Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol

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However, no universally accepted definition of recovery had been constructed until 1993 when William A. Anthony suggested that recovery involved living one’s best life even with mental health difficulties. In 2011, Leamy et al. created CHIME [Connectiveness, Hope, Identity, Meaning and purpose and Empowerment]. A concept that represents the key characteristics of recovery. It derived from a literature review into recovery from psychosis. Since 2011, the literature has examined these concepts individually and collectively to understand what they are in reality. However, few studies have investigated the internal mechanisms that causes a person to move from unwellness to recovery via CHIME. As such this proposed realist review will explore how and why the mechanisms within CHIME operate in individuals recovering from mental health challenges. Methods This review forms work package one of a PhD study into CHIME and mental health recovery in Ireland. It complies with relevant guidelines relating to realist reviews including Pawson et al’s. updated methodology, which consists of six phases: 1) setting up the review advisory panel and constructing initial programme theories; 2) searching for evidence; 3) selecting and appraising evidence; 4) extracting data; 5) analysing and synthesising data; and 6) ethics and dissemination. Discussion & Implications for Practice This proposed review will address a gap in the literature on the mechanism involved in recovery from mental health challenges. Unlike other review types, a realist review is theory orientated, allowing one to answer this review question by exploring how, why, and through what circumstances individuals reach recovery through CHIME. This review will inform future work packages of this PhD study. The proposed review will be written up and submitted to a peer-reviewed journal. Dissemination outside academia will be considered. Registration ID CRD420251038961 " } { "@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/8-94", "name": "Understanding the Mechanisms that Operate within CHIME: A Realist..." } } ] } Home Browse Understanding the Mechanisms that Operate within CHIME: A Realist... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Norton MJ, Byrne JP, Bedenik T et al. Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.12688/hrbopenres.14171.2 ) 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 Revised Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] Michael John Norton 1 , John Paul Byrne https://orcid.org/0000-0002-9961-8710 2 , Tina Bedenik https://orcid.org/0000-0002-5865-0263 3 , [...] Michael Ryan 4 , Catherine Brogan 5 , David Dwyer 6 , Killian Walsh 7 , Éidín Ní Shé https://orcid.org/0000-0002-1036-6044 2 Michael John Norton 1 , John Paul Byrne https://orcid.org/0000-0002-9961-8710 2 , [...] Tina Bedenik https://orcid.org/0000-0002-5865-0263 3 , Michael Ryan 4 , Catherine Brogan 5 , David Dwyer 6 , Killian Walsh 7 , Éidín Ní Shé https://orcid.org/0000-0002-1036-6044 2 PUBLISHED 17 Nov 2025 Author details Author details 1 PhD Scholar, Graduate School of Healthcare Management, Royal College of Surgeons in Ireland, Dublin, Leinster, D02 YN77, Ireland 2 Senior Lecturer, Graduate School of Healthcare Management, Royal College of Surgeons in Ireland, Dublin, Leinster, D02 YN77, Ireland 3 Senior Post-Doctoral Researcher, Data Science Centre, School of Population Health, Royal College of Surgeons in Ireland, Dublin, Leinster, D02 YN77, Ireland 4 Head of Mental Health Engagement and Recovery, Office of Mental Health Engagement and Recovery, St. Loman’s Hospital, Palmerstown, Dublin, D20 HK69, Ireland 5 303 Duncreeven, Courtown Park, Catherine Brogan Consultancy, Kilcock, Kildare, W23 Y660, Ireland 6 Involvement Centre Co-Ordinator, Recovery College South East, Greenshill, Kilkenny, R95 YYC0, Ireland 7 Information Specialist, Library, Royal College of Surgeons in Ireland, 26 York Street, Dublin, D02 P796, Ireland Michael John Norton Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing John Paul Byrne Roles: Methodology, Supervision, Validation, Visualization, Writing – Review & Editing Tina Bedenik Roles: Investigation, Methodology, Supervision, Validation, Writing – Review & Editing Michael Ryan Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Catherine Brogan Roles: Methodology, Writing – Review & Editing David Dwyer Roles: Methodology, Writing – Review & Editing Killian Walsh Roles: Methodology, Resources, Software Éidín Ní Shé Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Recovery originated from the civil rights movement of the 1960s/70s. However, no universally accepted definition of recovery had been constructed until 1993 when William A. Anthony suggested that recovery involved living one’s best life even with mental health difficulties. In 2011, Leamy et al . created CHIME [ C onnectiveness, H ope, I dentity, M eaning and purpose and E mpowerment]. A concept that represents the key characteristics of recovery. It derived from a literature review into recovery from psychosis. Since 2011, the literature has examined these concepts individually and collectively to understand what they are in reality. However, few studies have investigated the internal mechanisms that causes a person to move from unwellness to recovery via CHIME. As such this proposed realist review will explore how and why the mechanisms within CHIME operate in individuals recovering from mental health challenges. Methods This review forms work package one of a PhD study into CHIME and mental health recovery in Ireland. It complies with relevant guidelines relating to realist reviews including Pawson et al ’s. updated methodology, which consists of six phases: 1) setting up the review advisory panel and constructing initial programme theories; 2) searching for evidence; 3) selecting and appraising evidence; 4) extracting data; 5) analysing and synthesising data; and 6) ethics and dissemination. Discussion & Implications for Practice This proposed review will address a gap in the literature on the mechanism involved in recovery from mental health challenges. Unlike other review types, a realist review is theory orientated, allowing one to answer this review question by exploring how, why, and through what circumstances individuals reach recovery through CHIME. This review will inform future work packages of this PhD study. The proposed review will be written up and submitted to a peer-reviewed journal. Dissemination outside academia will be considered. Registration ID CRD420251038961 READ ALL READ LESS Keywords CHIME, Mental Health, Personal Recovery, Realist Review, Theory Generation Corresponding Author(s) Michael John Norton ( [email protected] ) Close Corresponding author: Michael John Norton Competing interests: No competing interests were disclosed. Grant information: Health Research Board Ireland [APA-2022-022]. This work was also supported by the Irish Research Council Enterprise Partnership Scheme Postgraduate Scholarship [Grant code: EBPPG/2024/189]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Norton MJ 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: Norton MJ, Byrne JP, Bedenik T et al. Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.12688/hrbopenres.14171.2 ) First published: 26 Aug 2025, 8 :94 ( https://doi.org/10.12688/hrbopenres.14171.1 ) Latest published: 17 Nov 2025, 8 :94 ( https://doi.org/10.12688/hrbopenres.14171.2 ) Revised Amendments from Version 1 The revised protocol has a more focussed introduction section which highlights what has been researched in CHIME so far and the gaps in current knowledge which this proposed review aims to address. A revised figure 2 was created to demonstrate the cyclical and iterative process that is the realist review process. More detail has been given regarding the exclusion of quantitative research papers from this proposed review along with why we placed the cut of period for including studies from 2011 - present [2025]. In particular we have provided a rationale as to why pre-2011 papers were not included in this proposed review as the original review that created CHIME in the first place would have included such pre-2011 papers. Finally, more detail has been provided in the revised protocol in regards to the structure of the grey literature search for this review. The revised protocol has a more focussed introduction section which highlights what has been researched in CHIME so far and the gaps in current knowledge which this proposed review aims to address. A revised figure 2 was created to demonstrate the cyclical and iterative process that is the realist review process. More detail has been given regarding the exclusion of quantitative research papers from this proposed review along with why we placed the cut of period for including studies from 2011 - present [2025]. In particular we have provided a rationale as to why pre-2011 papers were not included in this proposed review as the original review that created CHIME in the first place would have included such pre-2011 papers. Finally, more detail has been provided in the revised protocol in regards to the structure of the grey literature search for this review. See the authors' detailed response to the review by Geoff Wong See the authors' detailed response to the review by Dr. Jutharat Thongsalab See the authors' detailed response to the review by Chalotte Heinsvig Poulsen READ REVIEWER RESPONSES Introduction Within the past few decades, mental health services have radically transformed on a structural, cultural, and philosophical level 1 . Today, mental health services operate on the bases of personal recovery. A type of recovery best described through William A. Anthony’s seminal 1993 work 2 , where he states that recovery is: “...a deeply personal unique process of changing one’s attitudes, values, feelings, goals, skills and/roles. It is a way of living a satisfying hopeful and contributing life even with the limitations caused by illness... includes the development of new meaning and purpose in life as one grows beyond the catastrophic effects of mental illness.” [ 2 , p.21]. As such, recovery is a strengths-based and person-centred concept, as it allows one to be viewed beyond their diagnostic label to that of a unique, whole person with wants and desires like others in society 3 , 4 . Not only has personal recovery a therapeutic value, but it is also a catalyst of individual practice and systemic cultural change. Of note, in Irish services, the current mental health policy, ‘ Sharing the Vison ,’ is underpinned by both trauma-informed practice and personal recovery 5 . In May 2024, the Office of Mental Health Engagement and Recovery [MHER] – an office within the Health Service Executive’s national structures responsible for the implementation of recovery in mental health services – published ‘ A National Framework for Recovery in Mental Health ’ 6 . This framework identifies four key ingredients for creating a recovery-oriented service including: 1. The centrality of lived experience, 2. The co-production or recovery-promoting services between all stakeholders, 3. An organisational commitment to the continuous development of recovery in Irish mental health services and 4. Supporting recovery-orientated learning and practice across all stakeholder groups 6 . Each of these principles are necessary to create recovery-oriented services. However, to achieve recovery orientation, staff and services must first understand the concept of recovery beyond the strict limitations of a positivist biomedical lens to something that is more interpretative and dependant on the unique experiences of the individual. To do this, MHER created a suite of training on recovery known as the ‘ Recovery Principles and Practice Workshop.’ A central tenet in this programme, which is used to support the embedding of recovery orientation, is the CHIME framework 6 , 7 [ Figure 1 ]. Figure 1. Figure depicts the five elements needed for recovery to occur. CHIME consists of the concepts c onnection, h ope, i dentity, m eaning and purpose and e mpowerment. CHIME consists of the concepts c onnection, h ope, i dentity, m eaning and purpose and e mpowerment. The CHIME framework was developed as a result of a systematic review and narrative synthesis of recovery in mental health for people with psychosis 8 . Since its construction in 2011, CHIME has been utilised for research, educational, and managerial purposes. A study by Penas et al . 9 utilised the dimensions of CHIME to create a validated instrument to measure the existence of CHIME within a service. This is the closest measure available to measuring the recovery orientation of a service. In addition, CHIME is used as part of educational packages within recovery college environments to support the recovery literacy of not just staff but also service users, family members/carers/supporters, and the public at large 10 . For example, see Recovery College West 11 . In addition, a recent UK-based systematic review noted through a process of citation content analysis where and how CHIME is currently utilised 12 . In addition, presently the CHIME framework has been extensively researched, particularly in anglosaxon countries where it is most widely utilised 13 , 14 . As noted above, since its construction in 2011, the concepts that make up CHIME have been explored collectively and individually 6 , 7 , 9 . Additionally, CHIME has also been used to create measures of personal recovery in mental health 9 , but also in the analysis of various interventions utilised by mental health services 15 . In recent years, CHIME has taken on additional letters as it has advanced, for instance CHIME-D has been used with D used to represent the word disability 16 . However, till now, no study has been formed that explicitly sets out to explore the underpinning mechanisms that formulate the concepts that are marked within the CHIME framework. The development of such a study is timely as services are now requesting guidance on how to enhance personal recovery in mental health on a micro [personal], meso [community] and macro [organisationa/societal] level 6 . As such, such a study would be of great service value to clinicians and other healthcare professionals in enhancing recovery in mental health through CHIME. As such, this review explores how a person moves from a place of unwellness to a place where they gain a sense of connection, hope, identity, meaning and purpose, and empowerment. In answering this question, a realist review was deemed most appropriate as it targets antecedents through questions such as who it works for, in what circumstances, why, and how 17 , 18 . Additionally, realist reviews are similar in nature and rigor to systematic reviews, but are utilised to understand the causal forces that allow a behavioural health construct to operate in one context but not in others 19 . In recent years, realist reviews have become popular as they allow researchers to immerse themselves in these meta-theoretical spaces to explain how interventions like CHIME work 20 . It is through exploring these meta-theoretical spaces that actions can be created, identified, and taken in order to inform policy and practice 21 . Unlike the original systematic review and narrative synthesis that created CHIME in the first place, realist reviews permit data from a wide range of sources with various degrees of quality. Including these various data sources in the production of refined initial programme theories will support the work of recovery specialists on the ground as well as the overarching PhD study itself, as it will provide a new theoretical understanding of the mechanisms that bring people from unwellness to wellness via CHIME. The refined initial programme theories created as a result of this proposed realist review will then inform work package two of this PhD, when service users and expert panel members will be interviewed to either confirm or deny the mechanisms uncovered over the process of this proposed realist review. As such, this present paper aims to document the methodology behind a proposed realist review which explores how and why the mechanisms within the CHIME [ C onnectiveness, H ope, I dentity, M eaning and purpose and E mpowerment] framework work in individuals who are in recovery from mental health challenges? Methods This protocol and the proposed realist review will comply with the R ealist A nd M eta-narrative E vidence S ynthesis: E volving S tandards -I [RAMESES-I] guidelines 22 – 24 . According to Duddy and Wong 25 , these standards will be used to guide the reporting of realist reviews. Further details on this are discussed below. This protocol was registered with PROSPERO [CRD420251038961] on April 29 th , 2025, and can be freely accessed. Realist review phases Systematic and scoping reviews have a step-by-step systemic approach to the review of the literature 26 – 28 . This is important for both review types so that they can enhance the reproducibility and transparency of how papers were searched from within the wider literature base 29 , 30 . Realist reviews differ from systematic and scoping reviews as they do not conform to a prescribed method to review the literature 18 . Instead, because of the realist’s focus on theory creation and explanation, the review process will be supported by a set of guiding principles rather than a prescribed structure 21 , 31 . As such, for the purposes of this realist review protocol, an essential step in creating the protocol was identifying what methodology to follow. This protocol followed the format proposed by Masterson et al . 32 and McCormack et al . 33 . The rationale for this is twofold: 1) both studies adhered more strictly to the RAMESES-I guidance and 2) both studies were situated within either the co-design space 32 or within an aspect of mental health service provision 33 . McCormack and colleagues 33 in particular note that a realist review comprises of five generalised steps that were originally devised by Pawson and colleagues 34 in their seminal work. These steps are as follows: 1. Set up of the review advisory panel and construct initial programme theories, 2. Searching for evidence, 3. Select and appraise evidence, 4. Extract the data, 5. Analyse and synthesis the data. These steps are similar to those utilised in generic systematic reviews, but they are notably different in terms of theoretical depth required to complete each step 35 . Figure 2 illustrates the five major steps of the realist review process adapted from McCormack et al . 33 . Additionally, a sixth step will be added to examine the ethics and dissemination of results, given that the present paper represents a protocol for a proposed realist review. Each step is described in detail below. Figure 2. Figure depicts the five phases of Pawson and colleagues process of conducting realist reviews as adapted from the work of McCormack and colleagues. Step one: setting up the review advisory panel and constructing the initial programme theories. Realist reviews are, by their very nature, are cyclical and iterative in their approach 36 . This means that the refinement of the initial programme theories constructed here occurs throughout the review itself 37 . In realist reviews, the first step is to identify a research focus and construct and reach an agreement regarding initial programme theories. Initial programme theories are both a theory of change and a theory of implementation and as such are iterative and subject to change. As noted previously, for this realist review, our focus will be to explore how and why the mechanisms within the CHIME [ C onnectedness, H ope, I dentity, M eaning and purpose and E mpowerment] framework work in individuals who are in recovery from mental health challenges. Given that realist reviews are explicitly theory orientated along with an emphasis on “how” and “why” within the focus statement above, this review approach is suitable for exploring the mechanisms that bring a person from a place of unwellness to the characteristics of CHIME as noted by Leamy et al ., 8 , 25 , 38 . The next subphase in this first step is to break down this focus into a series of “If...then...” statements 39 . If... then statements are simply explanatory accounts or statements that allow one to begin the process of programme theorising 40 . As noted in Table One , each element of CHIME received its own if... then... statement. This is because each element of CHIME works independently and together to support an individual’s personal recovery journey. Table 1. Table consists of the five if… then… statements – the starting point in creating initial programme theories. Table One: If…Then… Statements 1 If a person with lived experience of mental health challenges feels connected/disconnected with themselves, others around them and with their community, then this would have a long-lasting positive/negative impact on one’s mental health recovery journey. 2 If a person with lived experience of mental illness is experiencing hopefulness/hopelessness, then this would have an impact on the person’s outlook on life, thereby impacting their ongoing, mental health recovery journey. 3 If a person with mental health challenges experiences a sense of identity/a lack of identity, beyond that of the passive service user/patient, then this would have a profound impact on the individual’s mental health condition and their sense of self-worth, which thereby impacts one’s mental health recovery journey. 4 If a person who uses community mental health services develops/loses a sense of meaning and purpose in their lives, then this can positively/negatively impact a person’s wellbeing which can influence the person’s overall mental health recovery journey. 5 If a person with lived experience of mental health challenges experiences a sense of empowerment/disempowerment, then they can feel more/less in control of their mental wellbeing, leading to healthcare choices that ultimately a positive/ negative impact on one’s treatment plan and their overall mental health recovery journey. Once the if... then... statements are created, they are presented to the team members [ÉNS, JPB, and TB] for review and refinement. Once these if... then... statements are finalised, the next sub-step is to create the initial programme theories 41 . Initial programme theories are useful as they help reviewers understand how, for whom, why, and under what circumstances complex interventions such as CHIME work to achieve personal recovery in individuals with mental health challenges 42 . Essentially, an initial programme theory comes from the if... then... statements and consists of three essential parts: context, mechanism, and outcome (CMO) 43 . In a realist review CMOs, the context refers to the outside parameters of the formal programme architecture. In other words, it relates to the environment in which the mechanism occurs 44 . This can be in the backdrop of a historical event, or perhaps social and cultural norms 45 . However, it is a contextual interaction with the mechanism that produces the outcome. The mechanism is the underpinning generative force that, when interacting with the context, produces the outcome. It is subdivided into resources and how people respond to them. It is often hidden and extremely sensitive to variations in context 46 . Finally, the outcome is the result of the mechanism’s interaction with the context. These outcomes are often behavioural and can be either intentional or unintentional 45 . In short, these components come together to be known as a CMO configuration or an initial programme theory. The premise behind a CMO configuration is that the context and mechanism lead to an outcome. This process involved multiple readings of the if...then... statements in order to clearly assign elements to the context, mechanism, and outcome. Once MJN was satisfied that these elements were aligned correctly, the CMO configurations were circulated to the supervisory team for initial analysis and refinement, resulting in an initial set of plausible programme theories, as presented in Table Two . Table 2. Table consists of the original if… then… statements along with a first draft of the initial programme theories devised from these if…then… statements before review by the expert panel. 1. If a person with lived experience of mental health challenges feels connected/disconnected with themselves, others around them and with their community, whatever that community is to them, then this would have a long-lasting positive/negative impact on one’s mental health recovery journey. Context: A person with mental health difficulties in receipt of mental health services to support their mental health and wellbeing through regaining CHIME. Mechanism: Enters and/or resides in an environment that allows/inhibits a sense of connection. Outcome: The person feeling either a sense of connection or disconnection from themselves, others around them and with their environment leading to long lasting positive and negative effects on a person’s mental health recovery journey. 2. If a person with lived experience of mental illness is experiencing hopefulness/hopelessness, then this would have an impact on the person’s outlook on life, thereby impacting their ongoing, personal, mental health recovery journey. Context: A person with lived experience of having a mental illness who utilises the mental health services to support their mental wellbeing through regaining elements of wellbeing discussed within the CHIME framework. Mechanism: The person is, due to their ongoing mental health challenges, in a mindset that allows or inhibits a sense of hope to be created and maintained in their lives. Outcome: Leading the person to either feel or not feel a sense of hope, as indicating an impact on their ongoing, personal, mental health recovery journey. 3. If a person with mental health challenges experiences a sense of identity/a lack of identity, beyond that of the passive identity of a service user/patient, then this would have a profound impact on the individual’s mental health condition and their sense of self-worth, which thereby impacts one’s mental health recovery journey. Context: A person with lived experiences of mental health challenges who utilises mental health services for their ongoing mental health and wellbeing through reclaiming the elements of CHIME in their lives. Mechanism: The person has lost/gained a sense of identity to the point that the person stays within or moves beyond the passive service user/patient identity. Outcome: Leading to notable changes in how a person views their recovery and their measurement of their own perceived self-worth. 4. If a person who uses community mental health services develops/loses a sense of meaning and purpose in their lives, then this can positively/negatively impact a person’s wellbeing which can influence the person’s overall mental health recovery journey. Context: A person who avails of a community mental health service in order to reclaim aspect of CHIME needed for their ongoing mental health and wellbeing. Mechanism: The person, because of their engagement with community mental health services either develops or loses their perceived sense of meaning and purpose in their lives. Outcome: Leading to a positive/negative impact on a person’s own self-defined, personal recovery journey. 