Wellbeing After Stroke-2 (WAterS-2): a feasibility study with process evaluation exploring inclusive, accessible, online psychological support after stroke

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Abstract Objectives Explore feasibility and acceptability of upskilling a workforce to deliver a co-developed intervention, based on Acceptance and Commitment Therapy (ACT), to support psychological adjustment post-stroke targeting underserved groups. Design Multi-site, single-arm feasibility study with embedded mixed-methods process evaluation ( ISRCTN17628580 ). Setting Four NHS community stroke services across England. Participants 1 Stroke survivors ≥18 years of age, ≥4 months post-stroke, reporting psychological difficulties adjusting to stroke, able to consent and access remote group sessions in English; 2. Group facilitators from NHS stroke services, not ACT specialists. Intervention WAterS-2: an eight-session, remotely-delivered ACT-informed group intervention. Outcome measures Recruitment, fidelity, safety, acceptability and perceived value were assessed using fidelity checklists, post-intervention surveys and semi-structured interviews with stroke survivors and facilitators. Clinical outcomes including mood (HADS), wellbeing (ONS4), psychological flexibility (AAQ-ABI), measured post-group and three-months later. Results Nineteen stroke survivors recruited (mean 9.6 months post-stroke; n=5 (26%) minoritised ethnicities; n=10 (52%) with aphasia). Thirteen facilitators - including two peer support workers - delivered the intervention with fidelity following structured training across four services. Drop-out was low (2/19; 11%); with 15 (79%) attending ≥5/8 sessions. Remote data collection was feasible (79% follow-up completion), with no adverse events recorded. Acceptability was high: survivors valued peer connection, grounding and mindfulness practices. ACT metaphors were helpful for some but challenging for others, including some with aphasia. Online delivery was suitable but limited informal connection. Facilitators reported increased capability, incorporating ACT skills into routine care. NHS workforce pressures and geographically-constrained referral pathways limited recruitment reach. Conclusions WAterS-2 is feasible, safe, acceptable and inclusive. A mixed workforce, including NHS peer support workers, can be upskilled to deliver with fidelity. Inclusion of underserved groups is achievable but requires active strategies beyond standard NHS referral routes. Findings inform a provisional logic model and a future pragmatic trial. Registration ISRCTN17628580 (registered 16/08/2024). Strengths and Limitations of this study This feasibility study used a mixed-methods process evaluation, enabling a rich account of both feasibility indicators and implementation considerations across NHS sites. We included stroke survivors with communication difficulties and from minoritised ethnic backgrounds, groups typically excluded from stroke rehabilitation research. People and Communities involvement was embedded throughout all stages of study design, delivery and interpretation. The single-arm design and small sample size prevent causal or effectiveness inferences, and delivery of only one group per site limits assessment of variability across teams. Recruitment was undertaken by clinical staff from existing caseloads, introducing potential for referral bias.