Implementation evaluation of community-based physical activity programmes for secondary prevention following stroke in Ireland: a RE-AIM and CFIR-informed mixed-methods study protocol using ExWell Medical as a case study.

Overview and rationale Stroke is a major public health challenge and one of the leading causes of long-term disability worldwide and in Ireland. Although advances in acute stroke care have improved survival, many stroke survivors continue to experience persistent physical, cognitive, psychological, and social difficulties. In Ireland, more than 57,000 people are estimated to be living with stroke, with approximately 7,500 new strokes occurring annually. As the Irish population ages, the number of people living with stroke-related disability and requiring long-term support is expected to rise substantially. This creates increasing pressure on healthcare systems to provide sustainable and effective models of secondary prevention and rehabilitation in community settings. Physical activity and structured exercise are recognised internationally as essential components of secondary prevention after stroke. Exercise-based rehabilitation can improve mobility, physical function, cardiovascular health, and overall wellbeing while potentially reducing the risk of recurrent stroke and hospitalisation. National and international policy frameworks, including the Health Service Executive (HSE) National Stroke Strategy and the European Stroke Organisation’s Stroke Action Plan for Europe, emphasise the importance of accessible community-based physical activity programmes for stroke survivors. Despite strong policy support and growing evidence regarding the benefits of exercise after stroke, important implementation gaps remain. There is limited understanding of how community-based exercise programmes are delivered in routine practice, how referral pathways operate, which stroke survivors engage with these services, what barriers influence participation, and what organisational or system-level factors affect long-term sustainability. In Ireland particularly, there is insufficient implementation-focused evidence to guide decisions regarding scale-up, funding, workforce planning, and integration of such programmes into existing stroke care pathways. This research forms part of the broader INsPIRE (Informing National Policy for Physical Activity-based Secondary Prevention of Stroke in Ireland) project, funded through the Health Research Board Evidence for Policy programme. The project aims to generate timely, policy-relevant evidence to support national decision-making regarding scalable and sustainable community-based physical activity programmes for people living after stroke. Study aim The overall aim of this study is to conduct a mixed-methods implementation evaluation of community-based physical activity programmes for secondary prevention following stroke in Ireland, using the ExWell Medical programme as a real-world case study. Rather than evaluating whether exercise is clinically effective, this research focuses on understanding how programmes are implemented, delivered, adopted, experienced, and sustained in routine community practice. The study seeks to generate implementation-relevant evidence that can inform national policy, health service planning, and future scale-up of community-based exercise programmes for stroke survivors. Study design This study uses a convergent mixed-methods implementation evaluation design guided by two complementary implementation science frameworks: The RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance), which structures the evaluation of implementation outcomes relevant to population-level impact and scale-up. The Consolidated Framework for Implementation Research (CFIR 2.0), which supports systematic examination of contextual determinants influencing implementation across multiple levels, including intervention characteristics, organisational context, leadership, resources, and implementation processes. These frameworks were selected because they align closely with the study’s policy-focused objectives and provide a structured approach to understanding both implementation outcomes and the contextual factors shaping them. ExWell Medical as the case study The study uses ExWell Medical as a real-world case study of community-based exercise delivery. ExWell is a not-for-profit organisation providing supervised group exercise programmes with medical oversight for adults living with chronic conditions across more than 60 locations in Ireland. The programme includes: Structured exercise classes combining aerobic, resistance, balance, and core training Medical oversight Baseline and follow-up assessments Long-term participation opportunities Social and educational supports Participants are referred through healthcare professionals and social prescribing pathways. The programme is designed to support long-term health management and social engagement in community settings. This implementation evaluation will draw on secondary analysis of data from: The ExWell Stroke feasibility study, which is evaluating the adaptation and impact of the ExWell programme for people living post-stroke in Ireland. The ExWell CHO7 cohort study, which was a prospective cohort study exploring outcomes in 1200 participants attending the ExWell programme in Dublin West and Kildare. A range of data was collected including physical fitness measures, patient reported outcome measures and process outcomes including attendance and class retention. Data is available for a sub-group of participants with a history of stroke. Quantitative component The quantitative component focuses on examining participant flow through the ExWell programme pathway from referral through induction, programme uptake, participation, and longer-term engagement. Data sources include: ExWell referral records Attendance and retention data Engagement tracking Key outcomes include: Proportion of referrals involving stroke survivors Referral sources and pathways Induction attendance Programme commencement rates Attendance dose and participation frequency Retention at 3 and 6 months Dropout and re-engagement Functional mobility characteristics Use of mobility aids and support requirements The study will also examine timelines across the participant pathway, including referral-to-induction and induction-to-class-start intervals. Quantitative data will be analysed using descriptive statistics and, where appropriate, inferential analyses including paired statistical tests and mixed-effects models. Qualitative component The qualitative component explores experiences, perceptions, and contextual determinants influencing implementation and sustainability through semi-structured interviews and focus groups. Participants will include: Stroke survivors referred to the ExWell programme (Semi-structured interviews) ExWell staff involved in programme delivery (Focus groups) Referring clinicians and healthcare professionals (Semi-structured interviews) Policymakers and national stroke rehabilitation stakeholders (Semi-structured interviews) Topic guides informed by RE-AIM and CFIR will explore: Referral experiences and access pathways Programme acceptability and perceived benefits Barriers and facilitators to participation Integration within existing stroke services Workforce capacity and training needs Sustainability and funding considerations Policy and system-level challenges Qualitative data will undergo reflexive thematic analysis using NVivo software. Coding and interpretation will be iterative and collaborative, with attention to experiential accounts, organisational influences, and policy relevance. Data integration The study adopts a convergent mixed-methods approach, whereby quantitative and qualitative findings will be integrated during interpretation. This integration will allow the research team to: Explain quantitative patterns through qualitative insights Identify contextual influences on implementation outcomes Examine how organisational and system-level factors shape programme delivery Develop a comprehensive understanding of sustainability and scalability Integrated findings will contribute to broader policy synthesis activities within the INsPIRE project, including future use of GRADE Evidence-to-Decision frameworks. Expected outcomes and significance This study is expected to provide a clearer understanding of how community-based exercise programmes for stroke survivors operate in everyday practice in Ireland. The findings will help identify what supports successful participation and what barriers may prevent people from engaging or remaining involved in these programmes. The study will generate evidence on referral pathways, programme uptake, attendance, retention, and long-term engagement among stroke survivors participating in the ExWell programme. It will also explore the experiences and perspectives of stroke survivors, healthcare professionals, programme staff, policymakers, and stakeholders to better understand the factors influencing programme delivery and sustainability. By identifying barriers and facilitators to implementation at individual, organisational, and health-system levels, the study will provide practical insights into how community-based physical activity programmes can be improved, integrated within stroke care pathways, and sustained over time. The findings are intended to support national policy and service planning by informing decisions regarding future funding, workforce development, referral systems, and the potential scale-up of community-based exercise programmes for stroke survivors across Ireland. The study aligns closely with Sláintecare priorities and the Health Service Executive’s National Stroke Strategy, contributing evidence to support more accessible, equitable, and sustainable models of stroke secondary prevention and long-term recovery in the community.