Successful implementation in health care depends on understanding that interventions operate within complex adaptive systems shaped by context, relationships, and power. Lived experience perspectives provide critical insights into contextual determinants that influence implementation success, such as barriers, facilitators, and sociocultural dynamics. However, lived experience engagement is often inconsistently operationalized and insufficiently theorized within implementation research.Inclusive implementation begins with an equitable research design and continues through intervention development, the selection of implementation strategies, and the evaluation of implementation outcomes. Embedding lived experience across these stages may trigger mechanisms that increase the likelihood of improved acceptability, feasibility, fidelity, and sustainability, while strengthening relevance and reach across populations and settings.This paper presents a principle-based, realist-informed approach to integrating lived experience into implementation science. Drawing on established frameworks, including the Consolidated Framework for Implementation Research (CFIR), i-PARIHS, RE-AIM, and Proctor's implementation outcomes, the paper conceptualizes lived experience engagement as a context-sensitive process. This process introduces resources capable of triggering mechanisms that operate through three generative principles: navigating power, building relational resilience, and adopting a learning mindset. We propose that these mechanisms are activated through evidence-informed implementation strategies such as shared governance, facilitation, equitable remuneration, capacity-building, and iterative learning cycles.Evaluation of lived experience engagement is essential for understanding whether inclusive approaches lead to meaningful change. This requires examining processes within the research group, external influences, and broader system-level factors. Evaluating lessons learned, impact achieved, and long-term sustainability ensures that lived experience engagement contributes not only to better implementation, but also to more equitable and effective health care. SPANISH ABSTRACT:http://links.lww.com/IJEBH/A598.

Introduction: Providers of medical degree programs need to ensure that graduates represent the diverse communities they serve. Disabled students face barriers to accessing and completing medical programs. As the call for a more inclusive and supportive medical education culture grows internationally, it is essential to understand the perspectives of disabled medical students in Australasia. To inform the ongoing discussion concerning inclusive medical education, this study aimed to describe disabled medical students’ experiences regarding the inclusive culture of a medical degree program at a University in New Zealand. Methods: Semi-structured interviews and a “writing” story-elicitation activity were conducted with five participants who self-identified as experiencing disability and who were enrolled in a medical degree program. Interviews were between 1 and 1.5 hours, transcribed verbatim and subject to narrative analysis. Results: Data are presented through three archetype participant narrative summaries preceding three overarching themes. Participants generally reported experiencing passive allyship regarding disability and received support from staff, students and disability support services. However, they also recounted instances where their disabilities were negatively framed and stigmatised as hindrances. These experiences led to a reluctance to disclose further needs, with participants feeling that accommodating their disabilities was solely their responsibility. They expressed a desire for the medical school to proactively create opportunities and spaces to normalise and validate the needs of disabled students. Conclusion: Findings illustrate how medical programs can better position themselves as proactive allies by creating opportunities for disabled students, thereby better reflecting society’s diversity.

This manuscript considers the drivers towards inclusive research in the field of disability and rehabilitation; including some of the tools and frameworks that may support its realisation. We, a group of researchers engaged in rehabilitation research from lived experience and ‘conventional’ (non-lived experience) positions, reflect on our collective endeavours to bring about inclusion in research and specify the systemic factors constraining inclusion in research. We conclude by asking the following: how might we reimagine systems where the mechanisms of research production are in the hands of those impacted by the research, and where are intersectionalities both sought and valued?

