Submitted:
22 May 2026
Posted:
27 May 2026
You are already at the latest version
Abstract
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.
Keywords:
community-based rehabilitation
; stroke
; low-resource contexts
Background
Stroke has been identified as one of the leading causes of disability worldwide, with four times disability reported in low and middle income countries (LMICs) in comparison to high-income countries (LMICs) [1]. The global burden of stoke-related disability is predicted to increase in LMICs along with the rise of non-communicable diseases, due to factors such as increased life expectancy [1,2,3]. Age is a potent risk factor for stroke, and a three fold increase among older people aged 60 years or older have been projected to be experienced in Africa in the next 25 years [2]. The burden of stroke in sub-Saharan Africa (SSA) has been reported to increase trends in stroke incidence, prevalence, and mortality, [4,5,6].
While the burden of stroke increases in SSA, stroke rehabilitation services remain scarce, especially at the community level [7,8,9]. Stroke survivors in Sub-Saharan Africa (SSA) are often discharged from the hospital within days with significant activity limitations that affect their ability to function at home and in the community [10,11,12]. Family and community stroke awareness are majorly limited, which may result in seeking medical services only from traditional and faith healers. Likewise, out of pocket cost and transportation are significant barriers for accessing the limited available community-level rehabilitation facilities. However, stroke-rehabilitation needs in SSA are usually much broader in scope, including activities of daily living, communication, and return to work [10,12].
In SSA, there are many competing health needs against the backdrop of limited healthcare resources. Specialized human health care resources are scant. The number of rehabilitation professionals (e.g., physiotherapists, occupational therapists, speech and language pathologists) are a small fraction of those required [13,14,15] or non-existent [14,16]. Furthermore, much of the evidence and service delivery options for stroke rehabilitation arise from high-resource contexts, where specialized equipment, infrastructures, financial, human, and other rehabilitation resources exist. However, those resources are not present in low resource contexts [8,9,11,17,18]. Of note, low-resource contexts here refer to the places with structural constraints in equipment, human and other healthcare resources – these are often found in, but not restricted to, LMICs [19]. There is a strong need for developing, testing, and deploying community-level, accessible stroke services applicable in low resource contexts.
Community-based interventions that are designed with existing and /or sustainable resources for adaptation in low resource contexts may improve stroke related activities and life after stroke [18,20]. Resource-appropriate service delivery models are imperative for any community-based stroke rehabilitation initiative. Task shifting and task-sharing, where health professionals train and oversee the work of non-professional community agents or volunteers to partly deliver specific interventions under supportive supervision, has been suggested as one strategy to use in low resource settings [20,21,22]. Initiatives need to be implemented with high consideration of sustainability utilizing local and cultural resources.
The Life After Stroke Centre (LASC) in Nigeria is an innovative, context-sensitive model of community-based service delivery to augment stroke rehabilitation and recovery services. The LASC has been operating in Onitsha, Nigeria, for close to a decade, offering programs 2-3 days/week [23]. Programs are informed by evidence-based stroke rehabilitation guidelines and activities are designed and adapted to be implementable in the context of low-resource settings, with consideration of the available human, financial and material resources [23]. During our implementation, preliminary and initial assessment of stroke survivors at the LASC is conducted by health professionals, who identify goals and appropriate programs to address the goals. Programmatic activities are primarily delivered as a group, by non-professionals or volunteers (called stroke ambassadors) who have been trained by healthcare professionals, with continuous monitoring and supportive supervision from the health professionals. This model is meant to optimize the use of the more scant and costly specialized human resources and to be both implementable and affordable.
Over nearly a decade, the LASC has achieved a pragmatic, sustained implementation, in Onitsha, Nigeria. More recently, there has been an effort to further standardize the service delivery, to enable replication in other settings. The initiative is led by a Nigeria Non-Governmental Organization; Stroke Action, with support from an international multi-disciplinary group of stroke rehabilitation researchers and advocates, known as the OSCAIL (Organized Stroke Care Across Income Levels) Investigators.
