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Abstract Background The aim of this study was to identify factors that influence patients’ motivation and ability to self-manage their diabetes and depressive symptoms. Methods From 2016-17, in-depth interviews were conducted with 62 patients receiving the INDEPENDENT care model across two clinics in India. Using a realist evaluationapproach, a hypothesized program theory for patient activation was tested and refined. Findings The refined theory demonstrates that motivation, education, and engagement cumulatively contribute to patient activation. Conclusion The results indicate that positive and sustained patient-provider relationships drive patient motivation and enhance implementation of the care model.