Background: There is a lack of consumer-friendly tools to empower and support people living with spinal cord injury (SCI) to self-manage complex health needs in community. This article describes the co-design process of the new SCI Health Maintenance Tool (SCI-HMT). Methods: Co-design of the SCI-HMT using a mixed-methods approach included a rapid review, e-Delphi surveys with range of multidisciplinary health care professionals (n = 62), interviews of participants with SCI (n = 18) and general practitioners (n = 4), focus groups (n = 3 with 7, 4, and 4 participants with SCI, respectively), design workshops with stakeholders (n = 11, 8), and end-user testing (n = 41). Results: The SCI-HMT (healthmaintenancetool.com) was developed based on participatory research with data synthesis from multiple sources. Five priority health maintenance issues for bladder, bowel, skin, pain, and autonomic dysreflexia were originally covered. Best practice recommendations, red flag conditions, referrals, and clinical pathways were agreed on through an e-Delphi technique. Qualitative analysis identified six broad key concepts for self-management, including early symptom recognition, role of SCI peers, knowledge sharing with primary care, general practitioners as gatekeepers, and shared decision-making and highlighted a need to place much stronger emphasis on mental health and well-being. Design workshops and end-user testing provided key insights about user experience, functionality, and content for the SCI-HMT. Conclusion: The co-design process engaging end users, including people with SCI and general practitioners, enabled a shared understanding of the problem and identification of important needs and how to meet them. Informed by this process, the SCI-HMT is a freely accessible resource supporting SCI self-management, shared decision-making, and early problem identification.

Moving from participatory approaches incorporating co-design to co-production in health research involves a commitment to full engagement and partnership with people with lived experience through all stages of the research process—start to finish. However, despite the increased enthusiasm and proliferation of research that involves co-production, practice remains challenging, due in part to the lack of consensus on what constitutes co-production, a lack of guidance about the practical steps of applying this approach in respect to diverse research methods from multiple paradigms, and structural barriers within academia research landscape. To navigate the challenges in conducting co-produced research, it has been recommended that attention be paid to focusing and operationalising the underpinning principles and aspirations of co-production research, to aid translation into practice. In this article, we describe some fundamental principles essential to conducting co-production research (sharing power, relational resilience, and adopting a learning mindset) and provide tangible, practical strategies, and processes to engage these values. In doing so, we hope to support rehabilitation researchers who wish to engage in co-production to foster a more equitable, ethical, and impactful collaboration with people with lived experience and those involved in their circle of care.

PURPOSE:Many disabled people require support workers to complete personal care, daily tasks and participate in life roles. Due to the intimate nature of community disability support in domestic environments, understanding what facilitates positive relationships is paramount. We examined the intricate interplay of context and mechanisms that drive positive relationship outcomes for disabled people, their family members and support workers. METHODS:A realist-informed, participatory methodology involving three participant groups: disabled people, family members, and disability support workers. RESULTS:Sixteen participants participated in two workshops per group (5 disabled people, 5 family members, and 6 disability support workers). All three participant groups prioritised three key generative mechanism processes involved in positive relationship outcomes: (1) having clear communication, (2) building trust, and (3) developing a sense of flow. We describe how each mechanism manifested in a unique way for each group, and also how the activation of each mechanism was influenced by a dynamic resources/tensions balance specific to each group. CONCLUSION:We describe the interaction between three mechanism processes involved in triadic relationships between disabled people, family members, and support workers. Attention is now required to explore strategies to negotiate the resource/tension balance particular to each group.

BACKGROUND:Despite advances in managing secondary health complications after spinal cord injury (SCI), challenges remain in developing targeted community health strategies. In response, the SCI Health Maintenance Tool (SCI-HMT) was developed between 2018 and 2023 in NSW, Australia to support people with SCI and their general practitioners (GPs) to promote better community self-management. Successful implementation of innovations such as the SCI-HMT are determined by a range of contextual factors, including the perspectives of the innovation recipients for whom the innovation is intended to benefit, who are rarely included in the implementation process. During the digitizing of the booklet version of the SCI-HMT into a website and App, we used the Consolidated Framework for Implementation Research (CFIR) as a tool to guide collection and analysis of qualitative data from a range of innovation recipients to promote equity and to inform actionable findings designed to improve the implementation of the SCI-HMT.METHODS:Data from twenty-three innovation recipients in the development phase of the SCI-HMT were coded to the five CFIR domains to inform a semi-structured interview guide. This interview guide was used to prospectively explore the barriers and facilitators to planned implementation of the digital SCI-HMT with six health professionals and four people with SCI. A team including researchers and innovation recipients then interpreted these data to produce a reflective statement matched to each domain. Each reflective statement prefaced an actionable finding, defined as alterations that can be made to a program to improve its adoption into practice.RESULTS:Five reflective statements synthesizing all participant data and linked to an actionable finding to improve the implementation plan were created. Using the CFIR to guide our research emphasized how partnership is the key theme connecting all implementation facilitators, for example ensuring that the tone, scope, content and presentation of the SCI-HMT balanced the needs of innovation recipients alongside the provision of evidence-based clinical information.CONCLUSIONS:Understanding recipient perspectives is an essential contextual factor to consider when developing implementation strategies for healthcare innovations. The revised CFIR provided an effective, systematic method to understand, integrate and value recipient perspectives in the development of an implementation strategy for the SCI-HMT.TRIAL REGISTRATION:N/A.