In this context, using an established implementation science framework, [24] this study aims to identify the field experiences of implementation facilitators, barriers and strategies at the seminal LASC in Onitsha, Nigeria. The study’s focus will span from the current standardization of the LASC program to retrospectively include the knowledge gained from the decade of its pragmatic, real-world implementation. The results can inform further studies, implementation, and scale-up of the LASC concept in other low-resources contexts in need of a context-sensitive, resource-appropriate, holistic model of community-based stroke recovery and rehabilitation.
Methods
Design & Ethics:
This is a qualitative case study, using key-informant interviews and ethnographic methods, subject to secondary, triangulated data analysis of the implementation determinants.
The data input for this study was generated during a field visit to the LASC in Onitsha as part of quality-improvement and service-development operations from the OSCAIL group: an international group of experts continuously partnering with the Stroke Action Nigeria for supporting the technical development of the LASC over time. In the supportive field visit, the partnering members (SB, JB, members of the OSCAIL group) conducted data collection which consisted of own field notes, reflections, observations and collected information from key-informants, as fully anonymized. Those de-identified notes were the data corpus of the research, subject to a data sharing agreement (OSU ID A205-0015) between the OSCAIL group and the external analysts for the secondary data analysis. Validation procedure through cross-checking occurred with key informants at the LASC over the final results. All the key informants provided written, signed consent to publish these findings.
Procedural overview:
International visitors (SB, JB) performed a multi-method, iterative qualitative data collection (i.e., key-informant & stakeholder interviews; participant observation) combined with an iterative synthesis on the implementation determinants and activities. These international visitors used a custom-made, pre-designed enquiry guide to inform the iterative data collection and synthesis (see Supplementary Appendix 1). That enquiry guide was derived from the Consolidated Framework for Implementation Research (CFIR) 2.0. [24] Then two external analysts (TJ, AS) conducted a secondary thematic analysis of the synthesized, de-identified fieldwork notes. The aims were to qualitatively analyze the 1) implementation facilitators, and the 2) implementation barriers and respective strategies for feasibly implementing the LASC in Onitsha, Nigeria. Finally, in addition to being results themselves, the thematic-analysis findings were also coded against and translated to a CFIR-based map of salient implementation facilitators and barriers. This report follows the Standards for Reporting Qualitative Research and guidelines for reporting qualitative studies [25].
Context of the research:
The qualitative study was conducted at the LASC in Onitsha, Nigeria. The LASC has been operating in this location for nearly a decade, having been established by Stroke Action Nigeria, a locally funded NGO which promotes the LASC development and manages its operations. Supported by the local coauthors (RM, IO; AO, OO), the data collection occurred in Nigeria, in February 2024, during a week-long study visit to the LASC by the two international experts (SB, JB) in supporting standardization of LASC data management. The week-long study visit enabled an intense, in-person, full-time immersive experience with the existing LASC structure, operations, and culture; it was the first time these international experts had traveled to the LASC in Nigeria. The case study of the implementation determinants and strategies included nearly one decade of pragmatic developments and implementation of the LASC in Onitsha (i.e., since 2015), and the current activities toward standardizing the LASC model and operations which has been partly facilitated by a short-term pilot grant funding.
Data collection details: process, tool, methods & participants:
During their week-long trip to Onitsha, the two international visiting experts (SB; JB) performed iterative, multi-method, data collection consisting of key-informant & stakeholder interviews as well as participant observation. The data obtained was iteratively combined with an immediate, anonymized data synthesis and response-gap analysis. The visiting experts used the custom-made, pre-designed enquiry guide to inform the iterative data collection and synthesis derived from the CFIR 2.0 [24] (Supplementary Appendix 1). That enquiry guide provided the visiting experts with the set of domains needed to iteratively gather and analyze information on the implementation determinants and activities, for either the historical or current context.
