development and planetary health. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (1) Author Response 02 Feb 2026 Marah Elfghi, Medical Education Unit, University College Cork School of Medicine, Cork, T12 AK54, Ireland Dear Reviewer, We would like to sincerely thank you for your careful reading of our manuscript and for your constructive and detailed feedback. We appreciate your positive assessment of the clarity of the article and the helpful suggestions provided. Below, we respond to each of your comments and outline the revisions made to the manuscript. Access to Appendices 1.Comment: The appendices were not accessible. Response: Thank you for bringing this to our attention. The appendices are provided as supplementary material in Reference 49 Editorial and Language Corrections: 2.Comment: “CC&S education remain” should read “remains”. “An essential competency” should read “a set of competencies”. The sentence beginning “Whereas…” is incomplete. “To our knowledge” should read “To the best of our knowledge” Response: We thank the reviewer for noting these issues. All suggested grammatical and stylistic corrections have been implemented, including: Correction of verb agreement (“remains”) (pg.4) Revision to “a set of competencies” to reflect the multidimensional nature of CC&S competencies (pg.4) Correction of the incomplete sentence to ensure grammatical completeness (pg.5) Revision to “To the best of our knowledge” for academic precision (pg.5) Use of the Term “Programme Theory” 3.Comment: The term “programme theory” may be misleading, as “programme” is often interpreted as a full degree programme. Response: We appreciate this important conceptual clarification. We have revised the manuscript to explicitly define “programme theory” in the realist sense, clarifying that it refers to an explanatory theory of how educational interventions work, rather than an entire degree programme. Additional explanatory text has been added at first use to avoid ambiguity and support readers less familiar with realist methodology. (pg. 5) Clarification of “Mechanism” 4.Comment: The meaning of “mechanism” is unclear and may be confused with delivery methods or formats. Response: We agree with this observation. We have added a clear definition of “mechanism” consistent with realist methodology, explaining that mechanisms refer to the underlying processes (e.g. reasoning, motivation, engagement) triggered by an intervention within a specific context, rather than the intervention activities or delivery formats themselves. This clarification explicitly distinguishes mechanisms from teaching methods, formats, or educational activities. (pg. 6) Selection Criteria – Scope and Disciplinary Boundaries 5.Comment: Acknowledgement is needed that solutions to the triple planetary crisis extend beyond health disciplines. Response: Thank you for this valuable suggestion. We have added a statement acknowledging that addressing the interconnected challenges of climate change, biodiversity loss, and pollution requires contributions from multiple disciplines beyond health. We clarify that the present review focuses on health professions education while recognising the importance of broader interdisciplinary action. (pg. 9) Search End Date and Currency of the Review 6.Comment: The fixed end date (October 2024) risks the review being outdated by publication. Response: We appreciate this practical and important point. We have revised the protocol to state that the search will start from January 2024 onwards. (pg.9) Clarification of “Educational Format” 7.Comment: “Educational format” should clarify both the activity and mode of delivery. Response: Thank you for this suggestion. We have expanded the definition of “educational format” to explicitly include both the type of activity (e.g. lecture, assignment, workshop, simulation) and the mode of delivery (e.g. individual or team-based, face-to-face or online). (pg.10) Clarification of “Outcome” in CMO Framework 8.Comment: Outcomes can be short-term or long-term and should be clarified. Response: We agree with you. We have clarified this distinction in the protocol. Short-term outcomes (e.g., knowledge, attitudes, immediate skills acquisition) and long-term outcomes (e.g., sustained practice change, clinical outcomes) will be specified in our outcome definitions. We will include evaluation studies that measure outcomes at different timepoints, and what outcomes we extract will depend on how individual studies were designed and what they measured. Longitudinal studies will be particularly valuable for capturing long-term outcomes. We acknowledge this temporal distinction is important for understanding how mechanisms may operate differently over time. (pg.10) We thank the reviewer once again for their thoughtful and constructive feedback. The suggested revisions have significantly improved the precision, clarity, and methodological transparency of the manuscript. We believe the revised version addresses all concerns raised and