5. If a person with lived experience of mental health challenges experiences a sense of empowerment/disempowerment, then they can feel more/less in control of their mental wellbeing, leading to healthcare choices that ultimately have either a positive/negative impact on one’s treatment plan and their overall mental health recovery journey. Context: A person with lived experience of mental health challenges who engages with the mental health services in order to reclaim aspects of CHIME that are important for their ongoing mental health and wellbeing. Mechanism: The person is in a space that creates an environment where such individuals either become empowered or disempowered because of the process of being labelled as a service user. Outcome: Leading to feeling more/less in control of their mental wellbeing, which can lead to healthcare decisions that either benefits or challenges the person’s mental health during their own life-long, personalised recovery journey. Once the initial CMO configurations are constructed, the next subphase is to present these CMO configurations to a group of experts for review. This is necessary in order to ensure that the theories we test the literature with are relevant to the situational context of modern mental health services, which can be determined by consulting experts in this area. From MJNs’ previous work experience, the expert panel was brought together and consisted of six individuals: three academics: Dr. Éidín Ní Shé, Dr. John Paul Byrne, Dr. Tina Bedenik, the Head of MHER, Michael Ryan, the Chair of the National Implementation and Monitoring Committee [NIMC], and former Advancing Recovery in Ireland [ARI] co-lead: Catherine Brogan and Involvement Centre Co-Ordinator and former Peer Educator: David Dwyer. In this way, the expert panel represents a diverse group of academics and local Irish experts who have a key role in implementing CHIME into practice within an Irish context. Éidín Ní Shé is a health systems academic who has a particular proficiency in realist review methodology, having published a number of realist reviews in areas of health systems management. John Paul Byrne is an academic sociologist whose interest spans the social determinents shaping work in health and psychosocial work-life conditions. Tina Bedenik is a senior postdoctural fellow with a particular interent in the ethical applications of AI in clinical decision making. Michael Ryan is a service user by background and has utilised his lived experience to support the creation and implementation of the recovery movement in Ireland. Catherine Brogan is a service provider, originally a psychiatric nurse by trade. She has utilised her practice wisdom to support, along with Michael Ryan, the creation of ARI and has for several years been a leader in creating environments that are recovery orientated within mental health. Finally, David Dwyer is also a service user by background and has utilised his lived experience to support recovery through recovery education and through the management of recovery on the ground through peer-led involvement centres. These individuals were sent an invitation letter [Appendix A] containing the above CMO configurations, along with the meeting date and associated details. Due to the proximity of all parties to one another in the country, the expert panel convened online via MS Teams and lasted approximately an hour and a half. At this meeting, the entire PhD project was presented to the expert panel, with specific attention given to work package one: the realist review. As part of this meeting, each CMO configuration was presented individually, with adequate time given for discussion of all aspects of each CMO configuration under examination. As a result, CMO configurations were added and others were refined with the support of the expert panel. After the meeting, the original CMOs were amended, and a sixth CMO was added based on the discussion. Additionally, these were added to the minutes, which were prepared and circulated among the expert panel members [Appendix B], who were then given the appropriate amount of time to respond and make further amendments to the edited CMO configurations. The finalised and amended CMO configurations are presented in Table Three below. Table 3. Table consists of the revised initial programme theories in the form of CMO configurations. These are the initial programme theories that were agreed between the research team and the expert panel. CMO Configuration One - Connection Context: A person who has experienced mental health challenges and as a result now attends a mental health service environment that enables/inhibits connection. Mechanism: Gaining/losing a sense of connection because of a person's point in their recovery at one set period in time. Outcome: Resulting in a person feeling/not feeling a sense of belonging, ease, being genuinely a part of something and finding one’s tribe in life. CMO Configuration Two - Hope Context: A person attending the mental health services is in an environment that allows them to either have hope or a loved one or staff holds hope whilst they work on their recovery. Mechanism: The service empowers/inhibits hope in a person in their recovery at a given moment in time. Outcome: Resulting in the person feeling hopeful for their ongoing recovery or hopeless regarding their future leading to behaviours that may or may not have a negative impact on a person’s physical and mental wellbeing. CMO Configuration Three - Identity Context: A person with lived/living experience of mental health challenges enters a mental health service where they discover/lose their identity. Mechanism: The person discovers/loses their identity due to their acceptance of lived reality at that moment in time. Outcome: Resulting in a person discovering/losing hope, gaining/losing a positive sense of self, of self-efficacy along with feeling stigmatised/destigmatised because of how they view their identity. CMO Configuration Four – Meaning and Purpose Context: A person who enters a mental health service for their mental health and wellbeing and whilst there, they discover/lose their sense of meaning and purpose in their lives. Mechanism: The person discovers/loses meaning and purpose in their lives on their recovery journey at that moment in time. Outcome: Leading to either a lack of/sense of self-worth, self-efficacy and a positive/negative sense of self and their placement within the world. CMO Configuration Five - Empowerment Context: A person experiencing mental health challenges enters a mental health service and whilst there, they become empowered/disempowered Mechanism: Due to their identity as a service user along with where they are in their recovery at that moment in time. Outcome: Leading to the person feeling/not feeling a sense of empowerment/disempowerment and self-efficacy. CMO Configuration Six - CHIME Context: A person who attends the mental health services enters an environment that is either conducive or not to CHIME. Mechanism: Due to their placement within this environment, the person discovers/loses connectedness, hope, identity, meaning and purpose and empowerment. Outcome: This results in a person feeling/not feeling a sense of hopefulness in their life which impacts their sense of belonging, ease, self, self-efficacy and self-worth, resulting in the person feeling stigmatised/destigmatised, which impacts their mental health recovery journey. Step two: searching for evidence. According to Pawson et al . 34 , the next step of the realist review process will be to test these CMO configurations to see if the literature agrees and aligns with these hypothesised initial programme theories. In order to do this, the first step is to create a search strategy 47 . Search strategy development should be an iterative process that results in a strategy to search the literature that is both sensitive and specific to the topic under investigation 48 . Achieving this can be challenging and often requires several hours to properly construct 49 . As such, obtaining the advice and expertise provided by a librarian is seen as crucial to the process 50 , 51 . In keeping with best practice, KW, an information specialist librarian from the Royal College of Surgeons in Ireland, was consulted in the search strategy development. As a result of the expertise of KWs, Table Four , Table Five and Table Six were constructed to contain the search terms that were devised to support the research team in gathering citations for this realist review from three databases: CINAHL, PubMed, and psychINFO. Grey literature will be gathered through a process of grey literature searching proposed by Godin et al . 52 . Table 4. Table describes the search strategy for the database: PubMed. Table Four: Search Strategy for Pubmed No. Query Last Run Via Results #1 "Mental Health"[Mesh:NoExp] OR "Mental Disorders"[Mesh:NoExp] OR "mental health" OR "mental disorders" OR "psychiatric illness" OR "mental illness" PubMed 6,58,228 #2 "chime" OR "c.h.i.m.e" PubMed 610 #3 #1 AND #2 PubMed 79 #4 "Mental Health Recovery"[Mesh:NoExp] OR "Psychiatric Rehabilitation"[Mesh:NoExp] OR "mental health recovery" OR "psychological rehabilitation" OR "recovery" OR "personal recovery" PubMed 6,71,015 #5 "Interpersonal Relations"[Mesh:NoExp] OR "Loneliness"[Mesh:NoExp] OR "Social Isolation"[Mesh:NoExp] OR "Social Participation"[Mesh:NoExp] OR "Community Participation"[Mesh:NoExp] OR "Social Alienation"[Mesh:NoExp] OR "connection" OR "belonging" OR "loneliness" OR "social isolation" OR "social participation" PubMed 4,04,032 #6 "Hope"[Mesh:NoExp] OR "hope" OR "hopefulness" PubMed 1,11,501 #7 "Individuality"[Mesh:NoExp] OR "Self Concept"[Mesh:NoExp] OR "identity" OR "self concept" OR "self worth" OR "sense of self" PubMed 2,85,401 #8 "meaning" OR "purpose" OR "sense of purpose" OR "sense of meaning" OR "meaning making" PubMed 17,37,065 #9 "Empowerment"[Mesh:NoExp] OR "Self Efficacy"[Mesh:NoExp] OR "empowerment" OR "self efficacy" PubMed 78,289 #10 #3 AND #4 PubMed 60 #11 #3 AND #5 PubMed 7 #12 #3 AND #6 PubMed 41 #13 #3 AND #7 PubMed 39 #14 #3 AND #8 PubMed 40 #15 #3 AND #9 PubMed 40 #16 #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 PubMed 64 Table 5. Table describes the search strategy for the database: CINAHL. Table Five: Search Strategy for CINAHL No. Query Last Run Via Results S1 (MH "Mental Health") OR "mental health" OR (MH "Mental Disorders") OR "mental disorders" OR "psychiatric illness" OR "mental illness" E.Cinahl U 2,75,431 S2 "chime" OR "c.h.i.m.e" E.Cinahl U 131 S3 S1 AND S2 E.Cinahl U 44 S4 (MH "Mental Health Recovery") OR "mental health recovery" OR (MH "Psychiatric Rehabilitation") OR "psychological rehabilitation" OR "recovery" OR "personal recovery" E.Cinahl U 1,33,586 S5 "connection" OR "belonging" OR (MH "Interpersonal Relations") OR (MH "Loneliness") OR "loneliness" OR (MH "Social Isolation") OR "social isolation" OR (MH "Social Participation") OR "social participation" OR (MH "Community Participation") OR (MH "Social Alienation") E.Cinahl U 1,35,585 S6 (MH "Hope") OR "hope" OR "hopefulness" E.Cinahl U 29,184 S7 (MH "Individuality") OR "identity" OR (MH "Self Concept") OR "self concept" OR "self worth" OR "sense of self" E.Cinahl U 94,517 S8 "meaning" OR "purpose" OR "sense of purpose" OR "sense of meaning" OR "meaning making" E.Cinahl U 5,54,305 S9 (MH "Empowerment") OR "empowerment" OR (MH "Self Efficacy") OR "self efficacy" E.Cinahl U 68,736 S10 S3 AND S4 E.Cinahl U 42 S11 S3 AND S5 E.Cinahl U 14 S12 S3 AND S6 E.Cinahl U 32 S13 S3 AND S7 E.Cinahl U 30 S14 S3 AND S8 E.Cinahl U 33 S15 S3 AND S9 E.Cinahl U 33 S16 S10 OR S11 OR S12 OR S13 OR S14 OR S15 E.Cinahl U 43 Table 6. Table describes the search strategy for the database: psychINFO. Table Six: Search Strategy for psychINFO No. Query Last Run Via Results S1 DE "Mental Health" OR DE "Mental Disorders" OR "mental health" OR "mental disorders" OR "psychiatric illness" OR "mental illness" E. APA PsyInfo 9,54,356 S2 "chime" OR "c.h.i.m.e" E. APA PsyInfo 175 S3 S1 AND S2 E. APA PsyInfo 77 S4 "mental health recovery" OR "psychological rehabilitation" OR "recovery" OR "personal recovery" E. APA PsyInfo 96,931 S5 DE "Loneliness" OR DE "Social Isolation" OR "connection" OR "belonging" OR "loneliness" OR "social isolation" OR "social participation" E. APA PsyInfo 1,26,724 S6 DE "Hope" OR "hope" OR "hopefulness" E. APA PsyInfo 54,010 S7 DE "Individuality" OR DE "Self-Concept" OR "identity" OR "self concept" OR "self worth" OR "sense of self" E. APA PsyInfo 2,91,930 S8 "meaning" OR "purpose" OR "sense of purpose" OR "sense of meaning" OR "meaning making" E. APA PsyInfo 5,10,927 S9 DE "Empowerment" OR DE "Self-Efficacy" OR "empowerment" OR "self efficacy" E. APA PsyInfo 91,538 S10 S3 AND S4 E. APA PsyInfo 62 S11 S3 AND S5 E. APA PsyInfo 7 S12 S3 AND S6 E. APA PsyInfo 45 S13 S3 AND S7 E. APA PsyInfo 45 S14 S3 AND S8 E. APA PsyInfo 48 S15 S10 OR S11 OR S12 OR S13 OR S14 E. APA PsyInfo 63 The next step was to construct a pre-determined inclusion and exclusion criteria [ Table Seven ]. A pre-determined inclusion/exclusion criteria is important, as it will be used to support the shortlisting of articles for this review. For this reason, each inclusion/exclusion criterion was selected for a reason. The rationale for this is now discussed below: Table 7. Table describes the inclusion/exclusion criteria for this realist review. Inclusion Criteria Exclusion Criteria Peer reviewed and grey literature based qualitative and mixed methods articles Peer reviewed and grey literature based quantitative articles Literature reviews of any kind, opinion/perspective pieces, case studies, editorials, conference briefings 01 st January 2011-present Articles published before 2011 Articles published in the English language Articles published in languages that are not English Mental Health [as defined by World Health Organisation 64 ] and Illness [Any mental illness as described by the International Classification of Diseases-11 65 or Diagnostic and Statistical Manual of Mental Disorders 5-Text Revision 66 Addictions, Intellectual disabilities, physical health, dual diagnosis [of any kind] Focuses explicitly on CHIME – connection, hope, identity, meaning and purpose and empowerment Focuses on all other aspects of mental health recovery. In the identification of appropriate resources for inclusion in this realist review, qualitative and mixed methods papers will be included, whereas quantitative papers will not. The rationale for this is that papers with qualitative data allow for theoretical depth to occur, which is not possible with other quantitative methodologies and positivist positionings. Literature reviews of any kind, including meta-synthesis, will be excluded because of the reviewers’ positionality towards the original raw data used in the original study 1 . In other words, these review papers will be excluded as the reviewer is removed at least twice from the original raw data that was collected by the original study authors. As such, if reviews were included, it is possible that such reviews could misinterpret the original findings and make conclusions that are misleading due to the misinterpretation of the data presented by the original studies. Equally, the studies that report on the raw data included in such reviews may also be subject to bias or may not have been of sufficient quality, but yet included in such reviews due to, for example, a lack of papers identified for inclusion. As such, the findings of the review may not be accurate because of the inclusion of poorly conducted studies, which may impede the intended impact of the realist review. Grey literature will also be searched for relevant papers through a the process described by Godin and colleagues 52 . Godin and colleagues approach involves a four step process: 1) searching grey literature databases, 2) customised Google search engines, 3) targeted websites and 4) consultation with contact experts 52 . The articles to be collected will be from 2011 to the present [2025]. Articles published before 2011 will not be included as they would have been published before the literature review that created CHIME was published. Additionally, pre-2011 papers would have been captured by the original systematic review and narrative synthesis that constructed CHIME. Articles not published in English were excluded due to the inability of the review team in translating articles from other languages to English. Articles will be included only if they are relevant to mental health and illness. Articles discussing a dual diagnosis of any kind will be excluded because of the difficulties in distinguishing changes relating and not relating to mental health and illness alone. Finally, papers were also excluded if they spoke of an aspect of CHIME on their own and included if they spoke of all concepts of CHIME amalgamated together. Articles that examined other areas of mental health recovery were excluded from the review. Once the inclusion/exclusion criteria are defined, the next step is to search the literature to determine whether these initial programme theories are credible or not. The planned search will use an exhaustive screening process that describes a systematic process whereby all citations that arise from applying the search strategy to databases will be included as part of round one screening. As part of the creation of this realist review protocol, the search strings were applied to the relevant databases, and all citations that arose were then placed into a citation software package Covidence to help manage the remainder of the screening process, which will be discussed in further detail as part of step three of the realist review process devised by Pawson et al . 34 . Round one of the exhaustive screening process will be undertaken by both MJN and Information Specialist Librarian KW. Step three: select and appraise evidence. After round one of exhaustive searching concludes, a number of citations will have been found and added to the citation software package Covidence for the review team to review and narrow down further. Round two screening then occurs. Round two screening involves firstly eliminating any duplicates that may have been gathered as part of round one screening and then applying pre-determined inclusion/exclusion criteria [ Table Four ] to the abstracts of the remainder of the citations gathered over the course of round one screening. Round two screening will be undertaken by MJN and ÉNS, who will screen 10% of the papers at this phase to ensure rigor and adherence to the pre-determined inclusion/exclusion criteria 53 . Finally, round three screening will involve the application of a pre-determined inclusion/exclusion criteria [ Table Four ] to the full text of citations included in this study. Again, this round was conducted by MJN with ÉNS, reviewing 10% of papers at this stage of searching also. If there are any disagreements regarding the inclusion or exclusion of a paper, then a third reviewer [JPB] will review the citation and make the ultimate decision regarding the paper’s inclusion or exclusion. Any citations left after the three rounds of screening were included in this realist review. As such, the process described above is similar to that of an original systematic review with a particular focus on thoroughness and transparency 54 . This realist review will appraise included studies for richness, relevance, and rigor in line with the realist methodology of Pawson et al . 34 . According to Pawson et al ., 34 relevance relates to whether the paper addresses the theory under investigation. In addition, rigor relates to how the research supports the conclusions drawn by the author of the paper being examined 34 . Finally, richness refers to whether a paper has sufficient depth to meaningfully contribute to theory-building 21 . Unlike systematic reviews that appraise for quality purposes 55 – 57 , in realist reviews, one appraises relevance as the development of theory 21 . However, there is no agreed upon method for assessing relevance in realist reviews 58 . As such, in this review, when appraising included studies, the following questions will be posed to the literature: 1. Does reading the full text confirm the paper context and feature CHIME explicitly? 2. Does the article provide concepts/data on outcomes? Step four: extract the data. Data will be gathered only from primary sources because of the issue of positionality when it comes to secondary sources, as noted by Norton 1 . When it comes to primary sources, each citation will be examined thoroughly to identify the key aspects of each study, including the CMO configuration. Data collected from the citations that match these areas will be extracted by MJN into a data extraction form that will be developed by MJN prior to the commencement of this stage of Pawson and colleagues’ realist methodology. This data extraction document will be validated through consultation with the supervisory members of the review team (ÉNS, JPB, and TB). Once approved, this data extraction tool will test 10% of included studies using the below key aspects from each citation: Author[s], year and country of publication Aim of study Methodology utilised Sample and sample size Setting Study type – journal article, grey literature, dissertation etc. CHIME concept examined Context Mechanism Outcome Once 10% of studies have their data extracted, ÉNS will review the data extraction tool and the data collected from extraction. If she is satisfied by the tool’s performance on 10% of included paper, the primary reviewer [MJN] will utilize this tool for the remainder of the papers to be extracted. The process of data extraction is iterative, meaning that the data extraction tool will be constantly refined over the course of the realist review process 18 . It is also important to note that each paper may not contain a context, a mechanism or an outcome and as such, this can only be identified if the particular IPT is in itself identified. In other words, this protocol acknowledges that one cannot infer that something functions as a context or mechanism without first knowling the outcome it is relating to. In addition, rigor will be captured using the Crowe Critical Appraisal Tool 59 . It was decided to utilise this tool as it has been utilised in another realist review within the health sciences space 60 . Step five: analyse and synthesise data. The primary purpose of data synthesis is to determine what works, for whom, how, and under what circumstances, all in an attempt to refine the initial programme theories 35 . In this way, the word synthesis in this context differs from the same word for systematic reviews, as in this process, the purpose of synthesis is to make progress in the explanation of initial programme theories into refined intial programme theories 61 . In this realist review, two mechanisms are used to refine the initial programme theory. Firstly, summative content analysis will be conducted and will support the process of retroductive reasoning in order to develop the refined initial programme theories. Summative content analysis was devised by Hsieh and Shannon 62 , and it involves an iterative process of identifying keywords based on the stated headings in stage four of Pawson and colleagues’ 34 realist methodology to create a set of refined intial programme theories. Once these refined intial programme theories are defined, the second process is a validation exercise where our subject experts appointed during stage one of the realist methodology will reconvene to approve the newly developed refined intial programme theories. Step six: ethics and dissemination. In line with similar realist reviews, ethical approval will not be required, as although we have an expert panel consisting of academics [ÉNS, JPB, TB] and expert panel members [MR, CB, DD], they have all been included in the authorship of this paper. In addition, no ethical approval is required, as no primary data collection will take place for the purpose of this review. They will also be included in the authorship of the realist review itself. Reporting bias will be contained through a process of reflexivity where the primary reviewer [MJN] will engage in journalling to support the process of retroductive reasoning whilst also acknowledging any reporting bias that may impede the fair development of the refined intial programme theories. The complete review will be presented as a second article and submitted for publication in a peer-reviewed journal. In addition, the results of this proposed realist review may also be presented through other means, including conferences and recovery workshops delivered by recovery college personnel. This will be made possible through the Recovery and Engagement Programme Manager in charge of the recovery education workstream of MHER. Conclusion The present protocol provides a starting point for a comprehensive realist approach for a PhD project being conducted in order to understand the mechanisms that underpin the concept of personal recovery – in this case, CHIME 8 . The first phase of this process is a realist review. This is useful because it allows for a theoretical examination of the various mechanisms that underpin CHIME, and will result in a theoretical interpretation of the underlying structures and mechanisms that support a person in reaching connection, hope, identity, meaning and purpose, and empowerment 39 . To strengthen the realist review findings, the initial programme theories as well as the further developed refined intial programme theories were and will be examined by an expert panel who will then make recommendations for further refinement or agreement on the programme theories presented. To ensure that the papers selected for inclusion are relevant to the question posed, CHIME will need to be explicitly presented and referred to within the title, abstract, and full text of each included article in this realist review. This proposed realist review will add new knowledge to mental health recovery as it will either reinforce the initial programme theories created or provide new ones that can be investigated further in the next phase of the overarching study. As such, the findings of this proposed review will identify not only new avenues for exploration within CHIME, but also potential gaps in the knowledge base surrounding recovery that can be explored further. This proposed review is important, as it will also provide a unique method of exploring CHIME beyond the constraints of more traditional review methods. The results of this review will support work package two of the overarching PhD project which seeks to explore the inner mechanisms at play that allows a person to move from a state of unwellness towards recovery through CHIME. Data availability No data is associated with this article. Faculty Opinions recommended References 1. 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PubMed Abstract | Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 26 Aug 2025 ADD YOUR COMMENT Comment Author details Author details 1 PhD Scholar, Graduate School of Healthcare Management, Royal College of Surgeons in Ireland, Dublin, Leinster, D02 YN77, Ireland 2 Senior Lecturer, Graduate School of Healthcare Management, Royal College of Surgeons in Ireland, Dublin, Leinster, D02 YN77, Ireland 3 Senior Post-Doctoral Researcher, Data Science Centre, School of Population Health, Royal College of Surgeons in Ireland, Dublin, Leinster, D02 YN77, Ireland 4 Head of Mental Health Engagement and Recovery, Office of Mental Health Engagement and Recovery, St. Loman’s Hospital, Palmerstown, Dublin, D20 HK69, Ireland 5 303 Duncreeven, Courtown Park, Catherine Brogan Consultancy, Kilcock, Kildare, W23 Y660, Ireland 6 Involvement Centre Co-Ordinator, Recovery College South East, Greenshill, Kilkenny, R95 YYC0, Ireland 7 Information Specialist, Library, Royal College of Surgeons in Ireland, 26 York Street, Dublin, D02 P796, Ireland Michael John Norton Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing John Paul Byrne Roles: Methodology, Supervision, Validation, Visualization, Writing – Review & Editing Tina Bedenik Roles: Investigation, Methodology, Supervision, Validation, Writing – Review & Editing Michael Ryan Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Catherine Brogan Roles: Methodology, Writing – Review & Editing David Dwyer Roles: Methodology, Writing – Review & Editing Killian Walsh Roles: Methodology, Resources, Software Éidín Ní Shé Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information Health Research Board Ireland [APA-2022-022]. This work was also supported by the Irish Research Council Enterprise Partnership Scheme Postgraduate Scholarship [Grant code: EBPPG/2024/189]. 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: 17 Nov 2025, 8:94 https://doi.org/10.12688/hrbopenres.14171.2 version 1 Published: 26 Aug 2025, 8:94 https://doi.org/10.12688/hrbopenres.14171.1 Copyright © 2025 Norton MJ 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 Norton MJ, Byrne JP, Bedenik T et al. Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.12688/hrbopenres.14171.2 ) 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 2 VERSION 2 PUBLISHED 17 Nov 2025 Revised Views 0 Cite How to cite this report: Vilar-Lluch S. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15730.r51644 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v2#referee-response-51644 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 Sara Vilar-Lluch , Cardiff University, Cardiff, UK Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15730.r51644 Overall very clear and informative. The writing needs some polishing, please see notes below. Occasionally, some glossing of concepts is needed (also noted below). Abstract: - CHIME is defined as “A concept that represents the key ... Continue reading READ ALL Overall very clear and informative. The writing needs some polishing, please see notes below. Occasionally, some glossing of concepts is needed (also noted below). Abstract: - CHIME is defined as “A concept that represents the key characteristics of recovery”: CHIME is not “a concept”, it’s a “framework” - Please rephrase the following sentence, the wording is not clear (i.e. clearly state what the question is): “allowing one to answer this review question by exploring how, why, and through what circumstances individuals reach recovery through CHIME.” - Is the following necessary, considering that this is meant to be indexing? > “The proposed review will be written up and submitted to a peer-reviewed journal” Introduction p. 4: please ensure that a formal academic style is adopted throughout. For instance, in “However, till now, no study” > “till” should be “until”. p. 4: please revise wording “In answering this question, a realist review was deemed most appropriate” >> “to answer this question…” (please also note that a explicit research question is not provided; it is formulated as an aim). p. 4: please note that the last paragraph of the introduction starts and ends in the same manner (stating the aims of the review). Please avoid repetitions. Methods p. 4: please revise wording (repetition of verb “are”): “Realist reviews are, by their very nature, are cyclical and iterative in their approach” Table 1 (p, 6). All the “if… then…” statements start with “If a person with lived experience of mental health challenges” (or similar) except point 4 (“If a person who uses community mental health services”). Unless there is a reason for this change (in which case should be explained), please unify. p. 6: the relevance of physical proximity is not clear, if the meetings were online, please amend as necessary: “Due to the proximity of all parties to one another in the country, the expert panel convened online via MS Teams and lasted approximately an hour and a half” p. 6: please state the sixth element at the end of this sentence: “After the meeting, the original CMOs were amended, and a sixth CMO was added based on the discussion.” p. 6: please briefly explain the process alluded to after this sentence (or indicate which section of the paper provides this information if this is the case): “Grey literature will be gathered through a process of grey literature searching proposed by Godin et al .” This is then repeated at p. 8 (and the process is briefly explained); just refer there – or move the explanation to the methods, together with the other explanations. p. 6: this sentence appears redundant, please amend or simply delete, and introduce the rationale directly: “For this reason, each inclusion/exclusion criterion was selected for a reason.” p. 6: please unify verbal tenses. The methods were reported in past tense, but then there is a shift to future tense: “In the identification of appropriate resources for inclusion in this realist review, qualitative and mixed methods papers will be included, whereas quantitative papers will not”. Please unify. p. 8: please simply the following three sentences (they repeat the same information in different words and appear repetitive): “Literature reviews of any kind, including meta-synthesis, will be excluded because of the reviewers’ positionality towards the original raw data used in the original study1. In other words, these review papers will be excluded as the reviewer is removed at least twice from the original raw data that was collected by the original study authors. As such, if reviews were included, it is possible that such reviews could misinterpret the original findings and make conclusions that are misleading due to the misinterpretation of the data presented by the original studies.” p. 8: please rephrase this sentence, it appears odd: “Articles published before 2011 will not be included as they would have been published before the literature review that created CHIME was published.” p. 8: please unify tenses (here one is in past, and the following is in the future): “Articles not published in English were excluded due to the inability of the review team in translating articles from other languages to English. Articles will be included only if they are relevant to mental health and illness.” (same in the first paragraph of p. 9) p. 10: first paragraph. As before, there is inconsistency of tenses; the preceding sentence to the one copied is in future tense, this one in past (and the one that follows in future): “Again, this round was conducted by MJN with ÉNS, reviewing 10% of papers at this stage of searching also.” I understand that the paper reports a work in progress, but if this is meant to be a protocol, tenses need unification, otherwise it is confusing. p. 12: “rigor will be captured using the Crowe Critical Appraisal Tool” > please provide a brief gloss of this tool, it is not explained. 