Key informants, meaning the individuals who possess experiential knowledge or insights of phenomena under study, were identified by the local coauthors. Here, key informants were the local developers and implementors of the LASC, LASC staff, and LASC ambassadors, clinical directors of referring hospitals, and health system stakeholders at national level. Specifically, key informants and stakeholders at the micro-system level were LASC staff (n= 6) and NGO leadership (n= 4), and at the macro -system level were existing or potential referral hospital staff (n=3) and national health system staff (n=2). Data collection involved two individual, semi-structured interviews with the local LASC leaders, three group meetings with clinical directors of referring hospitals and one group meeting with national health system staff. Routine activities of the LASC were observed, including informal (i.e., unstructured, non-recorded) conversations with staff and care recipients. Collectively, these informants or stakeholders provided the grounds that enabled the international visitors to progressively input, synthesize, and refine the content in the enquiry guide. Importantly, the data entry involved the visitors/experts’ own observations and syntheses of the collected perspectives (i.e., no personally identifiable information or perspectives)
Importantly, over the week of the study visit, the data collection and synthesis process were highly iterative, amongst the team. The international visitors were inputting their syntheses into the evolving guide. When one or more items in the enquiry guide had unclear answers or no responses from the data/perspectives already obtained, additional data collection or participant checking was undertaken to address the gaps. This iterative process was repeated until analytical saturation was achieved (i.e., no gaps in the guide and no new information or perspectives were being added by the key informants or participant observation). In total, during the week-long visit, the international visitors collectively conducted approximately nine hours of participant observation, two hours of individual interviews with key informants and stakeholders at the LASC, and three hours of meetings with key informants and stakeholders at health system level. After the field trip, a total of six hours of participant checking occurred focusing on refining, complementing, confirming or clarifying the reported information and analytical products.
Analysis
In addition to the initial data synthesis performed locally by the international visitors, the resultant product was subject to an analytical form of investigator triangulation [26] and secondary thematic analysis performed by two external analysts (TJ, AS). That external analysis was meant to provide a qualitative meta-analytic product and reduce the potential of bias from the participant international visitors. In specific, the two external researchers conducted a secondary, inductive form of thematic analysis, using the Braun and Clarke guidance [27]. The goal was to identify key, overarching themes emerging from the initial, fully de-identified synthesis performed by the international visitors and enhance the interpretation and transferability of the results. Finally, based on the full thematic analysis, the two external analysts used the CFIR 2.0 to map out which key constructs of this implementation science framework were appraised as being salient barriers or facilitators for the implementation of the LASC in Nigeria.
Although conducted independently by the two external analysts, both the thematic-analysis and the CFIR-based [24] mapping involved a collaboration with the international visitors. This was particularly applied in the latter stages of the thematic analysis (i.e., reviewing, defining and naming themes as well as producing the report), and for refining the CFIR-mapped analysis. That process involved having the international visitors performing member checking with key informants for a strengthened validity and trustworthiness of the results provided.
Results
In these results, we describe the qualitative analysis of the implementation factors, and the qualitative analysis of the implementation barriers & strategies. We then provide a CFIR-based synthesis and map of both the facilitators and the barriers for the implementation of the LASC in Onitsha, Nigeria
- Qualitative analysis of the implementation facilitators
Table 1 provides a detailed analysis of the themes, codes, and synthesized content on the implementation facilitators of the LASC implementation in Onitsha, Nigeria. In that analysis, six themes facilitator emerged from 7 unique codes (ranged from 2 to 5 per theme): 1) A context-sensitive approach driven by local champions; 2) A holistic approach to addressing stroke survivors’ needs 3) Efficiencies and affordability leading to consistent patient attendance, including equitable; 4) Provision of transportation and lunch to improve attendance; 5) Referral mechanisms direct stroke survivors to the LASC and increase demand; 6) Community and policy stakeholder engagement increases understanding of the purpose of the LASC.
- 2.
- Qualitative analysis of the implementation barriers & strategies
Table 2 provides the thematic analysis for the implementation barriers and respective strategies. In total, five themes emerged out of 12 unique codes (ranged from 2 to 3 per sub-theme). The five themes were: 1) Further evidence is needed on effectiveness and implementation; 2) Variable funding affects long-term planning and operations; 3) Further integration into the health system and its priorities is needed; 4) Ongoing staff training and development is needed; 5) Space and technological constraints require consideration.