strengthens the overall contribution of the protocol. We welcome any further guidance you may wish to provide. Kind regards, Marah View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern McLean M. Peer Review Report For: Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :122 ( https://doi.org/10.21956/hrbopenres.15713.r52299) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-122/v1#referee-response-52299 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Anugwom E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 02 Jan 2026 | for Version 1 Edlyne Eze Anugwom , University of Nigeria, Nsukka, Nigeria 0 Views copyright © 2026 Anugwom E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions General Observations: The study is as timely as it is also seemingly overdue given the importance of climate change and its repercussions on all spheres of life in contemporary society. There is arguing the fact (despite the existence of pockets of incurable nay-sayers) that climate change is perhaps the most remarkable challenge of life in contemporary society as we know it. It does really begs the question why health professions education has not mainstreamed climate change into its curricular and models of practice soon enough! In this sense, the present study is a timely and welcome intervention that would hopefully energize not only the discourse of climate change in HPE but the evolvement of workable strategies and theory that would guide education and practice. The above notwithstanding, the following observations may be pertinent: The study shows a very good knowledge of the extant literature in the area of focus and this commendable and portrays the fact that the authors are very capable of achieving the aims of the study. In addition to the above, the study uses available or extant literature to provide further insights for its goals/outcomes generally. In other words, the authors clearly demonstrate that the study is anchored on evident paucity in the extant literature especially gaps existing in available empirical studies or reviews in the literature. In addition, it also drew insights from advocacy and the standing of health policy bodies/accreditation agencies in underlining the overarching need for CCS in HPE. However, there are too many jargons and health-related concepts that can potentially limit the value of the study for non-health professionals. Given the nature of climate change as both inter and multi-disciplinary, there may be need to simplify these jargons and go for words/phrases that are within the easy comprehension of general readers. Despite the fact that it has become standard fare to talk about ‘realist’ review, the study needs to capture the essence of the so-called realist review i.e., is it different from systematic review or is it part of systematic review. This is important in the light of the fact that there seems some ambivalence in the extant literature regarding the real status of the so-called realist review. For instance, there is the perception of realist review as simply another form of systematic review (see, Pawson et al., 2025 Ref 1) or as the elongation of the usual systematic review to include the why and where questions often glossed over in traditional systematic reviews. Thus, the extant literature would seem to suggest that realist review is an elongation of the systematic review in the sense of going beyond what works to also include for whom and under what circumstances or why (see, Weiss and Bucuvalas, 1980 Ref 2; Pawson, 2006 Ref 3; Wong et al., 2012 Ref 4). There is mention of the Context-Mechanism-Outcome (CMO) framework and this seems quite interesting; however, there is need to make explicit what ‘mechanism’ means. In other words, there is need to properly conceptualize it along the lines of what was done with regards to ‘context’. Comments on Methods: The authors have done quite an impressive job of detailing and specifying the methods to be adopted in the study. However, I believe that the methods could be further strengthened by looking at the following minor issues: There is need to unravel or explain exactly some key phrases used in the protocol, e.g., ‘detailed selection criteria’ – what does this mean? Also, the idea of grey literature though an old practice in qualitative studies should be further elaborated – what is grey literature in this case? In addition to the above, the choice of studies or literature published between 2014 and 2024 in the inclusion criteria needs to be justified; why this period? Also, why the exclusion of non-empirical works/studies? This seems strange for a protocol focused on developing a new theory! There is the stated objective of the protocol to bridge the gap between existing interventions and their effectiveness across different contexts. As interesting as the above sounds, the critical issue is how this goal can be achieved through the development of a new programme theory. In other words, there is need to further adumbrate or show in clear terms