Societal culture, space, and structure have been unprecedentedly disrupted during the COVID-19 pandemic creating disproportionate vulnerability for disabled people. However, the upheaval of many societal conditions has presented enabling opportunities for disabled people. We report on interviews with 30 disabled people during the first four-week Aotearoa New Zealand COVID-19 lockdown. Three key themes were interpreted: "I am experiencing less disability on a daily basis," encapsulating the experience of reduced disabling barriers for participants; "Working from home: the flexibility I have been asking for," summarizing the benefits of functioning in an enabling home/work space; and "Social connection opportunities are the same for everyone," overviewing participants reports that online opportunities presented a greater sense of belonging than before lockdown. Study findings highlight that despite a constant fear of the negative impact posed by COVID-19, there were numerous opportunities to reduce ablism through applying empowering factors inherent in novel cultural spaces.

STUDY DESIGN:Qualitative study using realist review. OBJECTIVES:To conceptualise how Early Intervention Vocational Rehabilitation (EIVR) functions within inpatient multidisciplinary contexts during spinal cord injury (SCI) rehabilitation. SETTING:New Zealand Spinal Unit. METHODS:People with newly acquired SCI and members of their rehabilitation team were observed in a range of rehabilitation sessions, team meetings and therapeutic interactions. Participants were also interviewed to explore how EIVR functioned alongside the multidisciplinary team (MDT). Interviews and observations were transcribed, coded and analysed using realist methods. RESULTS:We identified three primary contexts which influenced how EIVR was delivered within the MDT: (1) a united approach, (2) a flexible approach, and (3) a hesitant approach. These contexts generated four work-related outcomes for people with SCI; enhanced work self-efficacy, strengthened hope for work, maintained work identity, and the less desirable outcome of increased uncertainty about work. CONCLUSIONS:To optimise work outcomes for people after SCI, it is important to consider how EIVR is delivered and integrated within the wider MDT. Such an understanding can also inform the establishment of new EIVR services in different settings. Results suggest that unity, flexibility and clarity between EIVR services and the wider MDT are essential foundations for supporting people with SCI on their journey to employment. SPONSORSHIP:This research was funded by Health Research Council NZ grant in partnership with Canterbury District Health Board.

Purpose Early intervention vocational rehabilitation (EIVR) can improve return to work (RTW) outcomes for people with spinal cord injury (SCI). However, mechanisms explaining how and why EIVR works are not well understood. This study aims to develop a conceptual framework describing key mechanisms of EIVR intervention effect following SCI. Methods We synthesised data from a realist literature review with data from interviews of people with SCI (n = 30), a survey of people with SCI who had received EIVR (n = 37), a focus group of EIVR providers and a focus group of community vocational providers. We first synthesised the literature review and interviews to develop an initial programme theory describing the contexts in which mechanisms are activated to produce EIVR outcomes. Then we used data from the survey and focus groups to further refine the EIVR programme theory. Finally, a conceptual framework was developed to support knowledge dissemination. Results By ensuring consistent messaging across the multi-disciplinary team, EIVR programmes establish and maintain hope that work is possible following injury. Conversations about work allow individuals to determine the priority of work following injury. These conversations can also improve self-efficacy by providing individualized support to envisage pathways toward RTW goals and maintain worker identity. The synthesised study findings highlight the contexts and resources required to trigger activation of these mechanisms. Conclusions EIVR key mechanisms of effect are not specific to SCI as a health condition, therefore enabling this framework to be applied to other populations who face similar impairments and return to work barriers.