- 3.
- CFIR-based synthesis of implementation facilitators and barriers
Table 3 outlines a CFIR-based map and synthesis of the implementation domains from the analyses presented in Table 1 and Table 2. This CFIR-based synthesis was also informed by the content in Supplementary Appendix 2, which provides a de-identified detailed description of implementation requirements and activities, including objective information such as number of staff hired, their salaries, time allocation, the guidance provided by external collaborators, etc. The detailed appendix can be useful for pragmatically informing those planning or tasked to implement a LASC model in other low-resource resources.
In the CFIR-based synthesis of implementation facilitators and barriers (Table 3), some of the key facilitators emerged out of key attributes of the LASC model. For example, the local “adaptability” and local “sources” of the innovation development were implementation facilitators, likewise the “relative advantage” compared to any of the scant alternatives. That “relative advantage” emerged out of holistic patient needs being met with a resource-efficient model - with both operating costs and costs for attending patients being much lower than for any of the scant alternatives, although still more costly than some can afford. All these intrinsic attributes of the LASC contributed to its long-term pragmatic implementation. These attributes also generated substantive traction across stakeholders, including patient attendance.
Table 3 also shows that socio-behavioral or attitudinal issues like “local attitudes”, “culture”, “mission alignment”, or “motivation” were all facilitators for implementing the LASC because the LASC was considered responsive to local “needs” with locally available resources. Multiple stakeholders (e.g., staff, patients, local community leaders, referring hospital agents) have shown commitment and support for the LASC operations, which were seminally driven by local champions. In turn, these champions have been more than “implementation leads”. They can be better described as leading agents of change who have acted as local social entrepreneurs (establishing an NGO which runs the LASC), acting on a mission to sustainably address locally unmet stroke rehabilitation needs. In doing so, these local agents of change, have been establishing the needed “partnerships & connections”, seizing “available resources” in the community for resource efficiency, and have been developing advocacy for obtaining local traction and some national support from “high-level leaders”.
At that broader policy level, an increased awareness and support for the LASC has not been yet translated into more substantive action. For example, there is no public funding of LASC activities or formal integration with the health system yet, along with lack of operationalized priorities on deploying community-based stroke care. The current lack of integration and financing are barriers to the long-term implementation of the LASC, at least in an upscaled form (e.g., de-escalation may occur after the current pilot study funding).
As an important complement to the above, “implementation supports” have been provided, especially for the current pilot study, including from international researchers and facilitators. That support has been instrumental, including for the new study-related tasks, including for improved data collection and management. All of that increased the “complexity” of the tasks for the new LASC’s staff, hired for the pilot study period. That compounded with the increased service-delivery load derived from the enhanced patient recruitment, implying rearrangements of the staff’s “work infrastructure” and a necessary learning curve for staff on how to perform and manage all their new tasks.
Finally, further “implementation support” and “knowledge & information” tools may benefit future implementation endeavors. For example, the ongoing development of written, systematized evidence-informed modules of the LASC’s program activities can add to the reproducibility of the LASC model and written.
Discussion
This qualitative case study identifies the real-world implementation facilitators, barriers, and strategies associated with the first LASC in Nigeria. Spanning nearly a decade of pragmatic implementation and its current program, the research reveals critical attributes that have made the LASC model sustainably implementable in a low-resource context. Through triangulated thematic analysis and CFIR-based mapping, the study highlights the importance of the LASC as a context-sensitive service delivery model, driven by local champions, with capacity to meet patients’ needs holistically, utilizing locally available resources, and offering affordable care. In addition, the LASC incorporates other mechanisms that support equitable and reliable patient attendance, such as transportation, meals, and referrals. The CFIR-based synthesis further underscores the local “source,” “adaptability,” and “relative advantage” of LASC, which contrasts with the more expensive, discipline-specific, or often non-existent alternatives within the community. In turn, a more sustainable or widespread implementation of the LASC might benefit from the evidence and tools currently being developed to further supporting and documenting its feasibility, effectiveness, and reliable implementation across contexts. Stable funding and integration into the health system and its priorities can promote long-term planning and prevent operational constraints or de-escalation derived from unstable funding streams such international grants or local donations.
