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BACKGROUND: The Normalization Process Theory (NPT) is increasingly used for evaluating and understanding implementation processes of complex care interventions. One key tool for applying the NPT in research and practice is the NoMAD questionnaire, which offers a structured approach to examination of the four constructs that according to the NPT are central in implementation and normalisation processes. We aimed to evaluate the psychometric properties of the Swedish version S-NoMAD.

METHODS: Secondary analysis was performed on pooled S-NoMAD survey data from six implementation studies in different health and social care contexts. The NPT factor structure was tested by confirmatory factor analysis (CFA). Internal construct reliability was tested using Cronbach's alpha. Validity was confirmed by assessing the fit of the CFA using the fit measures Comparative Fit Index, Tucker-Lewis Index, root mean square error of approximation and standardised root mean square residual. Pearson correlations amongst the latent construct and general questions about the intervention were calculated.

RESULTS: The estimation results of the CFA indicate that the four-factor model implied by the NPT fits the data reasonably well. The factor loadings are of good sizes and the fit indices do not imply a mis-specified model. A good internal construct validity, indicated by a good model fit to the NPT four-construct model and acceptable to good internal reliability, was shown. External validity was also demonstrated.

CONCLUSIONS: The CFA results indicate that the S-NoMAD has good psychometric properties for capturing perceptions of people involved in various Swedish implementation studies conducted in both health and social care contexts, demonstrating its general applicability. They show that the S-NoMAD, unlike the majority of instruments for evaluation of implementation processes, is not context- and intervention-specific. The findings highlight the utility of the S-NoMAD and show that it meets some important criteria for pragmatic measures. Further studies are warranted on different interventions implemented in diverse contexts regarding the meaning of the magnitude of the NoMAD scores in order to clarify its potential value as a tool for assessment of implementation strategies and on psychometric properties beyond construct validity and internal construct reliability, for example on test-retest reliability and longitudinal studies focusing on responsiveness.

Introduction: Enhancing Quality of Life for Individuals with Stroke (EQL-stroke) is an international, collaborative multiphase project aiming to strengthen supported self-management for older adults recovering from stroke at home in Sweden, Latvia and the Netherlands. Existing poststroke pathways may provide insufficient support for self-management during the transition from hospital to home, and there is limited evidence on interventions that integrate social networks and everyday environmental context.

Methods and analysis: EQL-stroke uses a participatory, multimethod design across three phases. Phase I generates knowledge through policy review, qualitative interviews and people-place mapping (~25 participants per country) and includes cross-cultural adaptation of the Collective Efficacy of Networks Scale. Phase II co-designs and specifies a tailored social network-informed supported self-management intervention (the Network-Based Intervention), including core components and principles for local adaptation (~15 participants per country). Phase III will recruit approximately 20-40 stroke survivors for a single-arm pilot feasibility study with an 8-week follow-up and embedded process evaluation to assess feasibility, acceptability and fidelity in routine practice.

Ethics and dissemination: Ethical approval has been obtained from the Swedish Ethical Review Authority (reg. no. 2025-00083-01), the Rīgas Stradiņa Universitāte Research Ethical Committee (reg. no. Rīgas Stradiņa Universitāte Research Ethical Committee) and the Research Ethics Committee of the Faculty of Spatial Sciences, University of Groningen (reg. no. 2025-07). Findings will be disseminated through peer-reviewed publications, stakeholder engagement activities and patient/public channels.

Background Teach-Back is a widely recommended communication method to support patient understanding, yet little is known about how healthcare professionals learn Teach-Back in everyday clinical practice. The study aimed to explore how healthcare professionals learn Teach Back within an acute hospital setting, and how this learning is experienced and enacted in everyday clinical practice.

Methods This qualitative study invited staff in two healthcare settings that had partaken in a Teach-Back method training program. Participants included 18 healthcare professionals and four first-line managers. Data were generated through interviews conducted in the beginning and after the training program, and through observations of clinical encounters when applying the Teach-Back method. Data were analyzed using reflexive thematic analysis.

