Implementing and sustaining six-month post-stroke reviews: A complexity-informed, context-sensitive programme theory for clinical practice

Abstract

Introduction: Stroke is a leading cause of long-term disability. Six-month post-stroke reviews are recommended in multiple guidelines to identify the ongoing needs of stroke survivors and facilitate follow-up care. However, guidance on how to deliver these reviews optimally is limited. This study developed a complexity-informed, context-sensitive programme theory for the six-month post-stroke review, clarifying its core components and producing actionable recommendations to guide implementation and sustainability across diverse contexts. Methods: The programme theory was developed from empirically derived patterns identified in a multiple case study in England, based on data collected from interest-holder interviews, observations, and documentary analysis. Context-mechanism-outcome configurations were developed heuristically through a pragmatic approach. These informed the structure and content of the programme theory and logic model. A complexity theory lens facilitated identification of multi-level system dynamics, supporting applicability across diverse contexts. The model was iteratively refined by the research team and adjusted following validation feedback from international stroke rehabilitation experts and six-month post-stroke review interest-holders. Results: Fourteen context-mechanism-outcome configurations informed 13 core components nested within four core domains of the six-month review: Access & Inclusion; Identifying & Addressing Needs; Maintaining Quality; and System Integration. The real-world logic model illustrates how patient-, provider-and service-level outcomes emerge from interactions between the six-month review and the context in which it is delivered. The resulting actionable recommendations provide guidance for implementing and sustaining six-month post-stroke reviews in clinical practice, including flexible delivery formats, person-centred tailoring, integration across services, and strategies to enhance quality and equity. Conclusions: This study presents the first complexity-informed, context-sensitive programme theory for the six-month post-stroke review. By translating empirically driven theory into actionable recommendations, it supports clinicians and service planners in delivering person-centred, contextually adaptable follow-up care. It also provides a foundation for future evaluation of post-stroke services internationally, enabling systematic testing of its hypothesised outcomes and adaptation across diverse healthcare settings.