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: Health communication, recovery, applied linguistics 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 Vilar-Lluch S. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15730.r51644 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v2#referee-response-51644 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 Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Thongsalab DJ. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15730.r51531 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v2#referee-response-51531 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 25 Dec 2025 Dr. Jutharat Thongsalab , Boromarajonani College of Nursing Surin, Mueang Surin District, Surin, Thailand Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15730.r51531 Thank you for the revised version of this protocol. The authors have addressed several earlier comments. These changes have clearly enhanced the clarity and structure of the protocol. Some methodological aspects (e.g., proportion of double-screening, inter-rater agreement, and the decision ... Continue reading READ ALL Thank you for the revised version of this protocol. The authors have addressed several earlier comments. These changes have clearly enhanced the clarity and structure of the protocol. Some methodological aspects (e.g., proportion of double-screening, inter-rater agreement, and the decision to exclude quantitative studies) could be further strengthened, but these issues do not fundamentally compromise the coherence or feasibility of the proposed realist review. Furthermore, I recommend accepting this protocol. 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Thongsalab DJ. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15730.r51531 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v2#referee-response-51531 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 Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Poulsen CH. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15730.r51529 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v2#referee-response-51529 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 26 Nov 2025 Chalotte Heinsvig Poulsen , Copenhagen Research Unit for Recovery, Copenhagen, Denmark; Mental Health Center Glostrup, Centre for Applied Research in Mental Health, Mental Health Services, Capital region of denmark, Copenhagen, Denmark Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15730.r51529 I can read that you have accommodated my feedback regarding transparency and the ... Continue reading READ ALL I can read that you have accommodated my feedback regarding transparency and the positioning of the expert panel and other suggestions. I have no further comments. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Post doc researcher; Co-production; Peer support; Recovery-oriented research; Development of program theory; Critical realism; Proces evaluation; Randomized controlled trials supplemented by qualitative research about mechanisms of change and context. 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 Poulsen CH. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15730.r51529 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v2#referee-response-51529 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 Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Wong G. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15730.r51530 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v2#referee-response-51530 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 25 Nov 2025 Geoff Wong , University of Oxford, Oxford, UK Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15730.r51530 Thanks for taking the time to read and consider my comments. As none of the comments I ... Continue reading READ ALL Thanks for taking the time to read and consider my comments. As none of the comments I made were major and had to be addressed, I hope you found them helpful. Good luck with your review. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Realist review / synthesis and realist evaluation. 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 Wong G. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15730.r51530 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v2#referee-response-51530 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 Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 26 Aug 2025 Views 0 Cite How to cite this report: Poulsen CH. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15583.r50797 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v1#referee-response-50797 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 11 Nov 2025 Chalotte Heinsvig Poulsen , Copenhagen Research Unit for Recovery, Copenhagen, Denmark; Mental Health Center Glostrup, Centre for Applied Research in Mental Health, Mental Health Services, Capital region of denmark, Copenhagen, Denmark Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15583.r50797 Thank you for allowing me to read and peer review this thorough and well-written realist review protocol. The aim is clearly stated as a realist systematic review of qualitative studies focusing on the underlying mechanisms that facilitate the transition from ... Continue reading READ ALL Thank you for allowing me to read and peer review this thorough and well-written realist review protocol. The aim is clearly stated as a realist systematic review of qualitative studies focusing on the underlying mechanisms that facilitate the transition from mental distress to wellbeing and personal recovery, as described in the CHIME framework. The methodology is comprehensive, following criteria for realist reviews with a detailed and transparent account of programme theory development, research questions, search strategy, article selection, and reporting. The approach is easy to understand and reproducible for other researchers, and the process is effectively illustrated with the included figures and tables. The authors could benefit from further clarifying the following points: 1) Describe the positions of the author group - are anyone working from a lived experience of mental health recovery perspective? - and/or caregiver perspective? 2) More information about PPI research - the service users in the expert panel - who are they, how were they recruited? How is diversity, equal power sharing, safe and secure user involvement ensured? 3) To which degree was the expert panel involved? - was it user-involvement, co-production or co-creation? 4) How will the program theory iteratively be refined based on emerging data? 5) Do the authors have a plan for managing potential heterogeneity in study contexts and populations, and how will this be addressed in the synthesis? 6) Discussion of potential limitations inherent to realist systematic reviews compared to other types of reviews and how these will be mitigated. 7) Be aware that if the CHIME agronym should be explicitly presented and referred to within the title, abstract and full text - will exclude papers for example the attached paper by Egmose et al. 2024 - exploring the mechanisms of change in a group-based peer support intervention co-produced around the CHIME framework. 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. Egmose C, Poulsen C, Bjørkedal S, Eplov L: The ‘Paths to everyday life’ (PEER) trial – a qualitative study of mechanisms of change from the perspectives of individuals with mental health difficulties participating in peer support groups led by volunteer peers. BMC Psychiatry . 2024; 24 (1). Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Post doc researcher; Co-production; Peer support; Recovery-oriented research; Development of program theory; Critical realism; Proces evaluation; Randomized controlled trials supplemented by qualitative research about mechanisms of change and context. 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 Poulsen CH. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15583.r50797 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v1#referee-response-50797 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 25 Nov 2025 Michael John Norton , $usrAffiliation 25 Nov 2025 Author Response Thank you for allowing me to read and peer review this thorough and well-written realist review protocol. The aim is clearly stated as a realist systematic review of ... Continue reading Thank you for allowing me to read and peer review this thorough and well-written realist review protocol. The aim is clearly stated as a realist systematic review of qualitative studies focusing on the underlying mechanisms that facilitate the transition from mental distress to wellbeing and personal recovery, as described in the CHIME framework. The methodology is comprehensive, following criteria for realist reviews with a detailed and transparent account of programme theory development, research questions, search strategy, article selection, and reporting. The approach is easy to understand and reproducible for other researchers, and the process is effectively illustrated with the included figures and tables. Response: Thank you for your kind comment. We hope that the amendments made to this paper as a result of your feedback and the feedback of the other peer reviewers enhances the protocol further. The authors could benefit from further clarifying the following points: 1) Describe the positions of the author group - are anyone working from a lived experience of mental health recovery perspective? - and/or caregiver perspective? Response: Thank you for your comment. As per your feedback and the feedback of another reviewer, the positions of the author group are noted as part of stage one of the iterative process of realist reviews. 2) More information about PPI research - the service users in the expert panel - who are they, how were they recruited? How is diversity, equal power sharing, safe and secure user involvement ensured? Response: Thank you for this comment. PPI is central to this proposed research. The principal investigator is a service user himself along with two of the expert panel members. This ensures that the views of service users are central to the creation of this protocol and the subsequent review. As part of the realist review process, the refined IPTs will be presented to the expert panel for approval once data collection is completed. In answering point 1 above, we have already identified the expert panel personal. They were recruited from the principal investigators contacts through his work with the HSE Office of Mental Health Engagement and Recovery – an office that promotes recovery, co-production and service user involvement within mental health service provision. Finally, equal power sharing is ensured as all members of the expert panel have been involved in service user involvement and co-production for a number of years and fully understands the nuances of these processes not just in service provision but also in research. 3) To which degree was the expert panel involved? - was it user-involvement, co-production or co-creation? Response: Thank you for this comment. The expert panel were involved in the process through the co-production of the initial IPTs and will be involved again in the refinement of the IPTs through co-production. 4) How will the program theory iteratively be refined based on emerging data? Response: Thank you for this comment. The protocol outlines the process of how the papers were gathered and how the papers will be reviewed. Part of this process will be drawing out the context, mechanisms and outcomes of all the included papers. These will then be put together by aligning the new IPTs to the various elements of CHIME to see what refined IPTs relate to each concept and which concepts intertwine with each other. Additionally, these refined IPTs will be compared to the original IPTs that were co-produced with the expert panel to identify if what we found matches with these original IPTs. To further support this. The IPTs will refer to micro [personal], meso [service] and macro [system] factors and as such, these IPTs will be placed along this continuum with a diagram visually depicting this. This will then be brought to the expert panel for approval and once approved, write up of the realist review will commence. 5) Do the authors have a plan for managing potential heterogeneity in study contexts and populations, and how will this be addressed in the synthesis? Response: Thank you for this comment. This query is answered through point 4 above. We do anticipate heterogeneity in context and populations but this will be demonstrated through aligning the IPTs to a micro, meso and macro perspective where contexts in terms of individual, service or system will be demonstrated. This heterogeneity will also be visually demonstrated. 6) Discussion of potential limitations inherent to realist systematic reviews compared to other types of reviews and how these will be mitigated. Response: Thank you for this comment. This review differs from systematic reviews and scoping reviews as it is theory heavy, and the focus is on looking for potential mechanisms rather than examining potential depth and breadth of the literature base. This does raise questions of potential bias but this is mitigated because the focus is on developing mechanisms rather than elimination of bias. 7) Be aware that if the CHIME agronym should be explicitly presented and referred to within the title, abstract and full text - will exclude papers for example the attached paper by Egmose et al. 2024 - exploring the mechanisms of change in a group-based peer support intervention co-produced around the CHIME framework. Response: Thank you for this comment. We are aware that focusing on CHIME in these areas will exclude paper. However, as noted in point 6 the focus is on finding mechanisms, not on ensuring that the breadth/depth of literature is achieved. Thank you for allowing me to read and peer review this thorough and well-written realist review protocol. The aim is clearly stated as a realist systematic review of qualitative studies focusing on the underlying mechanisms that facilitate the transition from mental distress to wellbeing and personal recovery, as described in the CHIME framework. The methodology is comprehensive, following criteria for realist reviews with a detailed and transparent account of programme theory development, research questions, search strategy, article selection, and reporting. The approach is easy to understand and reproducible for other researchers, and the process is effectively illustrated with the included figures and tables. Response: Thank you for your kind comment. We hope that the amendments made to this paper as a result of your feedback and the feedback of the other peer reviewers enhances the protocol further. The authors could benefit from further clarifying the following points: 1) Describe the positions of the author group - are anyone working from a lived experience of mental health recovery perspective? - and/or caregiver perspective? Response: Thank you for your comment. As per your feedback and the feedback of another reviewer, the positions of the author group are noted as part of stage one of the iterative process of realist reviews. 2) More information about PPI research - the service users in the expert panel - who are they, how were they recruited? How is diversity, equal power sharing, safe and secure user involvement ensured? Response: Thank you for this comment. PPI is central to this proposed research. The principal investigator is a service user himself along with two of the expert panel members. This ensures that the views of service users are central to the creation of this protocol and the subsequent review. As part of the realist review process, the refined IPTs will be presented to the expert panel for approval once data collection is completed. In answering point 1 above, we have already identified the expert panel personal. They were recruited from the principal investigators contacts through his work with the HSE Office of Mental Health Engagement and Recovery – an office that promotes recovery, co-production and service user involvement within mental health service provision. Finally, equal power sharing is ensured as all members of the expert panel have been involved in service user involvement and co-production for a number of years and fully understands the nuances of these processes not just in service provision but also in research. 3) To which degree was the expert panel involved? - was it user-involvement, co-production or co-creation? Response: Thank you for this comment. The expert panel were involved in the process through the co-production of the initial IPTs and will be involved again in the refinement of the IPTs through co-production. 4) How will the program theory iteratively be refined based on emerging data? Response: Thank you for this comment. The protocol outlines the process of how the papers were gathered and how the papers will be reviewed. Part of this process will be drawing out the context, mechanisms and outcomes of all the included papers. These will then be put together by aligning the new IPTs to the various elements of CHIME to see what refined IPTs relate to each concept and which concepts intertwine with each other. Additionally, these refined IPTs will be compared to the original IPTs that were co-produced with the expert panel to identify if what we found matches with these original IPTs. To further support this. The IPTs will refer to micro [personal], meso [service] and macro [system] factors and as such, these IPTs will be placed along this continuum with a diagram visually depicting this. This will then be brought to the expert panel for approval and once approved, write up of the realist review will commence. 5) Do the authors have a plan for managing potential heterogeneity in study contexts and populations, and how will this be addressed in the synthesis? Response: Thank you for this comment. This query is answered through point 4 above. We do anticipate heterogeneity in context and populations but this will be demonstrated through aligning the IPTs to a micro, meso and macro perspective where contexts in terms of individual, service or system will be demonstrated. This heterogeneity will also be visually demonstrated. 6) Discussion of potential limitations inherent to realist systematic reviews compared to other types of reviews and how these will be mitigated. Response: Thank you for this comment. This review differs from systematic reviews and scoping reviews as it is theory heavy, and the focus is on looking for potential mechanisms rather than examining potential depth and breadth of the literature base. This does raise questions of potential bias but this is mitigated because the focus is on developing mechanisms rather than elimination of bias. 7) Be aware that if the CHIME agronym should be explicitly presented and referred to within the title, abstract and full text - will exclude papers for example the attached paper by Egmose et al. 2024 - exploring the mechanisms of change in a group-based peer support intervention co-produced around the CHIME framework. Response: Thank you for this comment. We are aware that focusing on CHIME in these areas will exclude paper. However, as noted in point 6 the focus is on finding mechanisms, not on ensuring that the breadth/depth of literature is achieved. Competing Interests: None Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 25 Nov 2025 Michael John Norton , $usrAffiliation 25 Nov 2025 Author Response Thank you for allowing me to read and peer review this thorough and well-written realist review protocol. The aim is clearly stated as a realist systematic review of ... Continue reading Thank you for allowing me to read and peer review this thorough and well-written realist review protocol. The aim is clearly stated as a realist systematic review of qualitative studies focusing on the underlying mechanisms that facilitate the transition from mental distress to wellbeing and personal recovery, as described in the CHIME framework. The methodology is comprehensive, following criteria for realist reviews with a detailed and transparent account of programme theory development, research questions, search strategy, article selection, and reporting. The approach is easy to understand and reproducible for other researchers, and the process is effectively illustrated with the included figures and tables. Response: Thank you for your kind comment. We hope that the amendments made to this paper as a result of your feedback and the feedback of the other peer reviewers enhances the protocol further. The authors could benefit from further clarifying the following points: 1) Describe the positions of the author group - are anyone working from a lived experience of mental health recovery perspective? - and/or caregiver perspective? Response: Thank you for your comment. As per your feedback and the feedback of another reviewer, the positions of the author group are noted as part of stage one of the iterative process of realist reviews. 2) More information about PPI research - the service users in the expert panel - who are they, how were they recruited? How is diversity, equal power sharing, safe and secure user involvement ensured? Response: Thank you for this comment. PPI is central to this proposed research. The principal investigator is a service user himself along with two of the expert panel members. This ensures that the views of service users are central to the creation of this protocol and the subsequent review. As part of the realist review process, the refined IPTs will be presented to the expert panel for approval once data collection is completed. In answering point 1 above, we have already identified the expert panel personal. They were recruited from the principal investigators contacts through his work with the HSE Office of Mental Health Engagement and Recovery – an office that promotes recovery, co-production and service user involvement within mental health service provision. Finally, equal power sharing is ensured as all members of the expert panel have been involved in service user involvement and co-production for a number of years and fully understands the nuances of these processes not just in service provision but also in research. 3) To which degree was the expert panel involved? - was it user-involvement, co-production or co-creation? Response: Thank you for this comment. The expert panel were involved in the process through the co-production of the initial IPTs and will be involved again in the refinement of the IPTs through co-production. 4) How will the program theory iteratively be refined based on emerging data? Response: Thank you for this comment. The protocol outlines the process of how the papers were gathered and how the papers will be reviewed. Part of this process will be drawing out the context, mechanisms and outcomes of all the included papers. These will then be put together by aligning the new IPTs to the various elements of CHIME to see what refined IPTs relate to each concept and which concepts intertwine with each other. Additionally, these refined IPTs will be compared to the original IPTs that were co-produced with the expert panel to identify if what we found matches with these original IPTs. To further support this. The IPTs will refer to micro [personal], meso [service] and macro [system] factors and as such, these IPTs will be placed along this continuum with a diagram visually depicting this. This will then be brought to the expert panel for approval and once approved, write up of the realist review will commence. 5) Do the authors have a plan for managing potential heterogeneity in study contexts and populations, and how will this be addressed in the synthesis? Response: Thank you for this comment. This query is answered through point 4 above. We do anticipate heterogeneity in context and populations but this will be demonstrated through aligning the IPTs to a micro, meso and macro perspective where contexts in terms of individual, service or system will be demonstrated. This heterogeneity will also be visually demonstrated. 6) Discussion of potential limitations inherent to realist systematic reviews compared to other types of reviews and how these will be mitigated. Response: Thank you for this comment. This review differs from systematic reviews and scoping reviews as it is theory heavy, and the focus is on looking for potential mechanisms rather than examining potential depth and breadth of the literature base. This does raise questions of potential bias but this is mitigated because the focus is on developing mechanisms rather than elimination of bias. 7) Be aware that if the CHIME agronym should be explicitly presented and referred to within the title, abstract and full text - will exclude papers for example the attached paper by Egmose et al. 2024 - exploring the mechanisms of change in a group-based peer support intervention co-produced around the CHIME framework. Response: Thank you for this comment. We are aware that focusing on CHIME in these areas will exclude paper. However, as noted in point 6 the focus is on finding mechanisms, not on ensuring that the breadth/depth of literature is achieved. Thank you for allowing me to read and peer review this thorough and well-written realist review protocol. The aim is clearly stated as a realist systematic review of qualitative studies focusing on the underlying mechanisms that facilitate the transition from mental distress to wellbeing and personal recovery, as described in the CHIME framework. The methodology is comprehensive, following criteria for realist reviews with a detailed and transparent account of programme theory development, research questions, search strategy, article selection, and reporting. The approach is easy to understand and reproducible for other researchers, and the process is effectively illustrated with the included figures and tables. Response: Thank you for your kind comment. We hope that the amendments made to this paper as a result of your feedback and the feedback of the other peer reviewers enhances the protocol further. The authors could benefit from further clarifying the following points: 1) Describe the positions of the author group - are anyone working from a lived experience of mental health recovery perspective? - and/or caregiver perspective? Response: Thank you for your comment. As per your feedback and the feedback of another reviewer, the positions of the author group are noted as part of stage one of the iterative process of realist reviews. 2) More information about PPI research - the service users in the expert panel - who are they, how were they recruited? How is diversity, equal power sharing, safe and secure user involvement ensured? Response: Thank you for this comment. PPI is central to this proposed research. The principal investigator is a service user himself along with two of the expert panel members. This ensures that the views of service users are central to the creation of this protocol and the subsequent review. As part of the realist review process, the refined IPTs will be presented to the expert panel for approval once data collection is completed. In answering point 1 above, we have already identified the expert panel personal. They were recruited from the principal investigators contacts through his work with the HSE Office of Mental Health Engagement and Recovery – an office that promotes recovery, co-production and service user involvement within mental health service provision. Finally, equal power sharing is ensured as all members of the expert panel have been involved in service user involvement and co-production for a number of years and fully understands the nuances of these processes not just in service provision but also in research. 3) To which degree was the expert panel involved? - was it user-involvement, co-production or co-creation? Response: Thank you for this comment. The expert panel were involved in the process through the co-production of the initial IPTs and will be involved again in the refinement of the IPTs through co-production. 4) How will the program theory iteratively be refined based on emerging data? Response: Thank you for this comment. The protocol outlines the process of how the papers were gathered and how the papers will be reviewed. Part of this process will be drawing out the context, mechanisms and outcomes of all the included papers. These will then be put together by aligning the new IPTs to the various elements of CHIME to see what refined IPTs relate to each concept and which concepts intertwine with each other. Additionally, these refined IPTs will be compared to the original IPTs that were co-produced with the expert panel to identify if what we found matches with these original IPTs. To further support this. The IPTs will refer to micro [personal], meso [service] and macro [system] factors and as such, these IPTs will be placed along this continuum with a diagram visually depicting this. This will then be brought to the expert panel for approval and once approved, write up of the realist review will commence. 5) Do the authors have a plan for managing potential heterogeneity in study contexts and populations, and how will this be addressed in the synthesis? Response: Thank you for this comment. This query is answered through point 4 above. We do anticipate heterogeneity in context and populations but this will be demonstrated through aligning the IPTs to a micro, meso and macro perspective where contexts in terms of individual, service or system will be demonstrated. This heterogeneity will also be visually demonstrated. 