how a new programme theory would bridge this gap or at the minimum the envisaged properties of the theory that could tackle this gap. Observations on Goals/Outcomes: The goals/outcomes of the study seem at the same time laudable/impressive and over-ambitious. It would make sense for the researchers to have a clear focus on what is achievable and practicable and not enticed by the desire to solve all problems or cover all universe. Therefore, the following may be helpful: The goal of the review protocol to examine CCS in HPE at the undergraduate, postgraduate and even continuing professional education as well as in diverse health care disciplines seems over-ambitious and may lead to the generation or development of a protocol or guide too-unwieldy and over-reaching to provide realistic guidance. It would seem too-much like a one-size-fits-all approach and thus have limited effectiveness/impact. There is still need to relate the outcome of the study which is stated to be ‘the development of a programme theory’ to the methodology chosen. A review may yield evidence or results regarding paucity of existing theoretical orientations but how to transit from this paucity (or even gaps) to the evolvement/generation of a new theory needs further nuancing especially since no efforts addressing the critique and evaluation of existing theories were mentioned in the methods. All the same, one must acknowledge the impressive array of theories mentioned that would inform the Initial Programme Theory (IPT); however, these theories are so diverse in both focus and disciplinary orientations that the challenge of how to really and productively synthesize them emerge. And this was not creatively factored into the protocol. Thus, the validity of the envisaged Refined Programme Theory (RPT) may be limited especially as it is expected to apply to a diverse academic, practice and disciplinary worlds. Moreso, there is need to understand the pre-requisites of a good theory generally and the efforts towards critiquing or generating a new theory must abide with some of these major conventions (see, Okeibunor and Anugwom, 2002 Ref 5; Whetten, 1989 Ref 6; Guest, 2024 Ref 7; Lange et al., 2025 Ref 8). Also, the goal to provide actionable insights for embedding CC&S education into HPE curricula globally was mentioned – this seems too ambitious and clearly not feasible given structural, curricula and contextual differences in HPE across the globe. HPE curricular differs across nations and sometimes within countries and regions. Therefore, aiming for actionable insights applicable globally may in truth seem like an overreach. References: Guest, O. (2024). “What Makes a good Theory, and How Do We Make a Theory Good”? Computational Brain and Behaviour 7 (1). https://doi.org/10.1007/s42113-023-00193-2 Lange, J., Freyer, N., Musfeld, P., Schonbrodt, F., & Leising, D. (2025). “A Checklist for Incentivizing and Facilitating Good Theory Building”. Zeitschrift fur Psychologie 233 (4): 279 – 283. https://doi.org/10.1027/2151-2604/a000604 Okeibunor, J.C. & Anugwom, E.E. (2002). Sociological Theory: an insight into dominant viewpoints. Nsukka: Fulladu Pawson, R. (2006). Evidence Based Policy: A Realist Perspective . London: Sage. https://doi.org/10.1080/15588740802262039 Pawson, R., Greenhalgh, T., Harvey, G., & Walshe, K. (2025). “Realist Review: A New Method of Systematic Review Designed for Complex Policy Interventions”. Journal of Health Services Research and Policy 10 (1): 21 – 34. https://doi.org/10.1258/1355819054308530 Weiss, C.H., & Bucuvalas, M.J. (1980). Social Science Research and Decision Making . Newbury Park: Sage Whetten, D. (1989). “What Constitutes a Theoretical Contribution”? Academy of Management Review 14 (4): 490 – 495. https://doi.org/10.2307/258554 Wong, G., Greenhalgh, T., Westhorp G., Pawson, R. (2012). “Realist Methods in Medical Education Research: What are They and What can They Contribute”? Medical Education 46 (1):89–96. https://doi.org/10.111/j.1365-2923.2011.04045.x . Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable References 1. Pawson R, Greenhalgh T, Harvey G, Walshe K: Realist review - a new method of systematic review designed for complex policy interventions. Journal of Health Services Research & Policy . 2005; 10 (1_suppl): 21-34 Publisher Full Text 2. CH, Weiss MJ, Bucuvalas: Social Science Research and Decision Making. https://archive.org/details/socialscienceres0000weis . 1980. 3. Triana R: Evidence-Based Policy: A Realist Perspective, by Ray Pawson. Journal of Policy Practice . 2008; 7 (4): 321-323 Publisher Full Text 4. Wong G, Greenhalgh T, Westhorp G, Pawson R: Realist methods in medical education research: what are they and what can they contribute?. Medical Education . 2012; 46 (1): 89-96 Publisher Full Text 5. JC, Okeibunor EE, Anugwom: Sociological Theory: an insight into dominant viewpoints. 2002. 6. Whetten D: What Constitutes a Theoretical Contribution?. The Academy of Management Review . 