Factors influencing the implementation of aerobic exercise after stroke in the UK from stroke survivor, staff and system perspectives: a mixed methods approach

Abstract

Introduction
Aerobic exercise is beneficial after stroke and recommended in the UK National Clinical Guidelines for Stroke (2023), but there are challenges to its implementation.

Aim
To determine the factors influencing the implementation of aerobic exercise after stroke in the UK from the perspectives of stroke survivors, staff, and a system.

Methodology
A convergent mixed-methods design was used comprising three studies exploring perspectives on the implementation of aerobic exercise. A qualitative systematic review, analysed using the Consolidated Framework for Implementation Research (CFIR), explored staff perspectives. A quantitative retrospective observational study using data from the UK National Audit of Cardiac Rehabilitation (NACR) explored a system perspective. A mixed method (primarily quantitative) survey investigated stroke survivor perspectives. The study’s findings were integrated in a joint display using the CFIR.

Findings
The integrated data showed points of convergence, but no divergence, with some single perspective factors. Convergent findings included the importance of aerobic exercise, support following stroke, and available resources. Stroke survivors and staff identified fear, lack of knowledge and motivation as barriers, and confidence as a factor. Stroke survivors’ comorbidities, deprivation, and exercise preferences are factors in implementation planning. Single perspective factors included safety and perceived risk to the stroke survivor, skill-sharing, training, collaboration, and organisation of services.

Conclusion
This integration generated the most comprehensive understanding of the factors influencing implementation of aerobic exercise after stroke to date. First steps towards increasing implementation in the UK could involve development of an educational ’how-to’ guide to delivering aerobic exercise post-stroke to improve knowledge and confidence amongst staff, and therefore stroke survivors. Development of an implementation strategy should include collaboration and stakeholder involvement to maximise success.

Contributions to knowledge
This research comprises the first time that implementation of aerobic exercise after stroke in the UK has been explored by integrating staff, stroke survivor, and system perspectives. This has enabled identification of factors common to multiple perspectives, thereby providing unique insight into how targeting one modifiable factor could, in fact, simultaneously address others.