6) Discussion of potential limitations inherent to realist systematic reviews compared to other types of reviews and how these will be mitigated. Response: Thank you for this comment. This review differs from systematic reviews and scoping reviews as it is theory heavy, and the focus is on looking for potential mechanisms rather than examining potential depth and breadth of the literature base. This does raise questions of potential bias but this is mitigated because the focus is on developing mechanisms rather than elimination of bias. 7) Be aware that if the CHIME agronym should be explicitly presented and referred to within the title, abstract and full text - will exclude papers for example the attached paper by Egmose et al. 2024 - exploring the mechanisms of change in a group-based peer support intervention co-produced around the CHIME framework. Response: Thank you for this comment. We are aware that focusing on CHIME in these areas will exclude paper. However, as noted in point 6 the focus is on finding mechanisms, not on ensuring that the breadth/depth of literature is achieved. Competing Interests: None Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Wong G. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15583.r50799 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v1#referee-response-50799 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 27 Oct 2025 Geoff Wong , University of Oxford, Oxford, UK Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15583.r50799 Overall comments: The manuscript is clearly written and a coherent explanation is provided for the use of a realist review approach. Major comments: None. Minor comments: As this is a realist ... Continue reading READ ALL Overall comments: The manuscript is clearly written and a coherent explanation is provided for the use of a realist review approach. Major comments: None. Minor comments: As this is a realist review, in your manuscript you may want to consider only using the word "mechanism" when you specifically mean it in a realist sense of the word - i.e. as a hidden, context-sensitive causal force. When reference is first made about the RAMESES I guidelines, there is mention of these standards being used to "guide the review itself and not its execution." I'm not quite sure what this means. The references 30 and 31 refer to the RAMESES publication standards for realist syntheses and so should be used to guide the reporting of realist syntheses (or reviews - the terms are synonymous). If guidance is needed for the conduct of realist syntheses, the the reference used should be: Wong G, Greenhalgh T, Westhorp G, Pawson R. Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project. Health Soc Care Deliv Res 2014;2(30). [Reference 1] When programme theory is mentioned in step 1, it is worth remembering that a programme theory is both a theory of change, and a theory of implementation / action. See either the RAMESES training materials for realist syntheses:https://www.ramesesproject.org/pgm-download_media.php?name=Realist_reviews_training_materials.pdf or here: https://www.ramesesproject.org/pgm-download_media.php?name=RAMESES_II_Theory_in_realist_evaluation.pdf The steps proposed for the realist review make sense. In step 1, a reasonable process has been undertaken to develop the CMO configurations that will populate the initial programme theory. These initial CMO configurations seem to me a reasonable first stab at providing causal explanations. Based on the details provided, the searches seem sensible and likely to find relevant data. Explanations are provided for the exclusion criteria what will be used. These on the whole make sense, though, you may want to reconsider excluding quantitative papers as these may provide 'nuggets' of relevant data that enable you to achieve a better degree of consilience. I am no content expert, but if the seminal papers for CHIME were published in 2011, there may be relevant papers published just before 2011. Hence, if you have not done so, it may be worth checking if setting the cut off 2 to 3 years earlier might yield any relevant papers. Whilst I can understand t-your rationale for excluding reviews, do consider citation tracking from the reviews - as this may be a means of identifying further relevant documents. In step 3, the selection and appraisal process makes sense. The three questions you propose seem a bit like overkill as relevance can be considered as whether a document has data that can contribute to realist programme theory in some way (e.g. to inform CMOCs, their relationships to each other or an aspect of the programme theory). You have not mentioned appraisal of rigour. On this issue you may find the second half of this book chapter of use: Data gathering for realist reviews: Looking for needles in haystacks. Wong G. In: Emmel N, Greenhalgh J, Manzano A, Monaghan M, Dalkin S, editors. Doing Realist Research. London: Sage, 2018 [Reference 2] In Step 4, I am not sure that it is ever as clean cut as to claim "In general, the introduction of citations will identify the context, the results of these same citations will identify the outcome, and the discussion of the text will help identify the mechanism.". You are likely to find that relevant data may come from any part of a document. Hence some flexibility in where you draw your data from will likely be needed. In your data extraction tool, you may not be able to find data that is specifically about context, mechanism or outcome. This is because such data on each of these concepts may not be present in one single document. And, it is challenging to be able to claim that something is functioning as context or mechanism, unless you can identify in which CMOC it is operating in. In other words, you can only infer that something is functioning as a context or mechanism if you know what the outcome it is related to. With regard to the use of the Crowe Critical Appraisal Tool, I presume you are planning to use it to appraise rigour and not relevance? If so, do consider reading the Data gathering for realist reviews book chapter that I have mentioned above, as following the process outlined in that book chapter may save you a lot of time and effort. In step 5 consider revising this sentence " all in an attempt to refine the initial programme theories into middle-range theories", because middle-range theory is not a type of theory, but more a description of the level of abstraction of a theory. See: https://www.ramesesproject.org/pgm-download_media.php?name=RAMESES_II_Theory_in_realist_evaluation.pdf In this step, you have not provided much detail on how you will develop the causal explanations (i.e. CMOCs) and programme theory. Whilst this is not necessarily needed in a protocol, you should ensure you provide such details for your PhD. There is no one set process you have to use to make sense of data, mainly because we all 'think' differently. But any process you use should be coherent, clearly explained and also used systematically. 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. Wong G, Greenhalgh T, Westhorp G, Pawson R: Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project. Health Services and Delivery Research . 2014; 2 (30): 1-252 Publisher Full Text 2. Wong G: Data Gathering in Realist Reviews: Looking for needles in haystacks. 2018. 131-146 Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Realist review / synthesis and realist evaluation. 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 Wong G. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15583.r50799 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v1#referee-response-50799 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 24 Nov 2025 Michael John Norton , $usrAffiliation 24 Nov 2025 Author Response The manuscript is clearly written and a coherent explanation is provided for the use of a realist review approach. Response: Thank you for this comment. We hope that ... Continue reading The manuscript is clearly written and a coherent explanation is provided for the use of a realist review approach. Response: Thank you for this comment. We hope that the amendments made as per your suggestions below will improve the overall usefulness of the protocol for our review. As this is a realist review, in your manuscript you may want to consider only using the word "mechanism" when you specifically mean it in a realist sense of the word - i.e. as a hidden, context-sensitive causal force. Response: Thank you for your comment. We have reread the protocol and have only used mechanisms when referring to a hidden, context-sensitive causal force as suggested. When reference is first made about the RAMESES I guidelines, there is mention of these standards being used to "guide the review itself and not its execution." I'm not quite sure what this means. The references 30 and 31 refer to the RAMESES publication standards for realist syntheses and so should be used to guide the reporting of realist syntheses (or reviews - the terms are synonymous). If guidance is needed for the conduct of realist syntheses, the reference used should be: Wong G, Greenhalgh T, Westhorp G, Pawson R. Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project. Health Soc Care Deliv Res 2014;2(30). Response: Thank you for your comment. We have reviewed the text in question and have amended same accordingly. We have also inserted your reference to strengthen the claims made. When programme theory is mentioned in step 1, it is worth remembering that a programme theory is both a theory of change, and a theory of implementation / action. See either the RAMESES training materials for realist syntheses: WEBSITE.pdf Response: Thank you for this comment. We have added a sentence to acknowledge this in the revised protocol. The steps proposed for the realist review make sense. Response: Thank you for this comment. In step 1, a reasonable process has been undertaken to develop the CMO configurations that will populate the initial programme theory. These initial CMO configurations seem to me a reasonable first stab at providing causal explanations. Response: Thank you for this comment. Based on the details provided, the searches seem sensible and likely to find relevant data. Explanations are provided for the exclusion criteria what will be used. These on the whole make sense, though, you may want to reconsider excluding quantitative papers as these may provide 'nuggets' of relevant data that enable you to achieve a better degree of consilience. Response: Thank you for your comment. We have excluded quantitative studies as personal recovery is a subjective process that cannot be adequately captured through positivist, quantitative means. Additionally, quanitative research lacks contextual depth and given that realist reviews aim to answer questions relating to why, how and under what circumstances a mechanism occurs, it was deemed inappropriate to include quanitative studies. I am no content expert, but if the seminal papers for CHIME were published in 2011, there may be relevant papers published just before 2011. Hence, if you have not done so, it may be worth checking if setting the cut off 2 to 3 years earlier might yield any relevant papers. Response: Thank you for also raising this comment. We restricted the inclusion/exclusion criteria to post 2011 studies for two reasons. Firstly, CHIME was constructed in a 2011 paper from Mary Leamy and colleagues in the UK and as a result, this review is looking for papers that include all elements of CHIME. Secondly, we also excluded pre-2011 studies as these would have been captured by the original systematic review method conducted by Leamy et al. when they carried out their review. As such, it was deemed unnecessary to include pre-2011 research studies. Whilst I can understand your rationale for excluding reviews, do consider citation tracking from the reviews - as this may be a means of identifying further relevant documents. Response: Thank you for your comment. We are unable to conduct citation chaining for this review as we are now presently finalising extraction and commencing write up of the actual realist review. However, we will endeavour to include in our methodology that citation chaining was recommended but was unable to be carried out due to the phase of the review where reviewers were at when your peer review comment was made. In step 3, the selection and appraisal process makes sense. The three questions you propose seem a bit like overkill as relevance can be considered as whether a document has data that can contribute to realist programme theory in some way (e.g. to inform CMOCs, their relationships to each other or an aspect of the programme theory). Response: Thank you for this comment. We have reviewed the text based on your feedback and revised it accordingly. You have not mentioned appraisal of rigour. On this issue you may find the second half of this book chapter of use: Data gathering for realist reviews: Looking for needles in haystacks. Wong G. In: Emmel N, Greenhalgh J, Manzano A, Monaghan M, Dalkin S, editors. Doing Realist Research. London: Sage, 2018 Response: Thank you for this comment. We have addressed appraisal of rigor through step 4 of the realist review process. In Step 4, I am not sure that it is ever as clean cut as to claim "In general, the introduction of citations will identify the context, the results of these same citations will identify the outcome, and the discussion of the text will help identify the mechanism.". You are likely to find that relevant data may come from any part of a document. Hence some flexibility in where you draw your data from will likely be needed. Response: Thank you for this comment. We have reviewed the piece of text highlighted and decided to remove the highlighted text. In your data extraction tool, you may not be able to find data that is specifically about context, mechanism or outcome. This is because such data on each of these concepts may not be present in one single document. And, it is challenging to be able to claim that something is functioning as context or mechanism, unless you can identify in which CMOC it is operating in. In other words, you can only infer that something is functioning as a context or mechanism if you know what the outcome it is related to. Response: Thank you for this comment. We have made note of this and included it under stage 4 of the realist review process within the discussions around the data extraction tool. With regard to the use of the Crowe Critical Appraisal Tool, I presume you are planning to use it to appraise rigour and not relevance? If so, do consider reading the Data gathering for realist reviews book chapter that I have mentioned above, as following the process outlined in that book chapter may save you a lot of time and effort. Response: Thank you for this comment. Yes, we plan to use it to appraise rigour and not relevance as previously stated. Thank you for your suggested reading, however, we are unable to implement it as we are already finalising data extraction and appraisal for the realist review itself at this time. In step 5 consider revising this sentence " all in an attempt to refine the initial programme theories into middle-range theories", because middle-range theory is not a type of theory, but more a description of the level of abstraction of a theory. See: WEBSITE.pdf Response: Thank you for this comment. We have revised this sentence based on your suggestion and have reviewed the remainder of the document to remove any reference to middle-ranged theory. In this step, you have not provided much detail on how you will develop the causal explanations (i.e. CMOCs) and programme theory. Whilst this is not necessarily needed in a protocol, you should ensure you provide such details for your PhD. There is no one set process you have to use to make sense of data, mainly because we all 'think' differently. But any process you use should be coherent, clearly explained and also used systematically. Response: Thank you for this comment. We will keep this in mind for the actual realist review paper as suggested. The manuscript is clearly written and a coherent explanation is provided for the use of a realist review approach. Response: Thank you for this comment. We hope that the amendments made as per your suggestions below will improve the overall usefulness of the protocol for our review. As this is a realist review, in your manuscript you may want to consider only using the word "mechanism" when you specifically mean it in a realist sense of the word - i.e. as a hidden, context-sensitive causal force. Response: Thank you for your comment. We have reread the protocol and have only used mechanisms when referring to a hidden, context-sensitive causal force as suggested. When reference is first made about the RAMESES I guidelines, there is mention of these standards being used to "guide the review itself and not its execution." I'm not quite sure what this means. The references 30 and 31 refer to the RAMESES publication standards for realist syntheses and so should be used to guide the reporting of realist syntheses (or reviews - the terms are synonymous). If guidance is needed for the conduct of realist syntheses, the reference used should be: Wong G, Greenhalgh T, Westhorp G, Pawson R. Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project. Health Soc Care Deliv Res 2014;2(30). Response: Thank you for your comment. We have reviewed the text in question and have amended same accordingly. We have also inserted your reference to strengthen the claims made. When programme theory is mentioned in step 1, it is worth remembering that a programme theory is both a theory of change, and a theory of implementation / action. See either the RAMESES training materials for realist syntheses: WEBSITE.pdf Response: Thank you for this comment. We have added a sentence to acknowledge this in the revised protocol. The steps proposed for the realist review make sense. Response: Thank you for this comment. In step 1, a reasonable process has been undertaken to develop the CMO configurations that will populate the initial programme theory. These initial CMO configurations seem to me a reasonable first stab at providing causal explanations. Response: Thank you for this comment. Based on the details provided, the searches seem sensible and likely to find relevant data. Explanations are provided for the exclusion criteria what will be used. These on the whole make sense, though, you may want to reconsider excluding quantitative papers as these may provide 'nuggets' of relevant data that enable you to achieve a better degree of consilience. Response: Thank you for your comment. We have excluded quantitative studies as personal recovery is a subjective process that cannot be adequately captured through positivist, quantitative means. Additionally, quanitative research lacks contextual depth and given that realist reviews aim to answer questions relating to why, how and under what circumstances a mechanism occurs, it was deemed inappropriate to include quanitative studies. I am no content expert, but if the seminal papers for CHIME were published in 2011, there may be relevant papers published just before 2011. Hence, if you have not done so, it may be worth checking if setting the cut off 2 to 3 years earlier might yield any relevant papers. Response: Thank you for also raising this comment. We restricted the inclusion/exclusion criteria to post 2011 studies for two reasons. Firstly, CHIME was constructed in a 2011 paper from Mary Leamy and colleagues in the UK and as a result, this review is looking for papers that include all elements of CHIME. Secondly, we also excluded pre-2011 studies as these would have been captured by the original systematic review method conducted by Leamy et al. when they carried out their review. As such, it was deemed unnecessary to include pre-2011 research studies. Whilst I can understand your rationale for excluding reviews, do consider citation tracking from the reviews - as this may be a means of identifying further relevant documents. Response: Thank you for your comment. We are unable to conduct citation chaining for this review as we are now presently finalising extraction and commencing write up of the actual realist review. However, we will endeavour to include in our methodology that citation chaining was recommended but was unable to be carried out due to the phase of the review where reviewers were at when your peer review comment was made. In step 3, the selection and appraisal process makes sense. The three questions you propose seem a bit like overkill as relevance can be considered as whether a document has data that can contribute to realist programme theory in some way (e.g. to inform CMOCs, their relationships to each other or an aspect of the programme theory). Response: Thank you for this comment. We have reviewed the text based on your feedback and revised it accordingly. You have not mentioned appraisal of rigour. On this issue you may find the second half of this book chapter of use: Data gathering for realist reviews: Looking for needles in haystacks. Wong G. In: Emmel N, Greenhalgh J, Manzano A, Monaghan M, Dalkin S, editors. Doing Realist Research. London: Sage, 2018 Response: Thank you for this comment. We have addressed appraisal of rigor through step 4 of the realist review process. In Step 4, I am not sure that it is ever as clean cut as to claim "In general, the introduction of citations will identify the context, the results of these same citations will identify the outcome, and the discussion of the text will help identify the mechanism.". You are likely to find that relevant data may come from any part of a document. Hence some flexibility in where you draw your data from will likely be needed. Response: Thank you for this comment. We have reviewed the piece of text highlighted and decided to remove the highlighted text. In your data extraction tool, you may not be able to find data that is specifically about context, mechanism or outcome. This is because such data on each of these concepts may not be present in one single document. And, it is challenging to be able to claim that something is functioning as context or mechanism, unless you can identify in which CMOC it is operating in. In other words, you can only infer that something is functioning as a context or mechanism if you know what the outcome it is related to. Response: Thank you for this comment. We have made note of this and included it under stage 4 of the realist review process within the discussions around the data extraction tool. With regard to the use of the Crowe Critical Appraisal Tool, I presume you are planning to use it to appraise rigour and not relevance? If so, do consider reading the Data gathering for realist reviews book chapter that I have mentioned above, as following the process outlined in that book chapter may save you a lot of time and effort. Response: Thank you for this comment. Yes, we plan to use it to appraise rigour and not relevance as previously stated. Thank you for your suggested reading, however, we are unable to implement it as we are already finalising data extraction and appraisal for the realist review itself at this time. In step 5 consider revising this sentence " all in an attempt to refine the initial programme theories into middle-range theories", because middle-range theory is not a type of theory, but more a description of the level of abstraction of a theory. See: WEBSITE.pdf Response: Thank you for this comment. We have revised this sentence based on your suggestion and have reviewed the remainder of the document to remove any reference to middle-ranged theory. In this step, you have not provided much detail on how you will develop the causal explanations (i.e. CMOCs) and programme theory. Whilst this is not necessarily needed in a protocol, you should ensure you provide such details for your PhD. There is no one set process you have to use to make sense of data, mainly because we all 'think' differently. But any process you use should be coherent, clearly explained and also used systematically. Response: Thank you for this comment. We will keep this in mind for the actual realist review paper as suggested. Competing Interests: None Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 24 Nov 2025 Michael John Norton , $usrAffiliation 24 Nov 2025 Author Response The manuscript is clearly written and a coherent explanation is provided for the use of a realist review approach. Response: Thank you for this comment. We hope that ... Continue reading The manuscript is clearly written and a coherent explanation is provided for the use of a realist review approach. Response: Thank you for this comment. We hope that the amendments made as per your suggestions below will improve the overall usefulness of the protocol for our review. As this is a realist review, in your manuscript you may want to consider only using the word "mechanism" when you specifically mean it in a realist sense of the word - i.e. as a hidden, context-sensitive causal force. Response: Thank you for your comment. We have reread the protocol and have only used mechanisms when referring to a hidden, context-sensitive causal force as suggested. When reference is first made about the RAMESES I guidelines, there is mention of these standards being used to "guide the review itself and not its execution." I'm not quite sure what this means. The references 30 and 31 refer to the RAMESES publication standards for realist syntheses and so should be used to guide the reporting of realist syntheses (or reviews - the terms are synonymous). If guidance is needed for the conduct of realist syntheses, the reference used should be: Wong G, Greenhalgh T, Westhorp G, Pawson R. Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project. Health Soc Care Deliv Res 2014;2(30). Response: Thank you for your comment. We have reviewed the text in question and have amended same accordingly. We have also inserted your reference to strengthen the claims made. When programme theory is mentioned in step 1, it is worth remembering that a programme theory is both a theory of change, and a theory of implementation / action. See either the RAMESES training materials for realist syntheses: WEBSITE.pdf Response: Thank you for this comment. We have added a sentence to acknowledge this in the revised protocol. The steps proposed for the realist review make sense. Response: Thank you for this comment. In step 1, a reasonable process has been undertaken to develop the CMO configurations that will populate the initial programme theory. These initial CMO configurations seem to me a reasonable first stab at providing causal explanations. Response: Thank you for this comment. Based on the details provided, the searches seem sensible and likely to find relevant data. Explanations are provided for the exclusion criteria what will be used. These on the whole make sense, though, you may want to reconsider excluding quantitative papers as these may provide 'nuggets' of relevant data that enable you to achieve a better degree of consilience. Response: Thank you for your comment. We have excluded quantitative studies as personal recovery is a subjective process that cannot be adequately captured through positivist, quantitative means. Additionally, quanitative research lacks contextual depth and given that realist reviews aim to answer questions relating to why, how and under what circumstances a mechanism occurs, it was deemed inappropriate to include quanitative studies. I am no content expert, but if the seminal papers for CHIME were published in 2011, there may be relevant papers published just before 2011. Hence, if you have not done so, it may be worth checking if setting the cut off 2 to 3 years earlier might yield any relevant papers. Response: Thank you for also raising this comment. We restricted the inclusion/exclusion criteria to post 2011 studies for two reasons. Firstly, CHIME was constructed in a 2011 paper from Mary Leamy and colleagues in the UK and as a result, this review is looking for papers that include all elements of CHIME. Secondly, we also excluded pre-2011 studies as these would have been captured by the original systematic review method conducted by Leamy et al. when they carried out their review. As such, it was deemed unnecessary to include pre-2011 research studies. Whilst I can understand your rationale for excluding reviews, do consider citation tracking from the reviews - as this may be a means of identifying further relevant documents. Response: Thank you for your comment. We are unable to conduct citation chaining for this review as we are now presently finalising extraction and commencing write up of the actual realist review. However, we will endeavour to include in our methodology that citation chaining was recommended but was unable to be carried out due to the phase of the review where reviewers were at when your peer review comment was made. In step 3, the selection and appraisal process makes sense. The three questions you propose seem a bit like overkill as relevance can be considered as whether a document has data that can contribute to realist programme theory in some way (e.g. to inform CMOCs, their relationships to each other or an aspect of the programme theory). Response: Thank you for this comment. We have reviewed the text based on your feedback and revised it accordingly. You have not mentioned appraisal of rigour. On this issue you may find the second half of this book chapter of use: Data gathering for realist reviews: Looking for needles in haystacks. Wong G. In: Emmel N, Greenhalgh J, Manzano A, Monaghan M, Dalkin S, editors. Doing Realist Research. London: Sage, 2018 Response: Thank you for this comment. We have addressed appraisal of rigor through step 4 of the realist review process. In Step 4, I am not sure that it is ever as clean cut as to claim "In general, the introduction of citations will identify the context, the results of these same citations will identify the outcome, and the discussion of the text will help identify the mechanism.". You are likely to find that relevant data may come from any part of a document. Hence some flexibility in where you draw your data from will likely be needed. Response: Thank you for this comment. We have reviewed the piece of text highlighted and decided to remove the highlighted text. In your data extraction tool, you may not be able to find data that is specifically about context, mechanism or outcome. This is because such data on each of these concepts may not be present in one single document. And, it is challenging to be able to claim that something is functioning as context or mechanism, unless you can identify in which CMOC it is operating in. In other words, you can only infer that something is functioning as a context or mechanism if you know what the outcome it is related to. Response: Thank you for this comment. We have made note of this and included it under stage 4 of the realist review process within the discussions around the data extraction tool. With regard to the use of the Crowe Critical Appraisal Tool, I presume you are planning to use it to appraise rigour and not relevance? If so, do consider reading the Data gathering for realist reviews book chapter that I have mentioned above, as following the process outlined in that book chapter may save you a lot of time and effort. Response: Thank you for this comment. Yes, we plan to use it to appraise rigour and not relevance as previously stated. Thank you for your suggested reading, however, we are unable to implement it as we are already finalising data extraction and appraisal for the realist review itself at this time. In step 5 consider revising this sentence " all in an attempt to refine the initial programme theories into middle-range theories", because middle-range theory is not a type of theory, but more a description of the level of abstraction of a theory. See: WEBSITE.pdf Response: Thank you for this comment. We have revised this sentence based on your suggestion and have reviewed the remainder of the document to remove any reference to middle-ranged theory. In this step, you have not provided much detail on how you will develop the causal explanations (i.e. CMOCs) and programme theory. Whilst this is not necessarily needed in a protocol, you should ensure you provide such details for your PhD. There is no one set process you have to use to make sense of data, mainly because we all 'think' differently. But any process you use should be coherent, clearly explained and also used systematically. Response: Thank you for this comment. We will keep this in mind for the actual realist review paper as suggested. The manuscript is clearly written and a coherent explanation is provided for the use of a realist review approach. Response: Thank you for this comment. We hope that the amendments made as per your suggestions below will improve the overall usefulness of the protocol for our review. As this is a realist review, in your manuscript you may want to consider only using the word "mechanism" when you specifically mean it in a realist sense of the word - i.e. as a hidden, context-sensitive causal force. Response: Thank you for your comment. We have reread the protocol and have only used mechanisms when referring to a hidden, context-sensitive causal force as suggested. When reference is first made about the RAMESES I guidelines, there is mention of these standards being used to "guide the review itself and not its execution." I'm not quite sure what this means. The references 30 and 31 refer to the RAMESES publication standards for realist syntheses and so should be used to guide the reporting of realist syntheses (or reviews - the terms are synonymous). If guidance is needed for the conduct of realist syntheses, the reference used should be: Wong G, Greenhalgh T, Westhorp G, Pawson R. Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project. Health Soc Care Deliv Res 2014;2(30). Response: Thank you for your comment. We have reviewed the text in question and have amended same accordingly. We have also inserted your reference to strengthen the claims made. When programme theory is mentioned in step 1, it is worth remembering that a programme theory is both a theory of change, and a theory of implementation / action. See either the RAMESES training materials for realist syntheses: WEBSITE.pdf Response: Thank you for this comment. We have added a sentence to acknowledge this in the revised protocol. The steps proposed for the realist review make sense. Response: Thank you for this comment. In step 1, a reasonable process has been undertaken to develop the CMO configurations that will populate the initial programme theory. These initial CMO configurations seem to me a reasonable first stab at providing causal explanations. Response: Thank you for this comment. Based on the details provided, the searches seem sensible and likely to find relevant data. Explanations are provided for the exclusion criteria what will be used. These on the whole make sense, though, you may want to reconsider excluding quantitative papers as these may provide 'nuggets' of relevant data that enable you to achieve a better degree of consilience. Response: Thank you for your comment. We have excluded quantitative studies as personal recovery is a subjective process that cannot be adequately captured through positivist, quantitative means. Additionally, quanitative research lacks contextual depth and given that realist reviews aim to answer questions relating to why, how and under what circumstances a mechanism occurs, it was deemed inappropriate to include quanitative studies. I am no content expert, but if the seminal papers for CHIME were published in 2011, there may be relevant papers published just before 2011. Hence, if you have not done so, it may be worth checking if setting the cut off 2 to 3 years earlier might yield any relevant papers. Response: Thank you for also raising this comment. We restricted the inclusion/exclusion criteria to post 2011 studies for two reasons. Firstly, CHIME was constructed in a 2011 paper from Mary Leamy and colleagues in the UK and as a result, this review is looking for papers that include all elements of CHIME. Secondly, we also excluded pre-2011 studies as these would have been captured by the original systematic review method conducted by Leamy et al. when they carried out their review. As such, it was deemed unnecessary to include pre-2011 research studies. Whilst I can understand your rationale for excluding reviews, do consider citation tracking from the reviews - as this may be a means of identifying further relevant documents. Response: Thank you for your comment. We are unable to conduct citation chaining for this review as we are now presently finalising extraction and commencing write up of the actual realist review. However, we will endeavour to include in our methodology that citation chaining was recommended but was unable to be carried out due to the phase of the review where reviewers were at when your peer review comment was made. In step 3, the selection and appraisal process makes sense. The three questions you propose seem a bit like overkill as relevance can be considered as whether a document has data that can contribute to realist programme theory in some way (e.g. to inform CMOCs, their relationships to each other or an aspect of the programme theory). Response: Thank you for this comment. We have reviewed the text based on your feedback and revised it accordingly. You have not mentioned appraisal of rigour. On this issue you may find the second half of this book chapter of use: Data gathering for realist reviews: Looking for needles in haystacks. Wong G. In: Emmel N, Greenhalgh J, Manzano A, Monaghan M, Dalkin S, editors. Doing Realist Research. London: Sage, 2018 Response: Thank you for this comment. We have addressed appraisal of rigor through step 4 of the realist review process. In Step 4, I am not sure that it is ever as clean cut as to claim "In general, the introduction of citations will identify the context, the results of these same citations will identify the outcome, and the discussion of the text will help identify the mechanism.". You are likely to find that relevant data may come from any part of a document. Hence some flexibility in where you draw your data from will likely be needed. Response: Thank you for this comment. We have reviewed the piece of text highlighted and decided to remove the highlighted text. In your data extraction tool, you may not be able to find data that is specifically about context, mechanism or outcome. This is because such data on each of these concepts may not be present in one single document. And, it is challenging to be able to claim that something is functioning as context or mechanism, unless you can identify in which CMOC it is operating in. In other words, you can only infer that something is functioning as a context or mechanism if you know what the outcome it is related to. Response: Thank you for this comment. We have made note of this and included it under stage 4 of the realist review process within the discussions around the data extraction tool. With regard to the use of the Crowe Critical Appraisal Tool, I presume you are planning to use it to appraise rigour and not relevance? If so, do consider reading the Data gathering for realist reviews book chapter that I have mentioned above, as following the process outlined in that book chapter may save you a lot of time and effort. Response: Thank you for this comment. Yes, we plan to use it to appraise rigour and not relevance as previously stated. Thank you for your suggested reading, however, we are unable to implement it as we are already finalising data extraction and appraisal for the realist review itself at this time. In step 5 consider revising this sentence " all in an attempt to refine the initial programme theories into middle-range theories", because middle-range theory is not a type of theory, but more a description of the level of abstraction of a theory. See: WEBSITE.pdf Response: Thank you for this comment. We have revised this sentence based on your suggestion and have reviewed the remainder of the document to remove any reference to middle-ranged theory. In this step, you have not provided much detail on how you will develop the causal explanations (i.e. CMOCs) and programme theory. Whilst this is not necessarily needed in a protocol, you should ensure you provide such details for your PhD. There is no one set process you have to use to make sense of data, mainly because we all 'think' differently. But any process you use should be coherent, clearly explained and also used systematically. Response: Thank you for this comment. We will keep this in mind for the actual realist review paper as suggested. Competing Interests: None Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Thongsalab DJ. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15583.r49952 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v1#referee-response-49952 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 30 Sep 2025 Dr. Jutharat Thongsalab , Boromarajonani College of Nursing Surin, Mueang Surin District, Surin, Thailand Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15583.r49952 Thank you for the opportunity to review this interesting and timely protocol. The topic is important and relevant for advancing recovery-oriented mental health research. The paper is well-structured and demonstrates strong potential. I provide the following comments to strengthen clarity, ... Continue reading READ ALL Thank you for the opportunity to review this interesting and timely protocol. The topic is important and relevant for advancing recovery-oriented mental health research. The paper is well-structured and demonstrates strong potential. I provide the following comments to strengthen clarity, methodological rigor, and practical contribution. - I recommended that the author support the gap statement by systematically highlighting what CHIME research has achieved (measurement, validation, intervention use) and what remains unexplored (mechanisms, context-specific functioning). - The introduction part lacks a sharp demonstration of the evidence gap, a critical comparison with other review types, and a clear link to practice implications. Strengthening these aspects will make justification more persuasive. - The methods section is full and clear in structure but would benefit from greater rigor in evidence appraisal, inclusion criteria, extraction reliability, and analytic strategy. With these refinements, the review will be more credible and reproducible. - Step I, the author should clarify procedures for iterative refinement, include safeguards against confirmation bias, and discuss diversity/independence of the advisory panel. - Step II, Exclusion of quantitative studies is restrictive; yet some quantitative work (e.g., mediation, SEM, longitudinal studies) could inform mechanisms. Restricting to post-2011 excludes potentially relevant pre-CHIME conceptualizations that could enrich theory building. Reconsider exclusion of quantitative studies, broaden the grey literature strategy, and justify more clearly the 2011 cutoff. - Step III, Screening and appraisal are described (three rounds; Covidence; 10% double-screening). Appraisal using “relevance, rigor, richness” is conceptually valid but subjective; no plan for handling disagreements or measuring inter-rater agreement. Therefore, increase the proportion of double-screening, consider structured appraisal checklists (e.g., CASP, RAMESES appraisal tool), and report inter-rater reliability (e.g., Cohen’s κ). - Step IV doesn’t specify whether pilot testing of the extraction form will be done. Reliance on a single reviewer (MJN) for extraction, with supervisory oversight, carries a risk of bias. - Step V, the process described could produce descriptive categories rather than true realist synthesis. Explicitly describe the use of retroductive reasoning, provide examples of how initial CMOs will evolve into middle-range theories, and consider external validation beyond the author panel. - Step VI, add transparency on how independence of critique will be preserved, and describe dissemination beyond academic journals (e.g., co-produced outputs for service users). - Figure 2 uses “Inductive Reflexive Thematic Analysis” under synthesis. This terminology is more common in qualitative research, but realist reviews emphasize retroductive reasoning and CMO refinement. - The current wording may mislead readers about analytic methods. This figure presents the steps as linear, but realist reviews are inherently iterative (moving back and forth between theory building, searching, and refinement). This could misrepresent the cyclical nature of realist reviews. Some steps (e.g., “Upload onto NVivo for Analysis”) are tool-specific, which may not apply universally and make the figure feel like a workflow chart rather than a generalizable method. Meanwhile, other important elements (e.g., stakeholder engagement, retroductive reasoning, theory testing vs. refinement) are missing. Advisory panel engagement should appear not just at the start, but also during synthesis/validation. - Table 1 provides a useful but overly simplistic starting point for realist program theory development. It will benefit if you clarify distinctiveness by ensuring each CHIME domain’s If…The statement highlights unique mechanisms. Add one illustrative case or a brief exemplary per domain to ground the theory. - Table 2 shows the evolution into draft CMOs. I recommend improvement for it. The context should add diversity in settings (community vs. inpatient), roles (peer vs. clinician support), and cultural/systemic factors. Mechanisms should frame them as resources + reasoning (what is offered + how it is interpreted), e.g., “Access to peer groups (resource) triggers recognition of shared experience (reasoning)”. Outcomes should be more diverse by going beyond re-stating mechanisms, e.g., linking hope, such as increased engagement, reduced suicidality, and improved functioning. - Table 3 remains too generic, tautological, and individual-focused. With richer contextualization, sharper mechanism articulation, and more concrete outcomes, it could provide a robust foundation for theory testing in the review. - Table 4-6, Search strings like “Mental Health” OR “Mental Disorders” yield millions of hits (e.g., 6.5M in PubMed). This risks irrelevance and screening overload. It might indicate poor precision in early steps. Lack of Grey Literature Strategy in These Tables. Excluding pre-2011 studies may miss early CHIME conceptual development or precursors. Needs a stronger justification than “CHIME was published in 2011. - Table 7, please reconsider including quantitative studies that explore mechanisms (e.g., mediation, regression, factor analysis). Provide a rationale for excluding dual diagnosis/addiction populations or consider including them with sensitivity analysis. Is the rationale for, and objectives of, the study clearly described? Partly 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? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Psychiatric and Mental Health Nursing; Recovery-Oriented Care; Nursing Research Methods; Systematic and Review Methodology. 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 Thongsalab DJ. Reviewer Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15583.r49952 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-94/v1#referee-response-49952 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 24 Nov 2025 Michael John Norton , $usrAffiliation 24 Nov 2025 Author Response Thank you for the opportunity to review this interesting and timely protocol. The topic is important and relevant for advancing recovery-oriented mental health research. The paper is well-structured ... Continue reading Thank you for the opportunity to review this interesting and timely protocol. The topic is important and relevant for advancing recovery-oriented mental health research. The paper is well-structured and demonstrates strong potential. Response: Thank you for your comment. We hope that the amendments made to this paper will strengthen it further. I provide the following comments to strengthen clarity, methodological rigor, and practical contribution. Response: Thank you for this. We hope that the amendments the authorship team have accepted will have strengthened the paper further. I recommended that the author support the gap statement by systematically highlighting what CHIME research has achieved (measurement, validation, intervention use) and what remains unexplored (mechanisms, context-specific functioning). Response: Thank you for this comment. We have adjusted the rationale for realist review section to incorporate this comment. The introduction part lacks a sharp demonstration of the evidence gap, a critical comparison with other review types, and a clear link to practice implications. Strengthening these aspects will make justification more persuasive. Response: Thank you for this comment. The introduction has been sharpened to include the evidence gap and comparison with other review types along with a clearer link been made to practice implications. The methods section is full and clear in structure but would benefit from greater rigor in evidence appraisal, inclusion criteria, extraction reliability, and analytic strategy. With these refinements, the review will be more credible and reproducible. Response: Thank you for this comment. We are not trying to produce a systematic review which would rely on reproducibility. We are instead utilising a realist review methodology to uncover mechanisms. Although the search was rigorous, it does not need to be of the same standard as a systematic review where your concerns are of extreme importance. The evidence appraisal method has been taken and adopted from previous realist reviews which utilise this method. The inclusion criteria are robust given the review method. We believe you have commented on some of the other aspects of the inclusion criteria below, which we will address then. The extraction process follows a realist method and the analytic process is suitable, given the review type. Step I, the author should clarify procedures for iterative refinement, include safeguards against confirmation bias, and discuss diversity/independence of the advisory panel. Response: Thank you for your comment. Given the review type, safeguards against confirmation bias is not necessary. In regard to the diversity and independence of the advisory panel, the text now discusses these in step 1 of the realist review process. Step II, Exclusion of quantitative studies is restrictive; yet some quantitative work (e.g., mediation, SEM, longitudinal studies) could inform mechanisms. Response: Thank you for raising this comment. A conscious decision was made to exclude quantitative studies as personal recovery is a subjective experience that cannot be captured adequately through positivist quantitative means. In addition, quantitative research lacks contextual depth and given that realist reviews aim to demonstrate how, why and under what circumstances a mechanism operates, the inclusion of quanitative studies was deemed inappropriate. Restricting to post-2011 excludes potentially relevant pre-CHIME conceptualizations that could enrich theory building. Response: Thank you for also raising this comment. We restricted the inclusion/exclusion criteria to post 2011 studies for two reasons. Firstly, CHIME was constructed in a 2011 paper from Mary Leamy and colleagues in the UK and as a result, this review is looking for papers that include all elements of CHIME. Secondly, we also excluded pre-2011 studies as these would have been captured by the original systematic review method conducted by Leamy et al. when they carried out their review. As such, it was deemed unnecessary to include pre-2011 research studies. Reconsider exclusion of quantitative studies, broaden the grey literature strategy, and justify more clearly the 2011 cutoff. Response: Thank you for this comment. The rationale for excluding quantitative studies have been mentioned above. A couple of sentences has been added to describe the grey literature search mechanisms. The justification for the 2011 cutoff has been discussed above. Step III, Screening and appraisal are described (three rounds; Covidence; 10% double-screening). Appraisal using “relevance, rigor, richness” is conceptually valid but subjective; no plan for handling disagreements or measuring inter-rater agreement. Therefore, increase the proportion of double-screening, consider structured appraisal checklists (e.g., CASP, RAMESES appraisal tool), and report inter-rater reliability (e.g., Cohen’s κ). Response: Thank you for this comment. Given the theory focus of realist reviews, appraisal with relevance, rigor and richness is the noted procedure to appraise papers included in this realist review. A sentence has been added to this section to state the procedure if a disagreement between MJN and ÉNS occurs. The appraisal of included paper is discussed in stage four of the process, but as already stipulated above, the Crowe Critical appraisal Tool was used due to its continuous utilisation in other realist reviews published in the literature. Given the qualitative nature of this review, reporting inter-rater reliability is not necessary. Step IV doesn’t specify whether pilot testing of the extraction form will be done. Reliance on a single reviewer (MJN) for extraction, with supervisory oversight, carries a risk of bias. Response: Thank you for this comment. A sentence or two has been added to stage four to reflect this. As noted above, this review will not be a systematic review and as such, yes, bias is more likely to be present, but in qualitative research bias is countered by strong reflexivity. However, the review is more concerned with the construction of mechanisms rather than bias as realist reviews are theory heavy. Step V, the process described could produce descriptive categories rather than true realist synthesis. Explicitly describe the use of retroductive reasoning, provide examples of how initial CMOs will evolve into middle-range theories, and consider external validation beyond the author panel. Response: Thank you for this comment. Although we acknowledge your comment, we disagree with the statement that the process as outlined in stage 5 could produce descriptive categories. The process outlined in stage 5 is to support the development of refined initial programme theories and not the creation of middle-range programme theories which actually would require a realist evaluation in order for this to occur. External validation will occur through the expert panel as these are national experts on the implementation of CHIME into Irish services – where the overarching study is based. The review does not have funding to include international experts in the field. Stage 5 already discusses the retroductive reasoning to create refined IPTs. However, a sentence has been added to make this more visual. Step VI, add transparency on how independence of critique will be preserved, and describe dissemination beyond academic journals (e.g., co-produced outputs for service users). Response: The dissemination beyond academic journals is already described at the end of stage 6: “ In addition, the results of this proposed realist review may also be presented through other means, including conferences and recovery workshops delivered by recovery college personnel. This will be made possible through the Recovery and Engagement Programme Manager in charge of the recovery education workstream of MHER.” Reporting bias will be contained through a process of reflexivity and journaling as the realist review process unfolds. This will be further noted in stage 6 of the process. Figure 2 uses “Inductive Reflexive Thematic Analysis” under synthesis. This terminology is more common in qualitative research, but realist reviews emphasize retroductive reasoning and CMO refinement. Response: Thank you for this comment. The wording of Figure 2 has been reworded to reflect your suggestion. The current wording may mislead readers about analytic methods. This figure presents the steps as linear, but realist reviews are inherently iterative (moving back and forth between theory building, searching, and refinement). This could misrepresent the cyclical nature of realist reviews. Some steps (e.g., “Upload onto NVivo for Analysis”) are tool-specific, which may not apply universally and make the figure feel like a workflow chart rather than a generalizable method. Meanwhile, other important elements (e.g., stakeholder engagement, retroductive reasoning, theory testing vs. refinement) are missing. Advisory panel engagement should appear not just at the start, but also during synthesis/validation. Response: These amendments to Figure 2 have now been made. Thank you for reminding us to include these elements in the Figure and for your guidance regarding the cyclical nature of realist reviews which should now be demonstrated in Figure 2. Table 1 provides a useful but overly simplistic starting point for realist program theory development. It will benefit if you clarify distinctiveness by ensuring each CHIME domain’s If…Then statement highlights unique mechanisms. Add one illustrative case or a brief exemplary per domain to ground the theory. Response: Thanks for this comment. Although we respect your perspective regarding table 1, we find it important to include as is as this demonstrates to you, the reader/reviewer where the review started from. The If… then… statements as they stand do show each element of the CHIME framework but at this point the if… then… statements may not have a clear mechanism attached. This comes with further refinement of the if… then… statements into initial IPTs. We also think an illustrative case or brief exemplary per domain is not required as these domains are already well documented in the existing literature. Table 2 shows the evolution into draft CMOs. I recommend improvement for it. The context should add diversity in settings (community vs. inpatient), roles (peer vs. clinician support), and cultural/systemic factors. Mechanisms should frame them as resources + reasoning (what is offered + how it is interpreted), e.g., “Access to peer groups (resource) triggers recognition of shared experience (reasoning)”. Outcomes should be more diverse by going beyond re-stating mechanisms, e.g., linking hope, such as increased engagement, reduced suicidality, and improved functioning. Response: Thank you for this comment. This suggestion has been utilised in the actual realist review itself. However, although acknowledging the usefulness of the stated way to create IPTs, at this stage, due to advancement of the review process itself, making these amendments is now deemed impossible. However, the authors would like to thank you for raising this comment and wish to reassure you that this will be added to the review itself and be noted in the supplementary material as a deviation from the present protocol. Table 3 remains too generic, tautological, and individual-focused. With richer contextualization, sharper mechanism articulation, and more concrete outcomes, it could provide a robust foundation for theory testing in the review. Response: Thank you for this comment. The IPTs within table 3 cannot be changed as these IPTs have been approved by the expert panel to test within the actual realist review. However, what you have commented on is actually taking place within the review itself. Table 4-6, Search strings like “Mental Health” OR “Mental Disorders” yield millions of hits (e.g., 6.5M in PubMed). This risks irrelevance and screening overload. It might indicate poor precision in early steps. Lack of Grey Literature Strategy in These Tables. Excluding pre-2011 studies may miss early CHIME conceptual development or precursors. Needs a stronger justification than “CHIME was published in 2011. Response: Thank you for this comment. Table 4-6 were developed with the expertise of a librarian. Although we acknowledge your concern, we have already reached a stage in the review where we are extracting IPTs from included paper. As such, this comment can no longer be actioned upon. As noted above, a sentence or two has been added to state the process of grey literature searching as described by Godin and colleagues. A justification for excluding pre-2011 data has already been provided in the comments above. Table 7, please reconsider including quantitative studies that explore mechanisms (e.g., mediation, regression, factor analysis). Provide a rationale for excluding dual diagnosis/addiction populations or consider including them with sensitivity analysis. Response: Thank you for this comment. A justification has already been given as to why quantitative studies were excluded from this review. A rationale for excluding dual diagnosis/addiction populations has already been noted in the review. Here it states that they were excluded “… because of the difficulties in distinguishing changes relating and not relating to mental health and illness alone .” Thank you for the opportunity to review this interesting and timely protocol. The topic is important and relevant for advancing recovery-oriented mental health research. The paper is well-structured and demonstrates strong potential. Response: Thank you for your comment. We hope that the amendments made to this paper will strengthen it further. I provide the following comments to strengthen clarity, methodological rigor, and practical contribution. Response: Thank you for this. We hope that the amendments the authorship team have accepted will have strengthened the paper