1989; 14 (4). Publisher Full Text 7. Guest O: What Makes a Good Theory, and How Do We Make a Theory Good?. Computational Brain & Behavior . 2024; 7 (4): 508-522 Publisher Full Text 8. Lange J, Freyer N, Musfeld P, Schönbrodt F, et al.: A Checklist for Incentivizing and Facilitating Good Theory Building. Zeitschrift für Psychologie . 2025; 233 (4): 279-283 Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Social Dimensions of Climate Change; Development Studies; Political Economy; Public Health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 02 Feb 2026 Marah Elfghi, Medical Education Unit, University College Cork School of Medicine, Cork, T12 AK54, Ireland Dear Reviewer, We sincerely thank you for your thoughtful, generous, and constructive review of our realist review protocol. We greatly appreciate your recognition of the timeliness, relevance, and scholarly grounding of the study, as well as your detailed feedback, which has helped us strengthen the clarity, methodological rigour, and theoretical coherence of the protocol. Below, we respond to each of your comments in turn and outline the revisions made to the manuscript. General Observations: 1.Comment: The topic is timely and important, but the manuscript contains excessive jargon that may limit accessibility for non-health professionals. Response: We thank the reviewer for this thoughtful observation and agree that climate change is inherently interdisciplinary and of relevance beyond the health sector. The primary intended audience for this realist review, however, is educators, researchers, and policymakers working within health professions education. As such, the use of established terminology from health education, implementation science, and realist methodology is necessary to ensure conceptual precision and alignment with existing scholarly discourse in this field. That said, we have carefully reviewed the manuscript to ensure that key technical terms are used consistently and meaningfully, and that their application is appropriate to the aims of the study. Where specialist terminology is essential, it reflects commonly accepted language within health professions education and realist synthesis and is required to maintain methodological clarity and rigour. We believe that further simplification beyond this point would risk diluting important conceptual distinctions central to the realist approach. 2.Comment: The manuscript needs to more clearly explain what distinguishes a realist review from a systematic review. Response: Thank you for highlighting this important point. We have expanded the Background section to explicitly clarify the epistemological and methodological distinction between realist reviews and traditional systematic reviews. In particular, we now explain that realist reviews are theory-driven and focus on understanding how , why , for whom , and under what circumstances interventions work, rather than solely assessing effectiveness. We have added text positioning realist review as an extension beyond traditional systematic reviews, drawing on established realist literature to clarify this distinction and address ambivalence in the field. (pg. 5) 3.Comment: The Context–Mechanism–Outcome (CMO) framework is mentioned, but the concept of “mechanism” requires clearer conceptualisation. Response: We fully agree. We have added an explicit definition and conceptual explanation of “mechanism” within the realist tradition, distinguishing mechanisms from programme activities and outcomes. This clarification is now included in the Methods sections, ensuring consistency and conceptual transparency. (pg. 6) Comments on Methods 4.Comment: Key phrases such as “detailed selection criteria” and “grey literature” require clarification. Response: Thank you for your comment. We agree with you, we have defined detailed selection criteria: as the predefined inclusion and exclusion conditions used to decide which studies are eligible to be included. (pg.6) Additionally, we have expanded the description of grey literature, specifying what sources are included (e.g., policy reports, curricular documents, organisational reports) and explaining their relevance to realist theory development. (pg.8) 5.Comment: The inclusion of studies published between 2014 and 2024 requires justification, and the exclusion of non-empirical studies seems contradictory for theory development. Response: We appreciate this important critique. We have now justified the 2014 onwards timeframe, noting that most CC&S education initiatives in HPE emerged during this period alongside growing global policy and curricular momentum. (pg.9) Regarding non-empirical studies, we have clarified that while theoretical papers are excluded from formal inclusion, theory-informed insights are incorporated during the development of the Initial Programme Theory. Empirical studies are prioritised to ensure that theory refinement is grounded in observed contexts, mechanisms, and outcomes rather than abstract conceptualisation alone. (pg.9) 6.Comment: It is unclear how the