Applications to support cross-sectoral, person-centred and empowering stroke rehabilitation: Development, implementation, test, and evaluation of two co-designed applications

Introduction
Rehabilitation after stroke is crucial for enabling stroke survivors to develop the essential skills needed to enhance their functioning, physical activity, independence, and participation in everyday life activities. Central to achieving these goals are person-centred rehabilitation approaches that empower stroke survivors and their significant others by tailoring interventions to their individual needs and resources. Ensuring easy access to evidence-based stroke information, rehabilitation plans, person-centred interventions, and seamless, coordinated, cross-sectoral stroke rehabilitation are vital mechanisms of these approaches. Furthermore, the integration of information and communication technologies (ICTs) and applications (apps) holds promising potential in supporting person-centred stroke rehabilitation. Notably, the platforms in two known app-solutions, Mit Sygehus and Genoptræn.dk, operating within the Southern region of Denmark, have the potential to support cross-sectoral, person-centred, and empowering stroke rehabilitation.

Aim
The overall aim of this PhD thesis was to develop, implement, test and evaluate the co-designed content of two known app-solutions, Mit Sygehus and Genoptræn.dk, to support cross-sectoral, person-centred and empowering stroke rehabilitation for stroke survivors and their significant others. 

Design and methods
The overall design was the British Medical Research Council’s (MRC) framework for developing and evaluating complex interventions within health care.

Findings
Phase 1
Among the 46 studies included in the scoping review, the predominant focus was on stroke survivors in the chronic stage of recovery. Only three studies applied apps that supported more than one part of the complex rehabilitation process. This clearly underscored the necessity for developing apps that support greater part of the stroke rehabilitation process, including acute and subacute stroke rehabilitation, and the transfers between different rehabilitation settings.

Phase 2
The content of two known app-solutions, namely, Mit Sygehus and Genoptræn.dk, was co-designed based on stakeholders’ needs, prioritization, and research knowledge regarding existing apps, by using a systematic Experience-based Co-design methodology.

Phase 3
The developed prototypes of the apps were implemented, tested and evaluated in 10 stroke survivors and seven significant others throughout cross-sectoral stroke rehabilitation. Stroke survivors and significant others found the content of Mit Sygehus and Genoptræn.dk acceptable to support cross-sectoral, person-centred, and empowering stroke rehabilitation. However, Mit Sygehus was most accepted by significant others in the acute rehabilitation setting, while Genoptræn.dk was most accepted by stroke survivors in the subacute rehabilitation setting. More stringent implementation of both apps was needed; Genoptræn.dk should be implemented during acute stroke rehabilitation for stroke survivors being ready for self-training activities, and Mit Sygehus should be integrated more continuously during subacute and municipal rehabilitation.

Conclusion
The overall aim of this PhD project was to develop, implement, test, and evaluate the co-designed content of two known app-solutions, Mit Sygehus and Genoptræn.dk, to support cross-sectoral, person-centred and empowering stroke rehabilitation for stroke survivors and their significant others. The iterative and flexible framework of the MRC framework for developing and evaluating complex interventions overall guided the research phases within this PhD project. Stroke survivors and their significant others found the content of Mit Sygehus and Genoptræn.dk acceptable to support cross-sectoral, person-centred and empowering stroke rehabilitation. The following facilitating intra -and interactional mechanisms were identified and accommodated to support experiencing empowerment: access to free-of-charge apps, access to relevant knowledge, gaining insights into and an overview of the rehabilitation process, support of coordinated and coherent transfers between rehabilitation settings, person-centred exercises and guidelines using video recordings, support from health professionals to create positive self-training habits, and reduced significant other burden. Additionally, stroke survivors and their significant others felt an ongoing sense of progress through use of the apps, which supported motivation and engagement throughout the rehabilitation process. 

However, Mit Sygehus was most accepted by significant others in the acute rehabilitation setting, while Genoptræn.dk was most accepted by stroke survivors in the subacute rehabilitation setting. More stringent implementation of both apps was needed; Genoptræn.dk should be implemented during acute stroke rehabilitation for stroke survivors being ready for self-training activities, and Mit Sygehus should be integrated more continuously during subacute and municipal rehabilitation. Furthermore, using the apps to support cognitive rehabilitation and follow-up support postrehabilitation needs further exploration.