further. I recommended that the author support the gap statement by systematically highlighting what CHIME research has achieved (measurement, validation, intervention use) and what remains unexplored (mechanisms, context-specific functioning). Response: Thank you for this comment. We have adjusted the rationale for realist review section to incorporate this comment. The introduction part lacks a sharp demonstration of the evidence gap, a critical comparison with other review types, and a clear link to practice implications. Strengthening these aspects will make justification more persuasive. Response: Thank you for this comment. The introduction has been sharpened to include the evidence gap and comparison with other review types along with a clearer link been made to practice implications. The methods section is full and clear in structure but would benefit from greater rigor in evidence appraisal, inclusion criteria, extraction reliability, and analytic strategy. With these refinements, the review will be more credible and reproducible. Response: Thank you for this comment. We are not trying to produce a systematic review which would rely on reproducibility. We are instead utilising a realist review methodology to uncover mechanisms. Although the search was rigorous, it does not need to be of the same standard as a systematic review where your concerns are of extreme importance. The evidence appraisal method has been taken and adopted from previous realist reviews which utilise this method. The inclusion criteria are robust given the review method. We believe you have commented on some of the other aspects of the inclusion criteria below, which we will address then. The extraction process follows a realist method and the analytic process is suitable, given the review type. Step I, the author should clarify procedures for iterative refinement, include safeguards against confirmation bias, and discuss diversity/independence of the advisory panel. Response: Thank you for your comment. Given the review type, safeguards against confirmation bias is not necessary. In regard to the diversity and independence of the advisory panel, the text now discusses these in step 1 of the realist review process. Step II, Exclusion of quantitative studies is restrictive; yet some quantitative work (e.g., mediation, SEM, longitudinal studies) could inform mechanisms. Response: Thank you for raising this comment. A conscious decision was made to exclude quantitative studies as personal recovery is a subjective experience that cannot be captured adequately through positivist quantitative means. In addition, quantitative research lacks contextual depth and given that realist reviews aim to demonstrate how, why and under what circumstances a mechanism operates, the inclusion of quanitative studies was deemed inappropriate. Restricting to post-2011 excludes potentially relevant pre-CHIME conceptualizations that could enrich theory building. Response: Thank you for also raising this comment. We restricted the inclusion/exclusion criteria to post 2011 studies for two reasons. Firstly, CHIME was constructed in a 2011 paper from Mary Leamy and colleagues in the UK and as a result, this review is looking for papers that include all elements of CHIME. Secondly, we also excluded pre-2011 studies as these would have been captured by the original systematic review method conducted by Leamy et al. when they carried out their review. As such, it was deemed unnecessary to include pre-2011 research studies. Reconsider exclusion of quantitative studies, broaden the grey literature strategy, and justify more clearly the 2011 cutoff. Response: Thank you for this comment. The rationale for excluding quantitative studies have been mentioned above. A couple of sentences has been added to describe the grey literature search mechanisms. The justification for the 2011 cutoff has been discussed above. Step III, Screening and appraisal are described (three rounds; Covidence; 10% double-screening). Appraisal using “relevance, rigor, richness” is conceptually valid but subjective; no plan for handling disagreements or measuring inter-rater agreement. Therefore, increase the proportion of double-screening, consider structured appraisal checklists (e.g., CASP, RAMESES appraisal tool), and report inter-rater reliability (e.g., Cohen’s κ). Response: Thank you for this comment. Given the theory focus of realist reviews, appraisal with relevance, rigor and richness is the noted procedure to appraise papers included in this realist review. A sentence has been added to this section to state the procedure if a disagreement between MJN and ÉNS occurs. The appraisal of included paper is discussed in stage four of the process, but as already stipulated above, the Crowe Critical appraisal Tool was used due to its continuous utilisation in other realist reviews published in the literature. Given the qualitative nature of this review, reporting inter-rater reliability is not necessary. Step IV doesn’t specify whether pilot testing of the extraction form will be done. Reliance on a single reviewer (MJN) for extraction, with supervisory oversight, carries a risk of bias. Response: Thank you for this comment. A sentence or two has been added to stage four to reflect this. As noted above, this review will not be a systematic review and as such, yes, bias is more likely to be present, but in qualitative research bias is countered by strong reflexivity. However, the review is more concerned with the construction of mechanisms rather than bias as realist reviews are theory heavy. Step V, the process described could produce descriptive categories rather than true realist synthesis. Explicitly describe the use of retroductive reasoning, provide examples of how initial CMOs will evolve into middle-range theories, and consider external validation beyond the author panel. Response: Thank you for this comment. Although we acknowledge your comment, we disagree with the statement that the process as outlined in stage 5 could produce descriptive categories. The process outlined in stage 5 is to support the development of refined initial programme theories and not the creation of middle-range programme theories which actually would require a realist evaluation in order for this to occur. External validation will occur through the expert panel as these are national experts on the implementation of CHIME into Irish services – where the overarching study is based. The review does not have funding to include international experts in the field. Stage 5 already discusses the retroductive reasoning to create refined IPTs. However, a sentence has been added to make this more visual. Step VI, add transparency on how independence of critique will be preserved, and describe dissemination beyond academic journals (e.g., co-produced outputs for service users). Response: The dissemination beyond academic journals is already described at the end of stage 6: “ In addition, the results of this proposed realist review may also be presented through other means, including conferences and recovery workshops delivered by recovery college personnel. This will be made possible through the Recovery and Engagement Programme Manager in charge of the recovery education workstream of MHER.” Reporting bias will be contained through a process of reflexivity and journaling as the realist review process unfolds. This will be further noted in stage 6 of the process. Figure 2 uses “Inductive Reflexive Thematic Analysis” under synthesis. This terminology is more common in qualitative research, but realist reviews emphasize retroductive reasoning and CMO refinement. Response: Thank you for this comment. The wording of Figure 2 has been reworded to reflect your suggestion. The current wording may mislead readers about analytic methods. This figure presents the steps as linear, but realist reviews are inherently iterative (moving back and forth between theory building, searching, and refinement). This could misrepresent the cyclical nature of realist reviews. Some steps (e.g., “Upload onto NVivo for Analysis”) are tool-specific, which may not apply universally and make the figure feel like a workflow chart rather than a generalizable method. Meanwhile, other important elements (e.g., stakeholder engagement, retroductive reasoning, theory testing vs. refinement) are missing. Advisory panel engagement should appear not just at the start, but also during synthesis/validation. Response: These amendments to Figure 2 have now been made. Thank you for reminding us to include these elements in the Figure and for your guidance regarding the cyclical nature of realist reviews which should now be demonstrated in Figure 2. Table 1 provides a useful but overly simplistic starting point for realist program theory development. It will benefit if you clarify distinctiveness by ensuring each CHIME domain’s If…Then statement highlights unique mechanisms. Add one illustrative case or a brief exemplary per domain to ground the theory. Response: Thanks for this comment. Although we respect your perspective regarding table 1, we find it important to include as is as this demonstrates to you, the reader/reviewer where the review started from. The If… then… statements as they stand do show each element of the CHIME framework but at this point the if… then… statements may not have a clear mechanism attached. This comes with further refinement of the if… then… statements into initial IPTs. We also think an illustrative case or brief exemplary per domain is not required as these domains are already well documented in the existing literature. Table 2 shows the evolution into draft CMOs. I recommend improvement for it. The context should add diversity in settings (community vs. inpatient), roles (peer vs. clinician support), and cultural/systemic factors. Mechanisms should frame them as resources + reasoning (what is offered + how it is interpreted), e.g., “Access to peer groups (resource) triggers recognition of shared experience (reasoning)”. Outcomes should be more diverse by going beyond re-stating mechanisms, e.g., linking hope, such as increased engagement, reduced suicidality, and improved functioning. Response: Thank you for this comment. This suggestion has been utilised in the actual realist review itself. However, although acknowledging the usefulness of the stated way to create IPTs, at this stage, due to advancement of the review process itself, making these amendments is now deemed impossible. However, the authors would like to thank you for raising this comment and wish to reassure you that this will be added to the review itself and be noted in the supplementary material as a deviation from the present protocol. Table 3 remains too generic, tautological, and individual-focused. With richer contextualization, sharper mechanism articulation, and more concrete outcomes, it could provide a robust foundation for theory testing in the review. Response: Thank you for this comment. The IPTs within table 3 cannot be changed as these IPTs have been approved by the expert panel to test within the actual realist review. However, what you have commented on is actually taking place within the review itself. Table 4-6, Search strings like “Mental Health” OR “Mental Disorders” yield millions of hits (e.g., 6.5M in PubMed). This risks irrelevance and screening overload. It might indicate poor precision in early steps. Lack of Grey Literature Strategy in These Tables. Excluding pre-2011 studies may miss early CHIME conceptual development or precursors. Needs a stronger justification than “CHIME was published in 2011. Response: Thank you for this comment. Table 4-6 were developed with the expertise of a librarian. Although we acknowledge your concern, we have already reached a stage in the review where we are extracting IPTs from included paper. As such, this comment can no longer be actioned upon. As noted above, a sentence or two has been added to state the process of grey literature searching as described by Godin and colleagues. A justification for excluding pre-2011 data has already been provided in the comments above. Table 7, please reconsider including quantitative studies that explore mechanisms (e.g., mediation, regression, factor analysis). Provide a rationale for excluding dual diagnosis/addiction populations or consider including them with sensitivity analysis. Response: Thank you for this comment. A justification has already been given as to why quantitative studies were excluded from this review. A rationale for excluding dual diagnosis/addiction populations has already been noted in the review. Here it states that they were excluded “… because of the difficulties in distinguishing changes relating and not relating to mental health and illness alone .” Competing Interests: None Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 24 Nov 2025 Michael John Norton , $usrAffiliation 24 Nov 2025 Author Response Thank you for the opportunity to review this interesting and timely protocol. The topic is important and relevant for advancing recovery-oriented mental health research. The paper is well-structured ... Continue reading Thank you for the opportunity to review this interesting and timely protocol. The topic is important and relevant for advancing recovery-oriented mental health research. The paper is well-structured and demonstrates strong potential. Response: Thank you for your comment. We hope that the amendments made to this paper will strengthen it further. I provide the following comments to strengthen clarity, methodological rigor, and practical contribution. Response: Thank you for this. We hope that the amendments the authorship team have accepted will have strengthened the paper further. I recommended that the author support the gap statement by systematically highlighting what CHIME research has achieved (measurement, validation, intervention use) and what remains unexplored (mechanisms, context-specific functioning). Response: Thank you for this comment. We have adjusted the rationale for realist review section to incorporate this comment. The introduction part lacks a sharp demonstration of the evidence gap, a critical comparison with other review types, and a clear link to practice implications. Strengthening these aspects will make justification more persuasive. Response: Thank you for this comment. The introduction has been sharpened to include the evidence gap and comparison with other review types along with a clearer link been made to practice implications. The methods section is full and clear in structure but would benefit from greater rigor in evidence appraisal, inclusion criteria, extraction reliability, and analytic strategy. With these refinements, the review will be more credible and reproducible. Response: Thank you for this comment. We are not trying to produce a systematic review which would rely on reproducibility. We are instead utilising a realist review methodology to uncover mechanisms. Although the search was rigorous, it does not need to be of the same standard as a systematic review where your concerns are of extreme importance. The evidence appraisal method has been taken and adopted from previous realist reviews which utilise this method. The inclusion criteria are robust given the review method. We believe you have commented on some of the other aspects of the inclusion criteria below, which we will address then. The extraction process follows a realist method and the analytic process is suitable, given the review type. Step I, the author should clarify procedures for iterative refinement, include safeguards against confirmation bias, and discuss diversity/independence of the advisory panel. Response: Thank you for your comment. Given the review type, safeguards against confirmation bias is not necessary. In regard to the diversity and independence of the advisory panel, the text now discusses these in step 1 of the realist review process. Step II, Exclusion of quantitative studies is restrictive; yet some quantitative work (e.g., mediation, SEM, longitudinal studies) could inform mechanisms. Response: Thank you for raising this comment. A conscious decision was made to exclude quantitative studies as personal recovery is a subjective experience that cannot be captured adequately through positivist quantitative means. In addition, quantitative research lacks contextual depth and given that realist reviews aim to demonstrate how, why and under what circumstances a mechanism operates, the inclusion of quanitative studies was deemed inappropriate. Restricting to post-2011 excludes potentially relevant pre-CHIME conceptualizations that could enrich theory building. Response: Thank you for also raising this comment. We restricted the inclusion/exclusion criteria to post 2011 studies for two reasons. Firstly, CHIME was constructed in a 2011 paper from Mary Leamy and colleagues in the UK and as a result, this review is looking for papers that include all elements of CHIME. Secondly, we also excluded pre-2011 studies as these would have been captured by the original systematic review method conducted by Leamy et al. when they carried out their review. As such, it was deemed unnecessary to include pre-2011 research studies. Reconsider exclusion of quantitative studies, broaden the grey literature strategy, and justify more clearly the 2011 cutoff. Response: Thank you for this comment. The rationale for excluding quantitative studies have been mentioned above. A couple of sentences has been added to describe the grey literature search mechanisms. The justification for the 2011 cutoff has been discussed above. Step III, Screening and appraisal are described (three rounds; Covidence; 10% double-screening). Appraisal using “relevance, rigor, richness” is conceptually valid but subjective; no plan for handling disagreements or measuring inter-rater agreement. Therefore, increase the proportion of double-screening, consider structured appraisal checklists (e.g., CASP, RAMESES appraisal tool), and report inter-rater reliability (e.g., Cohen’s κ). Response: Thank you for this comment. Given the theory focus of realist reviews, appraisal with relevance, rigor and richness is the noted procedure to appraise papers included in this realist review. A sentence has been added to this section to state the procedure if a disagreement between MJN and ÉNS occurs. The appraisal of included paper is discussed in stage four of the process, but as already stipulated above, the Crowe Critical appraisal Tool was used due to its continuous utilisation in other realist reviews published in the literature. Given the qualitative nature of this review, reporting inter-rater reliability is not necessary. Step IV doesn’t specify whether pilot testing of the extraction form will be done. Reliance on a single reviewer (MJN) for extraction, with supervisory oversight, carries a risk of bias. Response: Thank you for this comment. A sentence or two has been added to stage four to reflect this. As noted above, this review will not be a systematic review and as such, yes, bias is more likely to be present, but in qualitative research bias is countered by strong reflexivity. However, the review is more concerned with the construction of mechanisms rather than bias as realist reviews are theory heavy. Step V, the process described could produce descriptive categories rather than true realist synthesis. Explicitly describe the use of retroductive reasoning, provide examples of how initial CMOs will evolve into middle-range theories, and consider external validation beyond the author panel. Response: Thank you for this comment. Although we acknowledge your comment, we disagree with the statement that the process as outlined in stage 5 could produce descriptive categories. The process outlined in stage 5 is to support the development of refined initial programme theories and not the creation of middle-range programme theories which actually would require a realist evaluation in order for this to occur. External validation will occur through the expert panel as these are national experts on the implementation of CHIME into Irish services – where the overarching study is based. The review does not have funding to include international experts in the field. Stage 5 already discusses the retroductive reasoning to create refined IPTs. However, a sentence has been added to make this more visual. Step VI, add transparency on how independence of critique will be preserved, and describe dissemination beyond academic journals (e.g., co-produced outputs for service users). Response: The dissemination beyond academic journals is already described at the end of stage 6: “ In addition, the results of this proposed realist review may also be presented through other means, including conferences and recovery workshops delivered by recovery college personnel. This will be made possible through the Recovery and Engagement Programme Manager in charge of the recovery education workstream of MHER.” Reporting bias will be contained through a process of reflexivity and journaling as the realist review process unfolds. This will be further noted in stage 6 of the process. Figure 2 uses “Inductive Reflexive Thematic Analysis” under synthesis. This terminology is more common in qualitative research, but realist reviews emphasize retroductive reasoning and CMO refinement. Response: Thank you for this comment. The wording of Figure 2 has been reworded to reflect your suggestion. The current wording may mislead readers about analytic methods. This figure presents the steps as linear, but realist reviews are inherently iterative (moving back and forth between theory building, searching, and refinement). This could misrepresent the cyclical nature of realist reviews. Some steps (e.g., “Upload onto NVivo for Analysis”) are tool-specific, which may not apply universally and make the figure feel like a workflow chart rather than a generalizable method. Meanwhile, other important elements (e.g., stakeholder engagement, retroductive reasoning, theory testing vs. refinement) are missing. Advisory panel engagement should appear not just at the start, but also during synthesis/validation. Response: These amendments to Figure 2 have now been made. Thank you for reminding us to include these elements in the Figure and for your guidance regarding the cyclical nature of realist reviews which should now be demonstrated in Figure 2. Table 1 provides a useful but overly simplistic starting point for realist program theory development. It will benefit if you clarify distinctiveness by ensuring each CHIME domain’s If…Then statement highlights unique mechanisms. Add one illustrative case or a brief exemplary per domain to ground the theory. Response: Thanks for this comment. Although we respect your perspective regarding table 1, we find it important to include as is as this demonstrates to you, the reader/reviewer where the review started from. The If… then… statements as they stand do show each element of the CHIME framework but at this point the if… then… statements may not have a clear mechanism attached. This comes with further refinement of the if… then… statements into initial IPTs. We also think an illustrative case or brief exemplary per domain is not required as these domains are already well documented in the existing literature. Table 2 shows the evolution into draft CMOs. I recommend improvement for it. The context should add diversity in settings (community vs. inpatient), roles (peer vs. clinician support), and cultural/systemic factors. Mechanisms should frame them as resources + reasoning (what is offered + how it is interpreted), e.g., “Access to peer groups (resource) triggers recognition of shared experience (reasoning)”. Outcomes should be more diverse by going beyond re-stating mechanisms, e.g., linking hope, such as increased engagement, reduced suicidality, and improved functioning. Response: Thank you for this comment. This suggestion has been utilised in the actual realist review itself. However, although acknowledging the usefulness of the stated way to create IPTs, at this stage, due to advancement of the review process itself, making these amendments is now deemed impossible. However, the authors would like to thank you for raising this comment and wish to reassure you that this will be added to the review itself and be noted in the supplementary material as a deviation from the present protocol. Table 3 remains too generic, tautological, and individual-focused. With richer contextualization, sharper mechanism articulation, and more concrete outcomes, it could provide a robust foundation for theory testing in the review. Response: Thank you for this comment. The IPTs within table 3 cannot be changed as these IPTs have been approved by the expert panel to test within the actual realist review. However, what you have commented on is actually taking place within the review itself. Table 4-6, Search strings like “Mental Health” OR “Mental Disorders” yield millions of hits (e.g., 6.5M in PubMed). This risks irrelevance and screening overload. It might indicate poor precision in early steps. Lack of Grey Literature Strategy in These Tables. Excluding pre-2011 studies may miss early CHIME conceptual development or precursors. Needs a stronger justification than “CHIME was published in 2011. Response: Thank you for this comment. Table 4-6 were developed with the expertise of a librarian. Although we acknowledge your concern, we have already reached a stage in the review where we are extracting IPTs from included paper. As such, this comment can no longer be actioned upon. As noted above, a sentence or two has been added to state the process of grey literature searching as described by Godin and colleagues. A justification for excluding pre-2011 data has already been provided in the comments above. Table 7, please reconsider including quantitative studies that explore mechanisms (e.g., mediation, regression, factor analysis). Provide a rationale for excluding dual diagnosis/addiction populations or consider including them with sensitivity analysis. Response: Thank you for this comment. A justification has already been given as to why quantitative studies were excluded from this review. A rationale for excluding dual diagnosis/addiction populations has already been noted in the review. Here it states that they were excluded “… because of the difficulties in distinguishing changes relating and not relating to mental health and illness alone .” Thank you for the opportunity to review this interesting and timely protocol. The topic is important and relevant for advancing recovery-oriented mental health research. The paper is well-structured and demonstrates strong potential. Response: Thank you for your comment. We hope that the amendments made to this paper will strengthen it further. I provide the following comments to strengthen clarity, methodological rigor, and practical contribution. Response: Thank you for this. We hope that the amendments the authorship team have accepted will have strengthened the paper further. I recommended that the author support the gap statement by systematically highlighting what CHIME research has achieved (measurement, validation, intervention use) and what remains unexplored (mechanisms, context-specific functioning). Response: Thank you for this comment. We have adjusted the rationale for realist review section to incorporate this comment. The introduction part lacks a sharp demonstration of the evidence gap, a critical comparison with other review types, and a clear link to practice implications. Strengthening these aspects will make justification more persuasive. Response: Thank you for this comment. The introduction has been sharpened to include the evidence gap and comparison with other review types along with a clearer link been made to practice implications. The methods section is full and clear in structure but would benefit from greater rigor in evidence appraisal, inclusion criteria, extraction reliability, and analytic strategy. With these refinements, the review will be more credible and reproducible. Response: Thank you for this comment. We are not trying to produce a systematic review which would rely on reproducibility. We are instead utilising a realist review methodology to uncover mechanisms. Although the search was rigorous, it does not need to be of the same standard as a systematic review where your concerns are of extreme importance. The evidence appraisal method has been taken and adopted from previous realist reviews which utilise this method. The inclusion criteria are robust given the review method. We believe you have commented on some of the other aspects of the inclusion criteria below, which we will address then. The extraction process follows a realist method and the analytic process is suitable, given the review type. Step I, the author should clarify procedures for iterative refinement, include safeguards against confirmation bias, and discuss diversity/independence of the advisory panel. Response: Thank you for your comment. Given the review type, safeguards against confirmation bias is not necessary. In regard to the diversity and independence of the advisory panel, the text now discusses these in step 1 of the realist review process. Step II, Exclusion of quantitative studies is restrictive; yet some quantitative work (e.g., mediation, SEM, longitudinal studies) could inform mechanisms. Response: Thank you for raising this comment. A conscious decision was made to exclude quantitative studies as personal recovery is a subjective experience that cannot be captured adequately through positivist quantitative means. In addition, quantitative research lacks contextual depth and given that realist reviews aim to demonstrate how, why and under what circumstances a mechanism operates, the inclusion of quanitative studies was deemed inappropriate. Restricting to post-2011 excludes potentially relevant pre-CHIME conceptualizations that could enrich theory building. Response: Thank you for also raising this comment. We restricted the inclusion/exclusion criteria to post 2011 studies for two reasons. Firstly, CHIME was constructed in a 2011 paper from Mary Leamy and colleagues in the UK and as a result, this review is looking for papers that include all elements of CHIME. Secondly, we also excluded pre-2011 studies as these would have been captured by the original systematic review method conducted by Leamy et al. when they carried out their review. As such, it was deemed unnecessary to include pre-2011 research studies. Reconsider exclusion of quantitative studies, broaden the grey literature strategy, and justify more clearly the 2011 cutoff. Response: Thank you for this comment. The rationale for excluding quantitative