development of a programme theory will bridge the gap between interventions and their effectiveness across contexts. Response: Thank you for your comment. Programme theory bridges this gap by explaining how and why interventions work differently across contexts. It identifies the mechanisms that are activated in particular contexts to produce outcomes, thereby explaining variation in effectiveness through context-mechanism-outcome configurations (as explained in pg.10) rather than simply documenting it. Observations on Goals and Outcomes 7.Comment: The goals of the study appear over-ambitious, particularly the inclusion of multiple educational levels and disciplines. Response: We acknowledge this concern and have revised the manuscript accordingly. We have refined the stated goals to emphasise theory-building rather than universal prescription, clarifying that the intent is not to propose a one-size-fits-all model but to develop an explanatory framework sensitive to contextual variation across educational levels and disciplines. (pg.5 and pg.11) 8.Comment: The relationship between theory development and the realist methodology requires clearer articulation. Response: We agree. We have strengthened the linkage between realist methodology and programme theory development, explicitly explaining how iterative CMO analysis leads to theory refinement. Furthermore, we have clarified how existing theories inform; but do not predetermine. These frameworks will be selectively refined the programme theory, and we have acknowledged the methodological challenge of synthesising diverse theoretical perspectives. (pg.8 and pg.11) 9.Comment: The ambition to generate globally applicable actionable insights is unrealistic given curricular and contextual variation. Response: We appreciate this important point. We have revised the language, we now emphasise that findings will offer transferable principles and context-sensitive insights, allowing educators and institutions to adapt recommendations to their local curricular, cultural, and policy environments. (pg.3 and pg.11) Once again, we sincerely thank you for your insightful and rigorous review. Your feedback has significantly strengthened the conceptual clarity, methodological transparency, and scholarly contribution of this protocol. We believe the revisions address your concerns and improve the overall quality and utility of the manuscript. We would be happy to address any further comments if required. Kind regards, Marah View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Anugwom EE. Peer Review Report For: Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :122 ( https://doi.org/10.21956/hrbopenres.15713.r51720) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-122/v1#referee-response-51720 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). You work at the same institute as any of the authors. You hope/expect to benefit (e.g. favour or employment) as a result of your submission. You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Stay Updated Sign up for content alerts and receive a weekly or monthly email with all newly published articles Register with HRB Open Research Already registered? Sign in Not now, thanks close PLEASE NOTE If you are an AUTHOR of this article, please check that you signed in with the account associated with this article otherwise we cannot automatically identify your role as an author and your comment will be labelled as a “User Comment”. If you are a REVIEWER of this article, please check that you have signed in with the account associated with this article and then go to your account to submit your report, please do not post your review here. If you do not have access to your original account, please contact us . All commenters must hold a formal affiliation as per our Policies . The information that you give us will be displayed next to your comment. User comments must be in English, comprehensible and relevant to the article under discussion. We reserve the right to remove any comments that we consider to be inappropriate, offensive or otherwise in breach of the User Comment Terms and Conditions . Commenters must not use a comment for personal attacks. When criticisms of the article are based on unpublished data, the data should be made available. I accept the User Comment Terms and Conditions Please confirm that you accept the User Comment Terms and Conditions. Affiliation ✕ refresh Please enter your institution. Note: To add your institution or organisation, start typing the name and then select the correct name from the list. Where applicable, the name will appear in both the original language and in English. Do not paste in the name. If the name does not appear in the drop-down list, we will display the information you have entered. ✕ refresh Country/Region * USA UK Canada China France Germany Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo (Serbia and Montenegro) Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Minor Outlying Islands of the United States Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Is South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Gambia The Netherlands Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu UK USA Uganda Ukraine United Arab Emirates United States Virgin Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Wallis and Futuna West Bank and Gaza Strip Western Sahara Yemen Zambia Zimbabwe Please select your country/region. You must enter a comment. Competing Interests Please disclose any competing interests that might be construed to influence your judgment of the article's or peer review report's validity or importance. Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). You work at the same institute as any of the authors. You hope/expect to benefit (e.g. favour or employment) as a result of your submission. You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Please state your competing interests The comment has been saved. An error has occurred. Please try again. Cancel Post var lTitle = "Climate Change and Sustainability in Health...".replace("'", ''); var linkedInUrl = "http://www.linkedin.com/shareArticle?url=https://hrbopenresearch.org/articles/8-122/v1" + "&title=" + encodeURIComponent(lTitle) + "&summary=" + encodeURIComponent('Read the article by '); var deliciousUrl = "https://del.icio.us/post?url=https://hrbopenresearch.org/articles/8-122/v1&title=" + encodeURIComponent(lTitle); var redditUrl = "http://reddit.com/submit?url=https://hrbopenresearch.org/articles/8-122/v1" + "&title=" + encodeURIComponent(lTitle); linkedInUrl += encodeURIComponent('Elfghi M et al.'); var offsetTop = /chrome/i.test( navigator.userAgent ) ? 4 : -10; var addthis_config = { ui_offset_top: offsetTop, services_compact : "facebook,twitter,www.linkedin.com,www.mendeley.com,reddit.com", services_expanded : "facebook,twitter,www.linkedin.com,www.mendeley.com,reddit.com", services_custom : [ { name: "LinkedIn", url: linkedInUrl, icon:"/img/icon/at_linkedin.svg" }, { name: "Mendeley", url: "http://www.mendeley.com/import/?url=https://hrbopenresearch.org/articles/8-122/v1/mendeley", icon:"/img/icon/at_mendeley.svg" }, { name: "Reddit", url: redditUrl, icon:"/img/icon/at_reddit.svg" }, ] }; var addthis_share = { url: "https://hrbopenresearch.org/articles/8-122", templates : { twitter : "Climate Change and Sustainability in Health Professions Education:.... Elfghi M et al., published by " + "@HRBOpenRes" + ", https://hrbopenresearch.org/articles/8-122/v1" } }; if (typeof(addthis) != "undefined"){ addthis.addEventListener('addthis.ready', checkCount); addthis.addEventListener('addthis.menu.share', checkCount); } $(".f1r-shares-twitter").attr("href", "https://twitter.com/intent/tweet?text=" + addthis_share.templates.twitter); $(".f1r-shares-facebook").attr("href", "https://www.facebook.com/sharer/sharer.php?u=" + addthis_share.url); $(".f1r-shares-linkedin").attr("href", addthis_config.services_custom[0].url); $(".f1r-shares-reddit").attr("href", addthis_config.services_custom[2].url); $(".f1r-shares-mendelay").attr("href", addthis_config.services_custom[1].url); function checkCount(){ setTimeout(function(){ $(".addthis_button_expanded").each(function(){ var count = $(this).text(); if (count !== "" && count != "0") $(this).removeClass("is-hidden"); else $(this).addClass("is-hidden"); }); }, 1000); } close How to cite this report {{reportCitation}} Cancel Copy Citation Details $(function(){R.ui.buttonDropdowns('.dropdown-for-downloads');}); $(function(){R.ui.toolbarDropdowns('.toolbar-dropdown-for-downloads');}); $.get("/articles/acj/14282/15713") new F1000.Clipboard(); new F1000.ThesaurusTermsDisplay("articles", "article", "15713"); $(document).ready(function() { $( "#frame1" ).on('load', function() { var mydiv = $(this).contents().find("div"); var h = mydiv.height(); console.log(h) }); var tooltipLivingFigure = jQuery(".interactive-living-figure-label .icon-more-info"), titleLivingFigure = tooltipLivingFigure.attr("title"); tooltipLivingFigure.simpletip({ fixed: true, position: ["-115", "30"], baseClass: 'small-tooltip', content:titleLivingFigure + " " }); tooltipLivingFigure.removeAttr("title"); $("body").on("click", ".cite-living-figure", function(e) { e.preventDefault(); var ref = $(this).attr("data-ref"); $(this).closest(".living-figure-list-container").find("#" + ref).fadeIn(200); }); $("body").on("click", ".close-cite-living-figure", function(e) { e.preventDefault(); $(this).closest(".popup-window-wrapper").fadeOut(200); }); $(document).on("mouseup", function(e) { var metricsContainer = $(".article-metrics-popover-wrapper"); if (!metricsContainer.is(e.target) && metricsContainer.has(e.target).length === 0) { $(".article-metrics-close-button").click(); } }); var articleId = $('#articleId').val(); if($("#main-article-count-box").attachArticleMetrics) { $("#main-article-count-box").attachArticleMetrics(articleId, { articleMetricsView: true }); } }); var figshareWidget = $(".new_figshare_widget"); if (figshareWidget.length > 0) { window.figshare.load("f1000", function(Widget) { // Select