Investigating Variation in Six-Month Post-Stroke Reviews

Six-month post-stroke reviews (6MRs) are recommended in clinical guidelines to identify ongoing needs and facilitate follow-up care for stroke survivors. However, guidance on how 6MRs should be delivered is limited, and empirical evidence to support implementation is sparse. Consequently, 6MRs have been implemented inconsistently, with substantial variation in service models historically reported. This thesis aimed to understand how the 6MR functions in practice and develop programme theory to guide future implementation and sustainment of 6MR services. A pragmatic explanatory sequential mixed-methods design was employed. First, a national survey of 6MR services in England quantified current variation in delivery and explored organisational factors associated with different service models. Second, a qualitative multiple case study incorporated interviews, observations and documentary analysis to explore how purpose is conceptualised and how context shapes delivery. Finally, findings were synthesised to develop a programme theory and logic model. The survey demonstrated substantial variation in how 6MRs are delivered in terms of structure and content. Qualitative findings showed that this variation was partly driven by how the perceived purpose of the 6MR was operationalised, with dissonance between interest-holder expectations influencing delivery and service user experience. Context played an active role in shaping access, responsiveness and outcomes, with recurring patterns of interaction identified between the 6MR and context at micro, meso-, and macro-levels. Together, these sequential studies make an original contribution to knowledge: empirically, by providing evidence of variation and patterns of contextual interaction; theoretically, through the first empirically grounded, complexity-informed, and context sensitive programme theory of the 6MR; and methodologically, through the integration of context and complexity in a multiple case study design. Together, these contributions explain how outcomes emerge through interactions between the 6MR and its context and provides a framework for purposeful adaptation to inform implementation, evaluation and sustainability of 6MR services across diverse settings.