studies have been mentioned above. A couple of sentences has been added to describe the grey literature search mechanisms. The justification for the 2011 cutoff has been discussed above. Step III, Screening and appraisal are described (three rounds; Covidence; 10% double-screening). Appraisal using “relevance, rigor, richness” is conceptually valid but subjective; no plan for handling disagreements or measuring inter-rater agreement. Therefore, increase the proportion of double-screening, consider structured appraisal checklists (e.g., CASP, RAMESES appraisal tool), and report inter-rater reliability (e.g., Cohen’s κ). Response: Thank you for this comment. Given the theory focus of realist reviews, appraisal with relevance, rigor and richness is the noted procedure to appraise papers included in this realist review. A sentence has been added to this section to state the procedure if a disagreement between MJN and ÉNS occurs. The appraisal of included paper is discussed in stage four of the process, but as already stipulated above, the Crowe Critical appraisal Tool was used due to its continuous utilisation in other realist reviews published in the literature. Given the qualitative nature of this review, reporting inter-rater reliability is not necessary. Step IV doesn’t specify whether pilot testing of the extraction form will be done. Reliance on a single reviewer (MJN) for extraction, with supervisory oversight, carries a risk of bias. Response: Thank you for this comment. A sentence or two has been added to stage four to reflect this. As noted above, this review will not be a systematic review and as such, yes, bias is more likely to be present, but in qualitative research bias is countered by strong reflexivity. However, the review is more concerned with the construction of mechanisms rather than bias as realist reviews are theory heavy. Step V, the process described could produce descriptive categories rather than true realist synthesis. Explicitly describe the use of retroductive reasoning, provide examples of how initial CMOs will evolve into middle-range theories, and consider external validation beyond the author panel. Response: Thank you for this comment. Although we acknowledge your comment, we disagree with the statement that the process as outlined in stage 5 could produce descriptive categories. The process outlined in stage 5 is to support the development of refined initial programme theories and not the creation of middle-range programme theories which actually would require a realist evaluation in order for this to occur. External validation will occur through the expert panel as these are national experts on the implementation of CHIME into Irish services – where the overarching study is based. The review does not have funding to include international experts in the field. Stage 5 already discusses the retroductive reasoning to create refined IPTs. However, a sentence has been added to make this more visual. Step VI, add transparency on how independence of critique will be preserved, and describe dissemination beyond academic journals (e.g., co-produced outputs for service users). Response: The dissemination beyond academic journals is already described at the end of stage 6: “ In addition, the results of this proposed realist review may also be presented through other means, including conferences and recovery workshops delivered by recovery college personnel. This will be made possible through the Recovery and Engagement Programme Manager in charge of the recovery education workstream of MHER.” Reporting bias will be contained through a process of reflexivity and journaling as the realist review process unfolds. This will be further noted in stage 6 of the process. Figure 2 uses “Inductive Reflexive Thematic Analysis” under synthesis. This terminology is more common in qualitative research, but realist reviews emphasize retroductive reasoning and CMO refinement. Response: Thank you for this comment. The wording of Figure 2 has been reworded to reflect your suggestion. The current wording may mislead readers about analytic methods. This figure presents the steps as linear, but realist reviews are inherently iterative (moving back and forth between theory building, searching, and refinement). This could misrepresent the cyclical nature of realist reviews. Some steps (e.g., “Upload onto NVivo for Analysis”) are tool-specific, which may not apply universally and make the figure feel like a workflow chart rather than a generalizable method. Meanwhile, other important elements (e.g., stakeholder engagement, retroductive reasoning, theory testing vs. refinement) are missing. Advisory panel engagement should appear not just at the start, but also during synthesis/validation. Response: These amendments to Figure 2 have now been made. Thank you for reminding us to include these elements in the Figure and for your guidance regarding the cyclical nature of realist reviews which should now be demonstrated in Figure 2. Table 1 provides a useful but overly simplistic starting point for realist program theory development. It will benefit if you clarify distinctiveness by ensuring each CHIME domain’s If…Then statement highlights unique mechanisms. Add one illustrative case or a brief exemplary per domain to ground the theory. Response: Thanks for this comment. Although we respect your perspective regarding table 1, we find it important to include as is as this demonstrates to you, the reader/reviewer where the review started from. The If… then… statements as they stand do show each element of the CHIME framework but at this point the if… then… statements may not have a clear mechanism attached. This comes with further refinement of the if… then… statements into initial IPTs. We also think an illustrative case or brief exemplary per domain is not required as these domains are already well documented in the existing literature. Table 2 shows the evolution into draft CMOs. I recommend improvement for it. The context should add diversity in settings (community vs. inpatient), roles (peer vs. clinician support), and cultural/systemic factors. Mechanisms should frame them as resources + reasoning (what is offered + how it is interpreted), e.g., “Access to peer groups (resource) triggers recognition of shared experience (reasoning)”. Outcomes should be more diverse by going beyond re-stating mechanisms, e.g., linking hope, such as increased engagement, reduced suicidality, and improved functioning. Response: Thank you for this comment. This suggestion has been utilised in the actual realist review itself. However, although acknowledging the usefulness of the stated way to create IPTs, at this stage, due to advancement of the review process itself, making these amendments is now deemed impossible. However, the authors would like to thank you for raising this comment and wish to reassure you that this will be added to the review itself and be noted in the supplementary material as a deviation from the present protocol. Table 3 remains too generic, tautological, and individual-focused. With richer contextualization, sharper mechanism articulation, and more concrete outcomes, it could provide a robust foundation for theory testing in the review. Response: Thank you for this comment. The IPTs within table 3 cannot be changed as these IPTs have been approved by the expert panel to test within the actual realist review. However, what you have commented on is actually taking place within the review itself. Table 4-6, Search strings like “Mental Health” OR “Mental Disorders” yield millions of hits (e.g., 6.5M in PubMed). This risks irrelevance and screening overload. It might indicate poor precision in early steps. Lack of Grey Literature Strategy in These Tables. Excluding pre-2011 studies may miss early CHIME conceptual development or precursors. Needs a stronger justification than “CHIME was published in 2011. Response: Thank you for this comment. Table 4-6 were developed with the expertise of a librarian. Although we acknowledge your concern, we have already reached a stage in the review where we are extracting IPTs from included paper. As such, this comment can no longer be actioned upon. As noted above, a sentence or two has been added to state the process of grey literature searching as described by Godin and colleagues. A justification for excluding pre-2011 data has already been provided in the comments above. Table 7, please reconsider including quantitative studies that explore mechanisms (e.g., mediation, regression, factor analysis). Provide a rationale for excluding dual diagnosis/addiction populations or consider including them with sensitivity analysis. Response: Thank you for this comment. A justification has already been given as to why quantitative studies were excluded from this review. A rationale for excluding dual diagnosis/addiction populations has already been noted in the review. Here it states that they were excluded “… because of the difficulties in distinguishing changes relating and not relating to mental health and illness alone .” Competing Interests: None Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 26 Aug 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 3 4 Version 2 (revision) 17 Nov 25 read read read read Version 1 26 Aug 25 read read read Dr. Jutharat Thongsalab , Boromarajonani College of Nursing Surin, Mueang Surin District, Thailand Geoff Wong , University of Oxford, Oxford, UK Chalotte Heinsvig Poulsen , Copenhagen Research Unit for Recovery, Copenhagen, Denmark; Mental Health Services, Capital region of denmark, Copenhagen, Denmark Sara Vilar-Lluch , Cardiff University, Cardiff, UK 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 Vilar-Lluch S. 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 2 Sara Vilar-Lluch , Cardiff University, Cardiff, UK 0 Views copyright © 2026 Vilar-Lluch S. 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 Overall very clear and informative. The writing needs some polishing, please see notes below. Occasionally, some glossing of concepts is needed (also noted below). Abstract: - CHIME is defined as “A concept that represents the key characteristics of recovery”: CHIME is not “a concept”, it’s a “framework” - Please rephrase the following sentence, the wording is not clear (i.e. clearly state what the question is): “allowing one to answer this review question by exploring how, why, and through what circumstances individuals reach recovery through CHIME.” - Is the following necessary, considering that this is meant to be indexing? > “The proposed review will be written up and submitted to a peer-reviewed journal” Introduction p. 4: please ensure that a formal academic style is adopted throughout. For instance, in “However, till now, no study” > “till” should be “until”. p. 4: please revise wording “In answering this question, a realist review was deemed most appropriate” >> “to answer this question…” (please also note that a explicit research question is not provided; it is formulated as an aim). p. 4: please note that the last paragraph of the introduction starts and ends in the same manner (stating the aims of the review). Please avoid repetitions. Methods p. 4: please revise wording (repetition of verb “are”): “Realist reviews are, by their very nature, are cyclical and iterative in their approach” Table 1 (p, 6). All the “if… then…” statements start with “If a person with lived experience of mental health challenges” (or similar) except point 4 (“If a person who uses community mental health services”). Unless there is a reason for this change (in which case should be explained), please unify. p. 6: the relevance of physical proximity is not clear, if the meetings were online, please amend as necessary: “Due to the proximity of all parties to one another in the country, the expert panel convened online via MS Teams and lasted approximately an hour and a half” p. 6: please state the sixth element at the end of this sentence: “After the meeting, the original CMOs were amended, and a sixth CMO was added based on the discussion.” p. 6: please briefly explain the process alluded to after this sentence (or indicate which section of the paper provides this information if this is the case): “Grey literature will be gathered through a process of grey literature searching proposed by Godin et al .” This is then repeated at p. 8 (and the process is briefly explained); just refer there – or move the explanation to the methods, together with the other explanations. p. 6: this sentence appears redundant, please amend or simply delete, and introduce the rationale directly: “For this reason, each inclusion/exclusion criterion was selected for a reason.” p. 6: please unify verbal tenses. The methods were reported in past tense, but then there is a shift to future tense: “In the identification of appropriate resources for inclusion in this realist review, qualitative and mixed methods papers will be included, whereas quantitative papers will not”. Please unify. p. 8: please simply the following three sentences (they repeat the same information in different words and appear repetitive): “Literature reviews of any kind, including meta-synthesis, will be excluded because of the reviewers’ positionality towards the original raw data used in the original study1. In other words, these review papers will be excluded as the reviewer is removed at least twice from the original raw data that was collected by the original study authors. As such, if reviews were included, it is possible that such reviews could misinterpret the original findings and make conclusions that are misleading due to the misinterpretation of the data presented by the original studies.” p. 8: please rephrase this sentence, it appears odd: “Articles published before 2011 will not be included as they would have been published before the literature review that created CHIME was published.” p. 8: please unify tenses (here one is in past, and the following is in the future): “Articles not published in English were excluded due to the inability of the review team in translating articles from other languages to English. Articles will be included only if they are relevant to mental health and illness.” (same in the first paragraph of p. 9) p. 10: first paragraph. As before, there is inconsistency of tenses; the preceding sentence to the one copied is in future tense, this one in past (and the one that follows in future): “Again, this round was conducted by MJN with ÉNS, reviewing 10% of papers at this stage of searching also.” I understand that the paper reports a work in progress, but if this is meant to be a protocol, tenses need unification, otherwise it is confusing. p. 12: “rigor will be captured using the Crowe Critical Appraisal Tool” > please provide a brief gloss of this tool, it is not explained. 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 Health communication, recovery, applied linguistics 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) Vilar-Lluch S. Peer Review Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15730.r51644) 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/8-94/v2#referee-response-51644 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Thongsalab D. 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. 25 Dec 2025 | for Version 2 Dr. Jutharat Thongsalab , Boromarajonani College of Nursing Surin, Mueang Surin District, Surin, Thailand 0 Views copyright © 2025 Thongsalab D. 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 Thank you for the revised version of this protocol. The authors have addressed several earlier comments. These changes have clearly enhanced the clarity and structure of the protocol. Some methodological aspects (e.g., proportion of double-screening, inter-rater agreement, and the decision to exclude quantitative studies) could be further strengthened, but these issues do not fundamentally compromise the coherence or feasibility of the proposed realist review. Furthermore, I recommend accepting this protocol. 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) Thongsalab DJ. Peer Review Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15730.r51531) 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/8-94/v2#referee-response-51531 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Poulsen C. 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. 26 Nov 2025 | for Version 2 Chalotte Heinsvig Poulsen , Copenhagen Research Unit for Recovery, Copenhagen, Denmark; Mental Health Center Glostrup, Centre for Applied Research in Mental Health, Mental Health Services, Capital region of denmark, Copenhagen, Denmark 0 Views copyright © 2025 Poulsen C. 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 I can read that you have accommodated my feedback regarding transparency and the positioning of the expert panel and other suggestions. I have no further comments. Competing Interests No competing interests were disclosed. Reviewer Expertise Post doc researcher; Co-production; Peer support; Recovery-oriented research; Development of program theory; Critical realism; Proces evaluation; Randomized controlled trials supplemented by qualitative research about mechanisms of change and context. 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) Poulsen CH. Peer Review Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15730.r51529) 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/8-94/v2#referee-response-51529 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Wong G. 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. 25 Nov 2025 | for Version 2 Geoff Wong , University of Oxford, Oxford, UK 0 Views copyright © 2025 Wong G. 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 Thanks for taking the time to read and consider my comments. As none of the comments I made were major and had to be addressed, I hope you found them helpful. Good luck with your review. Competing Interests No competing interests were disclosed. Reviewer Expertise Realist review / synthesis and realist evaluation. 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) Wong G. Peer Review Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15730.r51530) 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/8-94/v2#referee-response-51530 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Poulsen C. 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. 11 Nov 2025 | for Version 1 Chalotte Heinsvig Poulsen , Copenhagen Research Unit for Recovery, Copenhagen, Denmark; Mental Health Center Glostrup, Centre for Applied Research in Mental Health, Mental Health Services, Capital region of denmark, Copenhagen, Denmark 0 Views copyright © 2025 Poulsen C. 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 Thank you for allowing me to read and peer review this thorough and well-written realist review protocol. The aim is clearly stated as a realist systematic review of qualitative studies focusing on the underlying mechanisms that facilitate the transition from mental distress to wellbeing and personal recovery, as described in the CHIME framework. The methodology is comprehensive, following criteria for realist reviews with a detailed and transparent account of programme theory development, research questions, search strategy, article selection, and reporting. The approach is easy to understand and reproducible for other researchers, and the process is effectively illustrated with the included figures and tables. The authors could benefit from further clarifying the following points: 1) Describe the positions of the author group - are anyone working from a lived experience of mental health recovery perspective? - and/or caregiver perspective? 2) More information about PPI research - the service users in the expert panel - who are they, how were they recruited? How is diversity, equal power sharing, safe and secure user involvement ensured? 3) To which degree was the expert panel involved? - was it user-involvement, co-production or co-creation? 4) How will the program theory iteratively be refined based on emerging data? 5) Do the authors have a plan for managing potential heterogeneity in study contexts and populations, and how will this be addressed in the synthesis? 6) Discussion of potential limitations inherent to realist systematic reviews compared to other types of reviews and how these will be mitigated. 7) Be aware that if the CHIME agronym should be explicitly presented and referred to within the title, abstract and full text - will exclude papers for example the attached paper by Egmose et al. 2024 - exploring the mechanisms of change in a group-based peer support intervention co-produced around the CHIME framework. 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. Egmose C, Poulsen C, Bjørkedal S, Eplov L: The ‘Paths to everyday life’ (PEER) trial – a qualitative study of mechanisms of change from the perspectives of individuals with mental health difficulties participating in peer support groups led by volunteer peers. BMC Psychiatry . 2024; 24 (1). Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Post doc researcher; Co-production; Peer support; Recovery-oriented research; Development of program theory; Critical realism; Proces evaluation; Randomized controlled trials supplemented by qualitative research about mechanisms of change and context. 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 25 Nov 2025 Michael John Norton, Thank you for allowing me to read and peer review this thorough and well-written realist review protocol. The aim is clearly stated as a realist systematic review of qualitative studies focusing on the underlying mechanisms that facilitate the transition from mental distress to wellbeing and personal recovery, as described in the CHIME framework. The methodology is comprehensive, following criteria for realist reviews with a detailed and transparent account of programme theory development, research questions, search strategy, article selection, and reporting. The approach is easy to understand and reproducible for other researchers, and the process is effectively illustrated with the included figures and tables. Response: Thank you for your kind comment. We hope that the amendments made to this paper as a result of your feedback and the feedback of the other peer reviewers enhances the protocol further. The authors could benefit from further clarifying the following points: 1) Describe the positions of the author group - are anyone working from a lived experience of mental health recovery perspective? - and/or caregiver perspective? Response: Thank you for your comment. As per your feedback and the feedback of another reviewer, the positions of the author group are noted as part of stage one of the iterative process of realist reviews. 2) More information about PPI research - the service users in the expert panel - who are they, how were they recruited? How is diversity, equal power sharing, safe and secure user involvement ensured? Response: Thank you for this comment. PPI is central to this proposed research. The principal investigator is a service user himself along with two of the expert panel members. This ensures that the views of service users are central to the creation of this protocol and the subsequent review. As part of the realist review process, the refined IPTs will be presented to the expert panel for approval once data collection is completed. In answering point 1 above, we have already identified the expert panel personal. They were recruited from the principal investigators contacts through his work with the HSE Office of Mental Health Engagement and Recovery – an office that promotes recovery, co-production and service user involvement within mental health service provision. Finally, equal power sharing is ensured as all members of the expert panel have been involved in service user involvement and co-production for a number of years and fully understands the nuances of these processes not just in service provision but also in research. 3) To which degree was the expert panel involved? - was it user-involvement, co-production or co-creation? Response: Thank you for this comment. The expert panel were involved in the process through the co-production of the initial IPTs and will be involved again in the refinement of the IPTs through co-production. 4) How will the program theory iteratively be refined based on emerging data? Response: Thank you for this comment. The protocol outlines the process of how the papers were gathered and how the papers will be reviewed. Part of this process will be drawing out the context, mechanisms and outcomes of all the included papers. These will then be put together by aligning the new IPTs to the various elements of CHIME to see what refined IPTs relate to each concept and which concepts intertwine with each other. Additionally, these refined IPTs will be compared to the original IPTs that were co-produced with the expert panel to identify if what we found matches with these original IPTs. To further support this. The IPTs will refer to micro [personal], meso [service] and macro [system] factors and as such, these IPTs will be placed along this continuum with a diagram visually depicting this. This will then be brought to the expert panel for approval and once approved, write up of the realist review will commence. 5) Do the authors have a plan for managing potential heterogeneity in study contexts and populations, and how will this be addressed in the synthesis? Response: Thank you for this comment. This query is answered through point 4 above. We do anticipate heterogeneity in context and populations but this will be demonstrated through aligning the IPTs to a micro, meso and macro perspective where contexts in terms of individual, service or system will be demonstrated. This heterogeneity will also be visually demonstrated. 6) Discussion of potential limitations inherent to realist systematic reviews compared to other types of reviews and how these will be mitigated. Response: Thank you for this comment. This review differs from systematic reviews and scoping reviews as it is theory heavy, and the focus is on looking for potential mechanisms rather than examining potential depth and breadth of the literature base. This does raise questions of potential bias but this is mitigated because the focus is on developing mechanisms rather than elimination of bias. 7) Be aware that if the CHIME agronym should be explicitly presented and referred to within the title, abstract and full text - will exclude papers for example the attached paper by Egmose et al. 2024 - exploring the mechanisms of change in a group-based peer support intervention co-produced around the CHIME framework. Response: Thank you for this comment. We are aware that focusing on CHIME in these areas will exclude paper. However, as noted in point 6 the focus is on finding mechanisms, not on ensuring that the breadth/depth of literature is achieved. View more View less Competing Interests None reply Respond Report a concern Poulsen CH. Peer Review Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15583.r50797) 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/8-94/v1#referee-response-50797 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Wong G. 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. 27 Oct 2025 | for Version 1 Geoff Wong , University of Oxford, Oxford, UK 0 Views copyright © 2025 Wong G. 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 Overall comments: The manuscript is clearly written and a coherent explanation is provided for the use of a realist review approach. Major comments: None. Minor comments: As this is a realist review, in your manuscript you may want to consider only using the word "mechanism" when you specifically mean it in a realist sense of the word - i.e. as a hidden, context-sensitive causal force. When reference is first made about the RAMESES I guidelines, there is mention of these standards being used to "guide the review itself and not its execution." I'm not quite sure what this means. The references 30 and 31 refer to the RAMESES publication standards for realist syntheses and so should be used to guide the reporting of realist syntheses (or reviews - the terms are synonymous). If guidance is needed for the conduct of realist syntheses, the the reference used should be: Wong G, Greenhalgh T, Westhorp G, Pawson R. Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project. Health Soc Care Deliv Res 2014;2(30). [Reference 1] When programme theory is mentioned in step 1, it is worth remembering that a programme theory is both a theory of change, and a theory of implementation / action. See either the RAMESES training materials for realist syntheses:https://www.ramesesproject.org/pgm-download_media.php?name=Realist_reviews_training_materials.pdf or here: https://www.ramesesproject.org/pgm-download_media.php?name=RAMESES_II_Theory_in_realist_evaluation.pdf The steps proposed for the realist review make sense. In step 1, a reasonable process has been undertaken to develop the CMO configurations that will populate the initial programme theory. These initial CMO configurations seem to me a reasonable first stab at providing causal explanations. Based on the details provided, the searches seem sensible and likely to find relevant data. Explanations are provided for the exclusion criteria what will be used. These on the whole make sense, though, you may want to reconsider excluding quantitative papers as these may provide 'nuggets' of relevant data that enable you to achieve a better degree of consilience. I am no content expert, but if the seminal papers for CHIME were published in 2011, there may be relevant papers published just before 2011. Hence, if you have not done so, it may be worth checking if setting the cut off 2 to 3 years earlier might yield any relevant papers. Whilst I can understand t-your rationale for excluding reviews, do consider citation tracking from the reviews - as this may be a means of identifying further relevant documents. In step 3, the selection and appraisal process makes sense. The three questions you propose seem a bit like overkill as relevance can be considered as whether a document has data that can contribute to realist programme theory in some way (e.g. to inform CMOCs, their relationships to each other or an aspect of the programme theory). You have not mentioned appraisal of rigour. On this issue you may find the second half of this book chapter of use: Data gathering for realist reviews: Looking for needles in haystacks. Wong G. In: Emmel N, Greenhalgh J, Manzano A, Monaghan M, Dalkin S, editors. Doing Realist Research. London: Sage, 2018 [Reference 2] In Step 4, I am not sure that it is ever as clean cut as to claim "In general, the introduction of citations will identify the context, the results of these same citations will identify the outcome, and the discussion of the text will help identify the mechanism.". You are likely to find that relevant data may come from any part of a document. Hence some flexibility in where you draw your data from will likely be needed. In your data extraction tool, you may not be able to find data that is specifically about context, mechanism or outcome. This is because such data on each of these concepts may not be present in one single document. And, it is challenging to be able to claim that something is functioning as context or mechanism, unless you can identify in which CMOC it is operating in. In other words, you can only infer that something is functioning as a context or mechanism if you know what the outcome it is related to. With regard to the use of the Crowe Critical Appraisal Tool, I presume you are planning to use it to appraise rigour and not relevance? If so, do consider reading the Data gathering for realist reviews book chapter that I have mentioned above, as following the process outlined in that book chapter may save you a lot of time and effort. In step 5 consider revising this sentence " all in an attempt to refine the initial programme theories into middle-range theories", because middle-range theory is not a type of theory, but more a description of the level of abstraction of a theory. See: https://www.ramesesproject.org/pgm-download_media.php?name=RAMESES_II_Theory_in_realist_evaluation.pdf In this step, you have not provided much detail on how you will develop the causal explanations (i.e. CMOCs) and programme theory. Whilst this is not necessarily needed in a protocol, you should ensure you provide such details for your PhD. There is no one set process you have to use to make sense of data, mainly because we all 'think' differently. But any process you use should be coherent, clearly explained and also used systematically. 