Results Learning Teach-Back was identified as a multilevel workplace learning process that developed through interactions between individual experiences, interpersonal learning processes, organizational engagement, and workplace conditions. This was reflected in four interrelated themes: (1) Individual level: Learning by doing and experiencing Teach-Back: authentic Teach-Back encounters with patients were critical for skill development but could trigger insecurity when Teach-Back was experienced as unnatural. Emotional responses, discouragement and “aha” moments, shaped whether healthcare professionals used Teach-Back or not; (2) Interpersonal level: Learning through feedback and shared meaning: recurring peer reflection and supportive feedback were crucial for learning Teach-Back, yet often lacking; (3) Organizational level: Engaging the organization to promote learning: early adopters, ambassadors, leadership support, and interprofessional communication were decisive for learning Teach-Back; and (4) Workplace conditions: Making space for learning in a pressured work environment: staff shortages, turnover, and high workload constrained opportunities for doing and engaging in reflection and feedback about Teach-Back.

Conclusions Learning Teach-Back can be understood as a multilevel workplace learning process that develops through opportunities for practice, reflection, and collegial feedback in everyday clinical work. Supporting Teach-Back learning requires workplace learning approaches that foster shared meaning across professional teams, organizational engagement, and protected space for learning.

Trial registration ClinicalTrials.gov ID: NCT02925871. Registration date: first submitted 8 April 2016; first posted 6 October 2016.

Background: Rehabilitation after stroke is a complex process, and innovative solutions, including digital tools, have been suggested as way of meeting the challenge of limited access to services. F@ce 2.0 is a person-centred intervention for rehabilitation after stroke where goal achievement is supported by information and communication technology. Guidance for evaluation of complex interventions, such as that from the UK Medical Research Council (MRC), underlines the importance of evaluating not only the effects of an intervention but also process, such as its implementation in a clinical setting. The objective was therefore to study the implementation process of the F@ce 2.0 intervention for stroke survivors living at home as well as the interaction between the intervention and the implementation context.

Methods: A process evaluation of the implementation of F@ce 2.0 was conducted, informed by the MRC guidance for process evaluations, utilising a convergent mixed methods design. Participants included stroke survivors (n = 39), rehabilitation team members (n = 53) and managers (n = 6). Data were collected through a web server, surveys and interviews. Descriptive statistics were used for quantitative analysis. Qualitative data were analysed using a deductive thematic approach based on the Consolidated Framework for Implementation Research.

Results: Analysis revealed challenges in conducting research during the COVID-19 pandemic as well as limitations related to implementation planning in relation to the specific context. The reach of the intervention among stroke survivors was low, and fidelity issues were identified related to the teams' lack of readiness to deliver the intervention. Analysis of teams' perception of delivering the intervention revealed that they saw potential in using a structured instrument for person-centred goal setting and in goal reminders, but also a hesitation regarding the usability of the intervention for stroke survivors. Teams also expressed a need of further education in delivering the intervention.

Conclusions: The process evaluation showed that although rehabilitation teams recognized the potential of F@ce 2.0, implementation and reach were limited, largely due to insufficient contact with the teams for both support and monitoring. Earlier involvement of the rehabilitation teams would likely have helped identify educational needs and organizational conditions necessary for successful implementation.

Trial registration: ClinicalTrials.gov NCT04351178. Firs posted 2020-04-17. https://clinicaltrials.gov/study/NCT04351178 .

BACKGROUND: Living with gout impacts most dimensions of life. However, there is a lack of studies exploring the trajectory of patients' experiences of living with and being treated for gout, beyond the experiences during a flare. This study aimed to explore how individuals with gout experience the disease, its effects on daily life and their encounters with healthcare.

METHODS: A constructivist grounded theory was used, involving simultaneous data collection and analysis. Semi-structured individual interviews were conducted with 12 individuals living with gout and aged between 40 and 87 in Central Sweden.

RESULTS: Navigating the uncertainty of living with gout was represented through two categories: 'a mismatch between individuals' needs and the provision of care' and 'a process of adaptation'. The mismatch involved unmet needs for pain relief, feeling dismissed as having a minor condition and a lack of personalised care. The adaptation process included seeking explanations, developing self-management strategies and adjusting to pain and functional limitations.

CONCLUSIONS: Living with gout entails a significant degree of uncertainty. The process of adaptation is affected by a mismatch between individuals' needs and the care provided, in addition to the disease's 'roller coaster' nature and its slow progression.

PATIENT AND PUBLIC CONTRIBUTION: This study is part of a research project aimed at gathering knowledge essential for developing an intervention in primary care. A patient, appointed by the Swedish Rheumatism Association, is actively participating in the project's research group. The results of this study have been discussed and analysed within the research group, including input from the patient participant.

