What does upscaling stroke rehabilitation mean globally? A qualitative description of international variation in stroke rehabilitation and the influences on evidence-based practice

Abstract

Background: Demand for rehabilitation is expected to grow dramatically in the near future due to population ageing and increases in people living with chronic health conditions. For example, the global incidence of stroke is expected to increase to an estimated 70 million stroke survivors by 2030. In 2017, in response to this need, the World Health Organization (WHO) released a report -Rehabilitation 2030: a call for action – detailing the actions required to ‘upscale’ rehabilitation to meet this future demand on healthcare systems.

Aim: Using stroke as an example, this thesis explores what ‘upscaling’ might mean for rehabilitation health professionals in different parts of the world. This research has three aims: 1. To explore the scope of, and variability in, the practice of stroke rehabilitation globally, 2. To explore what upscaling stroke rehabilitation might mean for health professionals from countries at different stages of economic development around the world, and 3. To explore influences on the application of evidence-based stroke rehabilitation at regional levels.

Methods: This thesis employed a qualitative descriptive design. Interviews were conducted with clinical leaders in stroke rehabilitation from 12 countries around the world, purposefully sampled to ensure representation from high, middle, and low-income countries. Semi-structured interviews were conducted in English via videoconferencing, with the interview schedule sent to all participants in advance. Recordings from the interviews were transcribed and analysed using inductive content analysis.

Results: Twelve rehabilitation professionals participated in interviews from high, upper-middle, lower-middle, and low-income countries (United States, Germany, New Zealand, United Arab Emirates, England; Turkey, Colombia; Vietnam, Ghana, Pakistan; Nepal and Sierra Leone) and from different professional backgrounds (medicine, physiotherapy, occupational therapy, and speech language therapy). The findings covered three main topics. Firstly, the participants discussed the influence of local context on stroke service provision (e.g. political, organisation, and sociocultural factors). Secondly, upscaling was seen as a necessity, the participants discussed what they understood by the term “upscaling stroke rehabilitation” and what this might require in each of their countries (e.g. political will, governmental support, workforce developments, resourcing, and raised awareness of the need and the value of rehabilitation). Thirdly, they discussed the challenges they faced in implementing evidence-based stroke rehabilitation: general barriers (e.g. the complexity and quality of evidence, lack of time, lack of training, changing behaviours, and resources) and region specific barriers (e.g. language barriers, lack of research relevant to the local context, and lack of physical access to current research).

Conclusion: Although there have been many gains with the development of stroke rehabilitation internationally, further investment is required to ensure that this patient population group continues to receive the best quality care. In order for the WHO to be successful in implementing Rehabilitation 2030: a call for action, attention will need to be paid to political, professional, economic, and sociocultural issues at global and local levels. However, this work is well supported by health professionals in many countries all around the world and is the start of decisive action towards a brighter future for stroke survivors and their families.