PURPOSE To identify and examine subgroups of people with spinal cord injury (SCI) with different patterns of lived experience, and examine hidden impairments and disability among functionally independent and ambulant people. MATERIALS AND METHODS Latent profile analysis of population-based data from the Australian arm of the International Spinal Cord Injury (InSCI) Community survey (n = 1579). RESULTS Latent subgroups reflected levels of functional independence and extent of problems with health, activity/participation, environmental barriers, and self-efficacy. Quality of life (QoL), psychological profiles, and activity/participation were often as good or better in participants who reported lower (vs. higher) functional independence alongside comparable burden of health problems and environmental barriers. QoL, mental health, and vitality reflected self-efficacy and problem burdens more closely than functional independence. Ambulant participants reported a substantial burden of underlying, potentially hidden impairments, with QoL and mental health similar to wheelchair users. CONCLUSION Hidden disability among more independent and/or ambulant people with SCI can affect well-being substantially. Early and ongoing access to support, rehabilitation, and SCI specialist services is important irrespective of cause, type, severity of injury, and level of functional independence. Improved access to SCI expertise and equity of care would help to improve early recognition and management of hidden disability. TRIAL REGISTRATION Not applicable.

Abstract Background Māori have been found to experience marked health inequities compared to non-Māori, including for injury. Accessing healthcare services post-injury can improve outcomes; however, longer-term experiences of healthcare access for injured Māori are unknown. This paper reports on data from the longitudinal Prospective Outcomes of Injury Study – 10 year follow up (POIS-10) Māori study in Aotearoa/New Zealand (NZ), to qualitatively understand Māori experiences of accessing injury-related healthcare services long-term. Methods Follow-up telephone interviews were conducted with 305 POIS-10 Māori participants, who were injured and recruited 12-years earlier, experiencing a range of injury types and severities. Free text responses about trouble accessing injury-related health services were thematically analysed. Results Sixty-one participants (20%) reported trouble accessing injury-related health services and provided free text responses. Three related themes describing participants’ experiences were connected by the overarching concept that participants were engaging with a system that was not operating in a way it was intended to work: 1) Competing responsibilities and commitments encapsulates practical barriers to accessing services, such as a lack of time and having to prioritise other responsibilities such as work or whānau (family); 2) D isrupted mana refers to the feelings of personal disempowerment through, for example, receiving limited support, care or information tailored to participants’ circumstances and is a consequence of patients contending with the practical barriers to accessing services; and 3) Systemic abdication highlights systemic barriers including conflicting information regarding diagnoses and treatment plans, and healthcare provider distrust of participants. Conclusions Twelve years post-injury, a considerable proportion of Māori reported experiencing barriers to accessing healthcare services. To restore a sense of manaakitanga and improve Māori access to healthcare, Māori-specific supports are required and systemic barriers must be addressed and removed.

