Implementation of a Community-Based Life After Stroke Centre in a Low-Resource Context: Barriers, Facilitators and Strategies in Onitsha, Nigeria

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Background: The Life After Stroke Center (LASC) is an innovative, locally designed community-center based stroke-recovery program, involving task shifting and task-sharing with non-professionals. The LASC was designed to address the often-unmet stroke recovery and rehabilitation needs in low-resource contexts. Purpose: To identify the implementation facilitators, barriers and strategies of the LASC in Onitsha, Nigeria. Methods: We used a qualitative case study design, covering nearly a decade of real-world, local implementation. Field experiences were collected through key-informant interviews and field observations based on an enquiry guide informed by the Consolidated Framework for Implementation Research (CFIR) 2.0. Thematic analysis and CFIR-based mapping were conducted by two independent analysts.Results: Six facilitator themes emerged: A context-sensitive approach driven by local champions; A holistic approach to addressing stroke survivors’ needs; Efficiencies and affordability leading to consistent patient attendance, including equitable; Provision of transportation and lunch to improve attendance; Referral mechanisms direct stroke survivors to the LASC and increase demand; Community and policy stakeholder engagement increases understanding of the purpose of the LASC. Five themes on implementation barriers and strategies emerged: Further evidence is needed on effectiveness and implementation; Variable funding affects long-term planning and operations; Further integration into the health system and its priorities is needed; Ongoing staff training and development is needed; Space and technological constraints require consideration. In the CFIR-based synthesis, some key attributes of the “innovation” stood out as facilitators, such as its local “source”, “adaptability”, and “relative advantage” - including cost - compared to any of the scant alternatives.Conclusion: The LASC was purposively designed to be implementable in contexts with human resources, financial, and equipment constraints. Its context-appropriate design and implementation has made the LASC model implementable in a low-resource environment. The identified attributes of its pragmatic and feasibility-study implementation provide key insights for scale up, sustainability and replication in other low resource settings.

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