INTRODUCTION: Despite being a fundamental human right, access to assistive products varies between 3% and 90% across countries. Ensuring adequate and trained human resources is a prerequisite for improving access to assistive products. To support workforce planning and development, this study estimated the global workforce required for assistive technology provision to achieve a high level of access.

METHOD: This modeling study used estimates of the primary workforce for assistive technology provision and assistive product needs in a country with a high level of access and global assistive product needs, to predict the global workforce required to provide assistive technology in five product domains: cognition and communication, hearing, mobility and self-care, orthotics and prosthetics, and vision. The assistive product need estimates were based on self-reported data from WHO Rapid Assistive Technology Assessment surveys in 28 countries.

RESULTS: A total workforce for assistive technology provision of 4.4 (95% CI: 3.0-6.8) million full-time equivalents (FTE) would be required globally to achieve a high level of access to assistive products. Excluding the administrative workforce, this includes a workforce of 3.4 (2.3-5.4) million FTE, composed of 1.7 (1.3-2.2) million FTE providing mobility and self-care products, 0.9 (0.5-1.7) million FTE providing orthoses and prostheses, 0.5 (0.2-1.0) million FTE providing vision products, 0.3 (0.2-0.4) million FTE providing hearing products, and 0.05 (0.04-0.06) million FTE providing cognition and communication products.

CONCLUSION: Likely a conservative estimate of the required workforce size, this provides a cautious foundation for informing strategies to develop a workforce capable of meeting global assistive product needs and improving access.

UNLABELLED: Digital interventions may be a way of increasing access to rehabilitation after stroke, but there is limited knowledge on how they are perceived by stroke survivors. F@ce 2.0 is a home-based person-centred intervention for stroke rehabilitation that focuses on daily activities and participation in everyday life. The intervention spans over 8 weeks and uses Short-Message-Services (SMSs) to support goal achievement.

OBJECTIVES: The aim of this study was to explore and describe experiences of rehabilitation with F@ce 2.0 from the perspective of people with stroke.

DESIGN: Qualitative inquiry was based on individual interviews at two time points, post-intervention and 6 months post-inclusion. Data were analysed using reflexive thematic analysis.

SETTING: Home-based stroke rehabilitation in Sweden.

PARTICIPANTS: Twelve stroke survivors with mild to moderate stroke.

RESULTS: Three themes and seven sub-themes were constructed. The main themes were 'Setting personally relevant goals requires a trusting relationship',' SMSs as a tool for person-centred rehabilitation' and 'Collaboration with the team is essential for resuming daily activities after stroke'.

CONCLUSION: Supporting goal achievement through SMS messages may increase motivation and awareness in stroke rehabilitation. The results, however, illustrate the importance of personal meetings in rehabilitation, both for setting relevant goals and for identifying goal achievement strategies.

TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT04351178; https://clinicaltrials.gov/study/NCT04351178.

BACKGROUND: Experiencing a stroke disrupts the expected life course and can negatively impact cognitive, emotional, and physical functioning, making it a major source of disability globally. To support recovery, individuals can seek help by sharing their experiences in peer-to-peer support communities.

OBJECTIVE: The objective of this study was to use discourse analysis to examine how members of a peer-to-peer online support community for stroke survivors construct their understanding of the condition and use narratives to reconstruct their identity into different subject positions.

METHODS: The study context was a private Swedish peer-to-peer online support community created and administered by middle-aged people with lived experience of stroke. Data was collected through structured protocols that captured the content of posts and comments (n = 397). The analysis has followed the principles of Laclau and Mouffes discursive framework.

RESULTS: Our findings suggest that identity struggles revolve around looking ahead and negotiating normative expectations with oneself and others. We identified five subject positions: survivor, pathfinder, mentor, struggler, and outsider. These positions highlight the plurality and fluidity of post-stroke identity processes. Members often shifted between these roles based on changes in health, emotional state, or community interactions.

CONCLUSIONS: The diversity of subject positions demonstrates that stroke recovery is not a uniform process, emphasizing the importance of recognizing identity work as a core aspect of post-stroke adaptation. The findings highlight the need for more flexible, patient-centered services that accommodate diverse narratives, including those shaped by long-term disability, emotional trauma, and shifting life priorities.