a tag/tags defined in your page. In this tag we will place the widget. _.map(figshareWidget, function(el){ var widget = new Widget({ articleId: $(el).attr("figshare_articleId") //height:300 // this is the height of the viewer part. [Default: 550] }); widget.initialize(); // initialize the widget widget.mount(el); // mount it in a tag that's on your page // this will save the widget on the global scope for later use from // your JS scripts. This line is optional. //window.widget = widget; }); }); } close Error Close Add Reset F1000.MICROSERVICES.AFFILIATION = ''; $(document).ready(function () { $('.js-affiliations-form').each((index, form) => { new AffiliationForm({ formId: form.id, institutionErrorSelector: '.comment-enter-institution', departmentErrorSelector: '.comment-enter-department', placeSelector: '.js-add-comment-place', stateSelector: '.js-add-comment-state', zipCodeSelector: '.js-add-comment-zipcode', countrySelector: '.js-add-comment-country', countryErrorSelector: '.comment-enter-country', }); }); }); $(document).ready(function () { var reportIds = { "52163": 0, "52164": 0, "51716": 0, "52165": 0, "51717": 0, "52293": 0, "52166": 0, "51718": 0, "52294": 0, "52167": 0, "51719": 0, "52295": 0, "52168": 0, "51720": 29, "52296": 0, "53256": 0, "52169": 0, "51721": 0, "52297": 0, "53257": 8, "52170": 0, "51722": 0, "52298": 0, "52171": 0, "51723": 0, "52299": 20, "52172": 0, "51724": 0, "52300": 0, "51725": 0, "52301": 0, "52302": 0, "53393": 0, "52017": 0, "52018": 0, "52019": 0, "52020": 0, "52021": 0, "52022": 0, "52023": 0, "52024": 0, "52025": 0, "52026": 0, }; $(".referee-response-container,.js-referee-report").each(function(index, el) { var reportId = $(el).attr("data-reportid"), reportCount = reportIds[reportId] || 0; $(el).find(".comments-count-container,.js-referee-report-views").html(reportCount); }); var uuidInput = $("#article_uuid"), oldUUId = uuidInput.val(), newUUId = "7c186330-aadb-4fdd-9edb-bb44c3257f06"; uuidInput.val(newUUId); $("a[href*='article_uuid=']").each(function(index, el) { var newHref = $(el).attr("href").replace(oldUUId, newUUId); $(el).attr("href", newHref); }); }); Are you a HRB-funded researcher? Submission to HRB Open Research is open to all HRB grantholders or people working on a HRB-funded/co-funded grant on or since 1 January 2017. Sign up for information about developments, publishing and publications from HRB Open Research. First Name * You must provide your first name Last Name * You must provide your last name Email * You must provide a valid email address Institution You must provide an institution. Submit Thank you! We'll keep you updated on any major new updates to HRB Open Research HRB Open Research Browse How to Publish About Contact RSS Cookie Notice Privacy Notice Legal Submit Your Research © F1000 Research Limited and its licensors ISSN 2515-4826 | Legal background var F1000platform = new F1000.Platform({ name: "hrb", displayName: "HRB Open Research", hostName: "hrbopenresearch.org", id: "5", editorialEmail: "[email protected]", infoEmail: "[email protected]" }); Sign In Remember me Forgotten your password? Sign In Cancel Email or password not correct. Please try again Please wait... $(function(){ // Note: All the setup needs to run against a name attribute and *not* the id due the clonish // nature of facebox... $("a[id=googleSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("GOOGLE"); $("form[id=oAuthForm]").submit(); }); $("a[id=facebookSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("FACEBOOK"); $("form[id=oAuthForm]").submit(); }); $("a[id=orcidSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("ORCID"); $("form[id=oAuthForm]").submit(); }); }); If you've forgotten your password, please enter your email address below and we'll send you instructions on how to reset your password. The email address should be the one you originally registered with F1000. Email address not valid, please try again You registered with F1000 via Google, so we cannot reset your password. To sign in, please click here . If you still need help with your Google account password, please click here . You registered with F1000 via Facebook, so we cannot reset your password. To sign in, please click here . If you still need help with your Facebook account password, please click here . Code not correct, please try again Reset password Cancel Email us for further assistance. Server error, please try again. If your email address is registered with us, we will email you instructions to reset your password. If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance. Please wait... Register $(document).ready(function () { signIn.createSignInAsRow($("#sign-in-form-gfb-popup")); $(".target-field").each(function () { var uris = $(this).val().split("/"); if (uris.pop() === "login") { $(this).val(uris.toString().replace(",","/")); } }); }); (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9fec0b1f69624807',t:'MTc3OTI4NzQ2OQ=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();