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. Wong G, Greenhalgh T, Westhorp G, Pawson R: Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project. Health Services and Delivery Research . 2014; 2 (30): 1-252 Publisher Full Text 2. Wong G: Data Gathering in Realist Reviews: Looking for needles in haystacks. 2018. 131-146 Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Realist review / synthesis and realist evaluation. 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 24 Nov 2025 Michael John Norton, The manuscript is clearly written and a coherent explanation is provided for the use of a realist review approach. Response: Thank you for this comment. We hope that the amendments made as per your suggestions below will improve the overall usefulness of the protocol for our review. As this is a realist review, in your manuscript you may want to consider only using the word "mechanism" when you specifically mean it in a realist sense of the word - i.e. as a hidden, context-sensitive causal force. Response: Thank you for your comment. We have reread the protocol and have only used mechanisms when referring to a hidden, context-sensitive causal force as suggested. When reference is first made about the RAMESES I guidelines, there is mention of these standards being used to "guide the review itself and not its execution." I'm not quite sure what this means. The references 30 and 31 refer to the RAMESES publication standards for realist syntheses and so should be used to guide the reporting of realist syntheses (or reviews - the terms are synonymous). If guidance is needed for the conduct of realist syntheses, the reference used should be: Wong G, Greenhalgh T, Westhorp G, Pawson R. Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project. Health Soc Care Deliv Res 2014;2(30). Response: Thank you for your comment. We have reviewed the text in question and have amended same accordingly. We have also inserted your reference to strengthen the claims made. When programme theory is mentioned in step 1, it is worth remembering that a programme theory is both a theory of change, and a theory of implementation / action. See either the RAMESES training materials for realist syntheses: WEBSITE.pdf Response: Thank you for this comment. We have added a sentence to acknowledge this in the revised protocol. The steps proposed for the realist review make sense. Response: Thank you for this comment. In step 1, a reasonable process has been undertaken to develop the CMO configurations that will populate the initial programme theory. These initial CMO configurations seem to me a reasonable first stab at providing causal explanations. Response: Thank you for this comment. Based on the details provided, the searches seem sensible and likely to find relevant data. Explanations are provided for the exclusion criteria what will be used. These on the whole make sense, though, you may want to reconsider excluding quantitative papers as these may provide 'nuggets' of relevant data that enable you to achieve a better degree of consilience. Response: Thank you for your comment. We have excluded quantitative studies as personal recovery is a subjective process that cannot be adequately captured through positivist, quantitative means. Additionally, quanitative research lacks contextual depth and given that realist reviews aim to answer questions relating to why, how and under what circumstances a mechanism occurs, it was deemed inappropriate to include quanitative studies. I am no content expert, but if the seminal papers for CHIME were published in 2011, there may be relevant papers published just before 2011. Hence, if you have not done so, it may be worth checking if setting the cut off 2 to 3 years earlier might yield any relevant papers. Response: Thank you for also raising this comment. We restricted the inclusion/exclusion criteria to post 2011 studies for two reasons. Firstly, CHIME was constructed in a 2011 paper from Mary Leamy and colleagues in the UK and as a result, this review is looking for papers that include all elements of CHIME. Secondly, we also excluded pre-2011 studies as these would have been captured by the original systematic review method conducted by Leamy et al. when they carried out their review. As such, it was deemed unnecessary to include pre-2011 research studies. Whilst I can understand your rationale for excluding reviews, do consider citation tracking from the reviews - as this may be a means of identifying further relevant documents. Response: Thank you for your comment. We are unable to conduct citation chaining for this review as we are now presently finalising extraction and commencing write up of the actual realist review. However, we will endeavour to include in our methodology that citation chaining was recommended but was unable to be carried out due to the phase of the review where reviewers were at when your peer review comment was made. In step 3, the selection and appraisal process makes sense. The three questions you propose seem a bit like overkill as relevance can be considered as whether a document has data that can contribute to realist programme theory in some way (e.g. to inform CMOCs, their relationships to each other or an aspect of the programme theory). Response: Thank you for this comment. We have reviewed the text based on your feedback and revised it accordingly. You have not mentioned appraisal of rigour. On this issue you may find the second half of this book chapter of use: Data gathering for realist reviews: Looking for needles in haystacks. Wong G. In: Emmel N, Greenhalgh J, Manzano A, Monaghan M, Dalkin S, editors. Doing Realist Research. London: Sage, 2018 Response: Thank you for this comment. We have addressed appraisal of rigor through step 4 of the realist review process. In Step 4, I am not sure that it is ever as clean cut as to claim "In general, the introduction of citations will identify the context, the results of these same citations will identify the outcome, and the discussion of the text will help identify the mechanism.". You are likely to find that relevant data may come from any part of a document. Hence some flexibility in where you draw your data from will likely be needed. Response: Thank you for this comment. We have reviewed the piece of text highlighted and decided to remove the highlighted text. In your data extraction tool, you may not be able to find data that is specifically about context, mechanism or outcome. This is because such data on each of these concepts may not be present in one single document. And, it is challenging to be able to claim that something is functioning as context or mechanism, unless you can identify in which CMOC it is operating in. In other words, you can only infer that something is functioning as a context or mechanism if you know what the outcome it is related to. Response: Thank you for this comment. We have made note of this and included it under stage 4 of the realist review process within the discussions around the data extraction tool. With regard to the use of the Crowe Critical Appraisal Tool, I presume you are planning to use it to appraise rigour and not relevance? If so, do consider reading the Data gathering for realist reviews book chapter that I have mentioned above, as following the process outlined in that book chapter may save you a lot of time and effort. Response: Thank you for this comment. Yes, we plan to use it to appraise rigour and not relevance as previously stated. Thank you for your suggested reading, however, we are unable to implement it as we are already finalising data extraction and appraisal for the realist review itself at this time. In step 5 consider revising this sentence " all in an attempt to refine the initial programme theories into middle-range theories", because middle-range theory is not a type of theory, but more a description of the level of abstraction of a theory. See: WEBSITE.pdf Response: Thank you for this comment. We have revised this sentence based on your suggestion and have reviewed the remainder of the document to remove any reference to middle-ranged theory. In this step, you have not provided much detail on how you will develop the causal explanations (i.e. CMOCs) and programme theory. Whilst this is not necessarily needed in a protocol, you should ensure you provide such details for your PhD. There is no one set process you have to use to make sense of data, mainly because we all 'think' differently. But any process you use should be coherent, clearly explained and also used systematically. Response: Thank you for this comment. We will keep this in mind for the actual realist review paper as suggested. View more View less Competing Interests None reply Respond Report a concern Wong G. Peer Review Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15583.r50799) 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/8-94/v1#referee-response-50799 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Thongsalab D. 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. 30 Sep 2025 | for Version 1 Dr. Jutharat Thongsalab , Boromarajonani College of Nursing Surin, Mueang Surin District, Surin, Thailand 0 Views copyright © 2025 Thongsalab D. 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 Thank you for the opportunity to review this interesting and timely protocol. The topic is important and relevant for advancing recovery-oriented mental health research. The paper is well-structured and demonstrates strong potential. I provide the following comments to strengthen clarity, methodological rigor, and practical contribution. - I recommended that the author support the gap statement by systematically highlighting what CHIME research has achieved (measurement, validation, intervention use) and what remains unexplored (mechanisms, context-specific functioning). - The introduction part lacks a sharp demonstration of the evidence gap, a critical comparison with other review types, and a clear link to practice implications. Strengthening these aspects will make justification more persuasive. - The methods section is full and clear in structure but would benefit from greater rigor in evidence appraisal, inclusion criteria, extraction reliability, and analytic strategy. With these refinements, the review will be more credible and reproducible. - Step I, the author should clarify procedures for iterative refinement, include safeguards against confirmation bias, and discuss diversity/independence of the advisory panel. - Step II, Exclusion of quantitative studies is restrictive; yet some quantitative work (e.g., mediation, SEM, longitudinal studies) could inform mechanisms. Restricting to post-2011 excludes potentially relevant pre-CHIME conceptualizations that could enrich theory building. Reconsider exclusion of quantitative studies, broaden the grey literature strategy, and justify more clearly the 2011 cutoff. - Step III, Screening and appraisal are described (three rounds; Covidence; 10% double-screening). Appraisal using “relevance, rigor, richness” is conceptually valid but subjective; no plan for handling disagreements or measuring inter-rater agreement. Therefore, increase the proportion of double-screening, consider structured appraisal checklists (e.g., CASP, RAMESES appraisal tool), and report inter-rater reliability (e.g., Cohen’s κ). - Step IV doesn’t specify whether pilot testing of the extraction form will be done. Reliance on a single reviewer (MJN) for extraction, with supervisory oversight, carries a risk of bias. - Step V, the process described could produce descriptive categories rather than true realist synthesis. Explicitly describe the use of retroductive reasoning, provide examples of how initial CMOs will evolve into middle-range theories, and consider external validation beyond the author panel. - Step VI, add transparency on how independence of critique will be preserved, and describe dissemination beyond academic journals (e.g., co-produced outputs for service users). - Figure 2 uses “Inductive Reflexive Thematic Analysis” under synthesis. This terminology is more common in qualitative research, but realist reviews emphasize retroductive reasoning and CMO refinement. - The current wording may mislead readers about analytic methods. This figure presents the steps as linear, but realist reviews are inherently iterative (moving back and forth between theory building, searching, and refinement). This could misrepresent the cyclical nature of realist reviews. Some steps (e.g., “Upload onto NVivo for Analysis”) are tool-specific, which may not apply universally and make the figure feel like a workflow chart rather than a generalizable method. Meanwhile, other important elements (e.g., stakeholder engagement, retroductive reasoning, theory testing vs. refinement) are missing. Advisory panel engagement should appear not just at the start, but also during synthesis/validation. - Table 1 provides a useful but overly simplistic starting point for realist program theory development. It will benefit if you clarify distinctiveness by ensuring each CHIME domain’s If…The statement highlights unique mechanisms. Add one illustrative case or a brief exemplary per domain to ground the theory. - Table 2 shows the evolution into draft CMOs. I recommend improvement for it. The context should add diversity in settings (community vs. inpatient), roles (peer vs. clinician support), and cultural/systemic factors. Mechanisms should frame them as resources + reasoning (what is offered + how it is interpreted), e.g., “Access to peer groups (resource) triggers recognition of shared experience (reasoning)”. Outcomes should be more diverse by going beyond re-stating mechanisms, e.g., linking hope, such as increased engagement, reduced suicidality, and improved functioning. - Table 3 remains too generic, tautological, and individual-focused. With richer contextualization, sharper mechanism articulation, and more concrete outcomes, it could provide a robust foundation for theory testing in the review. - Table 4-6, Search strings like “Mental Health” OR “Mental Disorders” yield millions of hits (e.g., 6.5M in PubMed). This risks irrelevance and screening overload. It might indicate poor precision in early steps. Lack of Grey Literature Strategy in These Tables. Excluding pre-2011 studies may miss early CHIME conceptual development or precursors. Needs a stronger justification than “CHIME was published in 2011. - Table 7, please reconsider including quantitative studies that explore mechanisms (e.g., mediation, regression, factor analysis). Provide a rationale for excluding dual diagnosis/addiction populations or consider including them with sensitivity analysis. Is the rationale for, and objectives of, the study clearly described? Partly 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? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Psychiatric and Mental Health Nursing; Recovery-Oriented Care; Nursing Research Methods; Systematic and Review Methodology. 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 24 Nov 2025 Michael John Norton, Thank you for the opportunity to review this interesting and timely protocol. The topic is important and relevant for advancing recovery-oriented mental health research. The paper is well-structured and demonstrates strong potential. Response: Thank you for your comment. We hope that the amendments made to this paper will strengthen it further. I provide the following comments to strengthen clarity, methodological rigor, and practical contribution. Response: Thank you for this. We hope that the amendments the authorship team have accepted will have strengthened the paper further. I recommended that the author support the gap statement by systematically highlighting what CHIME research has achieved (measurement, validation, intervention use) and what remains unexplored (mechanisms, context-specific functioning). Response: Thank you for this comment. We have adjusted the rationale for realist review section to incorporate this comment. The introduction part lacks a sharp demonstration of the evidence gap, a critical comparison with other review types, and a clear link to practice implications. Strengthening these aspects will make justification more persuasive. Response: Thank you for this comment. The introduction has been sharpened to include the evidence gap and comparison with other review types along with a clearer link been made to practice implications. The methods section is full and clear in structure but would benefit from greater rigor in evidence appraisal, inclusion criteria, extraction reliability, and analytic strategy. With these refinements, the review will be more credible and reproducible. Response: Thank you for this comment. We are not trying to produce a systematic review which would rely on reproducibility. We are instead utilising a realist review methodology to uncover mechanisms. Although the search was rigorous, it does not need to be of the same standard as a systematic review where your concerns are of extreme importance. The evidence appraisal method has been taken and adopted from previous realist reviews which utilise this method. The inclusion criteria are robust given the review method. We believe you have commented on some of the other aspects of the inclusion criteria below, which we will address then. The extraction process follows a realist method and the analytic process is suitable, given the review type. Step I, the author should clarify procedures for iterative refinement, include safeguards against confirmation bias, and discuss diversity/independence of the advisory panel. Response: Thank you for your comment. Given the review type, safeguards against confirmation bias is not necessary. In regard to the diversity and independence of the advisory panel, the text now discusses these in step 1 of the realist review process. Step II, Exclusion of quantitative studies is restrictive; yet some quantitative work (e.g., mediation, SEM, longitudinal studies) could inform mechanisms. Response: Thank you for raising this comment. A conscious decision was made to exclude quantitative studies as personal recovery is a subjective experience that cannot be captured adequately through positivist quantitative means. In addition, quantitative research lacks contextual depth and given that realist reviews aim to demonstrate how, why and under what circumstances a mechanism operates, the inclusion of quanitative studies was deemed inappropriate. Restricting to post-2011 excludes potentially relevant pre-CHIME conceptualizations that could enrich theory building. Response: Thank you for also raising this comment. We restricted the inclusion/exclusion criteria to post 2011 studies for two reasons. Firstly, CHIME was constructed in a 2011 paper from Mary Leamy and colleagues in the UK and as a result, this review is looking for papers that include all elements of CHIME. Secondly, we also excluded pre-2011 studies as these would have been captured by the original systematic review method conducted by Leamy et al. when they carried out their review. As such, it was deemed unnecessary to include pre-2011 research studies. Reconsider exclusion of quantitative studies, broaden the grey literature strategy, and justify more clearly the 2011 cutoff. Response: Thank you for this comment. The rationale for excluding quantitative studies have been mentioned above. A couple of sentences has been added to describe the grey literature search mechanisms. The justification for the 2011 cutoff has been discussed above. Step III, Screening and appraisal are described (three rounds; Covidence; 10% double-screening). Appraisal using “relevance, rigor, richness” is conceptually valid but subjective; no plan for handling disagreements or measuring inter-rater agreement. Therefore, increase the proportion of double-screening, consider structured appraisal checklists (e.g., CASP, RAMESES appraisal tool), and report inter-rater reliability (e.g., Cohen’s κ). Response: Thank you for this comment. Given the theory focus of realist reviews, appraisal with relevance, rigor and richness is the noted procedure to appraise papers included in this realist review. A sentence has been added to this section to state the procedure if a disagreement between MJN and ÉNS occurs. The appraisal of included paper is discussed in stage four of the process, but as already stipulated above, the Crowe Critical appraisal Tool was used due to its continuous utilisation in other realist reviews published in the literature. Given the qualitative nature of this review, reporting inter-rater reliability is not necessary. Step IV doesn’t specify whether pilot testing of the extraction form will be done. Reliance on a single reviewer (MJN) for extraction, with supervisory oversight, carries a risk of bias. Response: Thank you for this comment. A sentence or two has been added to stage four to reflect this. As noted above, this review will not be a systematic review and as such, yes, bias is more likely to be present, but in qualitative research bias is countered by strong reflexivity. However, the review is more concerned with the construction of mechanisms rather than bias as realist reviews are theory heavy. Step V, the process described could produce descriptive categories rather than true realist synthesis. Explicitly describe the use of retroductive reasoning, provide examples of how initial CMOs will evolve into middle-range theories, and consider external validation beyond the author panel. Response: Thank you for this comment. Although we acknowledge your comment, we disagree with the statement that the process as outlined in stage 5 could produce descriptive categories. The process outlined in stage 5 is to support the development of refined initial programme theories and not the creation of middle-range programme theories which actually would require a realist evaluation in order for this to occur. External validation will occur through the expert panel as these are national experts on the implementation of CHIME into Irish services – where the overarching study is based. The review does not have funding to include international experts in the field. Stage 5 already discusses the retroductive reasoning to create refined IPTs. However, a sentence has been added to make this more visual. Step VI, add transparency on how independence of critique will be preserved, and describe dissemination beyond academic journals (e.g., co-produced outputs for service users). Response: The dissemination beyond academic journals is already described at the end of stage 6: “ In addition, the results of this proposed realist review may also be presented through other means, including conferences and recovery workshops delivered by recovery college personnel. This will be made possible through the Recovery and Engagement Programme Manager in charge of the recovery education workstream of MHER.” Reporting bias will be contained through a process of reflexivity and journaling as the realist review process unfolds. This will be further noted in stage 6 of the process. Figure 2 uses “Inductive Reflexive Thematic Analysis” under synthesis. This terminology is more common in qualitative research, but realist reviews emphasize retroductive reasoning and CMO refinement. Response: Thank you for this comment. The wording of Figure 2 has been reworded to reflect your suggestion. The current wording may mislead readers about analytic methods. This figure presents the steps as linear, but realist reviews are inherently iterative (moving back and forth between theory building, searching, and refinement). This could misrepresent the cyclical nature of realist reviews. Some steps (e.g., “Upload onto NVivo for Analysis”) are tool-specific, which may not apply universally and make the figure feel like a workflow chart rather than a generalizable method. Meanwhile, other important elements (e.g., stakeholder engagement, retroductive reasoning, theory testing vs. refinement) are missing. Advisory panel engagement should appear not just at the start, but also during synthesis/validation. Response: These amendments to Figure 2 have now been made. Thank you for reminding us to include these elements in the Figure and for your guidance regarding the cyclical nature of realist reviews which should now be demonstrated in Figure 2. Table 1 provides a useful but overly simplistic starting point for realist program theory development. It will benefit if you clarify distinctiveness by ensuring each CHIME domain’s If…Then statement highlights unique mechanisms. Add one illustrative case or a brief exemplary per domain to ground the theory. Response: Thanks for this comment. Although we respect your perspective regarding table 1, we find it important to include as is as this demonstrates to you, the reader/reviewer where the review started from. The If… then… statements as they stand do show each element of the CHIME framework but at this point the if… then… statements may not have a clear mechanism attached. This comes with further refinement of the if… then… statements into initial IPTs. We also think an illustrative case or brief exemplary per domain is not required as these domains are already well documented in the existing literature. Table 2 shows the evolution into draft CMOs. I recommend improvement for it. The context should add diversity in settings (community vs. inpatient), roles (peer vs. clinician support), and cultural/systemic factors. Mechanisms should frame them as resources + reasoning (what is offered + how it is interpreted), e.g., “Access to peer groups (resource) triggers recognition of shared experience (reasoning)”. Outcomes should be more diverse by going beyond re-stating mechanisms, e.g., linking hope, such as increased engagement, reduced suicidality, and improved functioning. Response: Thank you for this comment. This suggestion has been utilised in the actual realist review itself. However, although acknowledging the usefulness of the stated way to create IPTs, at this stage, due to advancement of the review process itself, making these amendments is now deemed impossible. However, the authors would like to thank you for raising this comment and wish to reassure you that this will be added to the review itself and be noted in the supplementary material as a deviation from the present protocol. Table 3 remains too generic, tautological, and individual-focused. With richer contextualization, sharper mechanism articulation, and more concrete outcomes, it could provide a robust foundation for theory testing in the review. Response: Thank you for this comment. The IPTs within table 3 cannot be changed as these IPTs have been approved by the expert panel to test within the actual realist review. However, what you have commented on is actually taking place within the review itself. Table 4-6, Search strings like “Mental Health” OR “Mental Disorders” yield millions of hits (e.g., 6.5M in PubMed). This risks irrelevance and screening overload. It might indicate poor precision in early steps. Lack of Grey Literature Strategy in These Tables. Excluding pre-2011 studies may miss early CHIME conceptual development or precursors. Needs a stronger justification than “CHIME was published in 2011. Response: Thank you for this comment. Table 4-6 were developed with the expertise of a librarian. Although we acknowledge your concern, we have already reached a stage in the review where we are extracting IPTs from included paper. As such, this comment can no longer be actioned upon. As noted above, a sentence or two has been added to state the process of grey literature searching as described by Godin and colleagues. A justification for excluding pre-2011 data has already been provided in the comments above. Table 7, please reconsider including quantitative studies that explore mechanisms (e.g., mediation, regression, factor analysis). Provide a rationale for excluding dual diagnosis/addiction populations or consider including them with sensitivity analysis. Response: Thank you for this comment. A justification has already been given as to why quantitative studies were excluded from this review. A rationale for excluding dual diagnosis/addiction populations has already been noted in the review. Here it states that they were excluded “… because of the difficulties in distinguishing changes relating and not relating to mental health and illness alone .” View more View less Competing Interests None reply Respond Report a concern Thongsalab DJ. Peer Review Report For: Understanding the Mechanisms that Operate within CHIME: A Realist Review Protocol [version 2; peer review: 4 approved] . HRB Open Res 2025, 8 :94 ( https://doi.org/10.21956/hrbopenres.15583.r49952) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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