Background: Rates of return-to-work after stroke are low, yet work is known to positively impact people’s wellbeing and overall health outcomes.Objective: To understand return-to-work trajectories, barriers encountered, and resources that may be used to better support participants during early recovery and rehabilitation.Participants: The experiences of 31 participants (aged 25–76 years) who had or had not returned to work after stroke were explored.Methods: Interview data were analysed using reflexive thematic analysis methods within a broader realist research approach.Results: Participants identified an early need to explore a changed and changing occupational identity within a range of affirming environments, thereby ascertaining their return-to-work options early after stroke. The results articulate resources participants identified as most important for their occupational explorations. Theme 1 provides an overview of opportunities participants found helpful when exploring work options, while theme 2 explores fundamental principles for ensuring the provided opportunities were perceived as beneficial. Finally, theme 3 provides an overview of prioritized return-to-work service characteristics.Conclusion: The range and severity of impairmentsexperienced by people following stroke are broad, and therefore their return-to-work needs are diverse. However, all participants, irrespective of impairment, highlighted the need for early opportunities to explore their changed and changing occupational identity. LAY ABSTRACTThe aim of this study was to understand how best to support people returning to work after a stroke. A total of 31 people who had or had not been able to return to paid work after stroke were interviewed. We listened to their experiences and considered what worked best for different people with a range of needs and aspirations. People talked about wanting opportunities soon after their stroke to explore changing thoughts about themselves and their ability to return to work. Conversations with participants and their families, often starting very early after stroke, were important. People also wanted opportunities to practise skills they typically used at work, such as social skills or planning and organizational tasks. Through these ongoing conversations and opportunities to practise, people talked about gradually regaining their confidence in the skills they had retained after their stroke, rather than focusing only on the difficulties they were experiencing.

Heart rate variability biofeedback (HRV-F) is a neurocardiac self-regulation therapy that aims to regulate cardiac autonomic nervous system activity and improve cardiac balance. Despite benefits in various clinical populations, no study has reported the effects of HRV-F in adults with a spinal cord injury (SCI). This article provides an overview of a neuropsychophysiological laboratory framework and reports the impact of an HRV-F training program on two adults with chronic SCI (T1 AIS A and T3 AIS C) with different degrees of remaining cardiac autonomic function. The HRV-F intervention involved 10 weeks of face-to-face and telehealth sessions with daily HRV-F home practice. Physiological (HRV, blood pressure variability (BPV), baroreflex sensitivity (BRS)), and self-reported assessments (Fatigue Severity Scale, Generalised Anxiety Disorder Scale, Patient Health Questionnaire, Appraisal of Disability and Participation Scale, EuroQol Visual Analogue Scale) were conducted at baseline and 10 weeks. Participants also completed weekly diaries capturing mood, anxiety, pain, sleep quality, fatigue, and adverse events. Results showed some improvement in HRV, BPV, and BRS. Additionally, participants self-reported some improvements in mood, fatigue, pain, quality of life, and self-perception. A 10-week HRV-F intervention was feasible in two participants with chronic SCI, warranting further investigation into its autonomic and psychosocial effects.

BACKGROUND: Early intervention vocational rehabilitation (EIVR) is used to optimize return to work (RTW) outcomes for people following spinal cord injury (SCI). However, theoretical clarity is required about how EIVR works, for whom and under what circumstances. OBJECTIVE: To develop a theoretical understanding of how people respond to EIVR following SCI and the contexts in which mechanisms of intervention effect are likely to be activated. METHODS: Realist research methods were used to analyze interviews with 30 participants who had received EIVR following SCI. RESULTS: We conceptualized the reporting of our analyses using a travel metaphor, encapsulating the types and degree of wayfinding support participants required to think about, plan and action their vocational aspirations. Developing, maintaining and enacting hope, supporting self-identity and vocational identity, and focusing on environmental context adaptations required to enact vocational aspirations, appear to be critical mechanisms of intervention effect within EIVR. CONCLUSIONS: Various contexts and mechanisms of EIVR contribute to successful negotiation, achievement and sustainability of RTW outcomes for people following SCI. These theoretical understandings can refine EIVR service provision within SCI rehabilitation and inform how EIVR can improve RTW outcomes for people with acquired neurological conditions in other rehabilitation contexts.

Engaging in a meaningful life where one can exercise autonomy has been proposed as a key aim of rehabilitation. Influenced by a neoliberal worldview, this has traditionally been characterised by a pursuit towards individual functional independence in which one completes tasks and activities unassisted. However for many persons, individual functional independence may not be a realistic, prioritised or beneficial goal. Many individuals must learn to work with support workers to exercise choice and control. Such relationships extend beyond a transactional nature and involve many subtle characteristics. In this article, I draw on my lived experience of partnering with support workers to illustrate the complexity of such relationships and how they can enable interdependence to serve as a vehicle to self-determination. I finish with some ideas about what rehabilitation can do to recognise the important role human connections play in facilitating interdependence. Understanding the nature of these relationships is necessary to provide services which value interdependence, supporting people to pursue a meaningful life following impairment.

Injury-related disability burden extends well beyond two years post-injury, especially for Māori (Indigenous) New Zealanders. Māori also experience greater difficulty accessing health services. This prospective cohort study extension uses mixed-methods and aims to understand and identify factors contributing to long-term experiences and outcomes (positive and negative) at 12 years post-injury for injured Māori and their whānau (families), and explore the barriers and facilitators to whānau flourishing, and access to health and rehabilitation services. Five hundred and sixty-six Māori, who were injured between 2007–2009, participated in the Prospective Outcomes of Injury Study (POIS). Of these, 544 consented to long-term follow up, and will be invited to participate in a POIS-10 Māori interview at 12 years post-injury. We anticipate a 65% follow-up rate (~n = 350). Aligned with the Meihana Model, interviews will collect information about multiple inter-related dimensions. Administrative injury and hospitalisation data up to 12 years post-injury will also be collected. Regression models will be developed to examine predictors of long-term health and disability outcomes, after adjusting for a range of confounders. POIS-10 Māori will identify key points in the injury and rehabilitation pathway to inform future interventions to improve post-injury outcomes for Māori and whānau, and will highlight the support required for Māori flourishing post-injury.

BACKGROUND: Early vocational rehabilitation following spinal cord injury (SCI) improves return to work (RTW) outcomes, but there is limited information about who benefits from such interventions, why and in what contexts. OBJECTIVE: We aimed to describe demographic and clinical characteristics and RTW outcomes of adults with SCI who received early vocational rehabilitation. We sought to identify key mechanisms of early vocational rehabilitation. METHODS: This is a cross-sectional survey of people with SCI recruited from the New Zealand Spinal Trust Vocational Rehabilitation Service, who had sustained an SCI within the previous five years. RESULTS: Of the 37 people who responded to the survey, 54% returned to paid work (90% of whom retained their pre-injury employment). Those in autonomous roles returned to work faster with greater odds of returning to their pre-injury employer and role. Participants highlighted the importance of feeling hopeful about RTW while still in the spinal unit as a key mechanism of effect within the early vocational intervention. CONCLUSIONS: Findings suggested key mechanisms of early vocational intervention could be framed by models of hope. However, for gains to be optimised, continuity of support beyond the acute stage was suggested as an area for future research.

Disabled people are disproportionately affected following disasters. Research exploring disability in disaster contexts is primarily focused on short to medium timeframes. Evidence on longer-term health and wellbeing outcomes is scant. In 2010-2011 Canterbury experienced a series of devastating earthquakes. In September 2012, the Canterbury Earthquake Recovery Authority initiated a population representative cross-sectional Wellbeing Survey, which has been administered at 12 time-points as of November 2020. This study analysed the pattern of disabled and non-disabled people responses over time across four variables: wellbeing, quality of life, sense of community, and stress. Observed mean changes were modelled and compared using fractional polynomial curves. Valid responses were available from 30,736 participants in total over the 12 time-points, of whom 18.4 % experienced disability. Significant time patterns and sustained group differences were observed across all four variables, with mean scores for those with a disability being 13.4 (95 % CI: 12.6, 14.2) lower in wellbeing, 0.54 (95 % CI: 0.51, 0.57) lower for quality of life, 0.34 (95 % CI: 0.30, 0.37) lower in stress, and by November 2020, 0.14 (95 % CI: 0.10, 0.18) lower in sense of community scores compared to their non-disabled counterparts. There appeared to be little difference in mean sense of community scores between groups immediately after the earthquake, suggesting a potential halo effect. Overall, these data suggest that the health and wellbeing outcomes for disabled people are significantly worse than non-disabled people. Findings emphasise the need for recovery efforts to focus on ameliorating significantly worse health and wellbeing outcomes experienced by disabled people.