These results can be understood in the broader context of global health initiatives, and the need for contextually appropriate and locally driven responses to the health care needs of the community [28,29,30,31]. The LASC model exemplifies how effective health interventions can be rooted in local contexts, championed by local leaders, and tailored to meet the specific needs of the community. This approach challenges the top-down, westernized, and externally imposed models that have historically dominated global health initiatives, often disregarding local customs, resources, and needs. Instead, the innovation development starts with the local problem, needs and resources [28,29,30,31]. This grass-rooted approach contrasts with the traditional knowledge translation model, which often begins by developing and testing an innovation under ideal conditions (i.e., often in high-resource contexts) and then implementing it into low-resource contexts – with limited to no sustainability [22,32].
Local champions —individuals who are intimately familiar with the community’s needs and dynamics — have developed the LASC model to target local needs with local resources and developed a sense of ownership and local empowerment, supported yet not dictated by international partners. The role of international technical assistance here (e.g., from the OSCAIL group) has been instrumental in building local research and study capacity [33]. Yet, the LASC remains locally owned, locally designed, locally tailored, and locally implemented. Any replications in SSA and other low resource-contest, albeit adaptable to unique local context, must retain the key attributes that made the LASC implementable in the first place.
One of those attributes was the LASC model’s ability to provide care at a fraction of the cost of traditional, discipline-specific alternatives, and doing so by meeting a more holistic set of rehabilitation needs. That is a crucial step in addressing the financial barriers that often render healthcare and rehabilitation a privilege for the few, especially in low-resource contexts [9]. While in continuous operations for a decade, the LASC implementation continues to face a lack of a stable funding which derives from a lack of integration into the health system. While increasingly advocated, [34,35] the integration of rehabilitation services into the health systems is often a work in progress in many low-resource countries. That has been the case also for the LASC in Nigeria where implementation facilitators have been partly offsetting that important implementation barrier.
Study of the real-world implementation of the LASC model in Nigeria offers valuable guidance on the ‘how to’ of potential expansion of the LASC into other low-resource contexts, including in SSA, as tailored and driven by local champions. With the implementation in other countries, cross-pollination and cross-country regional learning opportunities [36] may improve on implementation in a variety of low-resource implementation contexts. This case study provides both an historical and current perspective of what it takes to implement a LASC model. It does so by embedding a field-based data collection, triangulated secondary analysis, inductive thematic analytical approach, and finally a CFIR-based mapping of implementation barriers and facilitators. Along with some objective data also provided (e.g., costs of hiring staff and their time and task allocation; recruitment gains with grant-funded incentives for no-cost patient attendance), this study provides valuable insights for those initiating the design and implementation of community-based stroke rehabilitation models in a low-resource context.
Finally, in addition to results, data collection tools developed here can be of use for similar endeavors elsewhere. For instance, work with a Malawian NGO is underway, utilizing the enquiry guide from the outset of planning the establishment of a LASC in Malawi. This has begun with identifying the advantage of the LASC in the local context in Malawi, the facilitators and barriers to securing a physical space, and the need to establish and maintain relationships with local champions. The enquiry guide and the facilitators and barriers to implementation found in Nigeria, will inform the ongoing planning and delivery discussions and decisions in Malawi. This is one applied example of how the study materials and results provided here can be useful for enabling the development and implementation of community-based stroke rehabilitation models in other low-resource contexts.
Limitations
This study should be understood in the context of limitations. First, this is a case study within a country context; hence, although valuable attributes are disentangled as applicable to a low-resource context, the transferability to other low-resource contexts should be done cautiously. Second, the study covered a large time period (the last decade) but the data collection occurred during one week of current activities; hence recall bias may apply to the historical key-informant perspectives. Third, some of the study authors (RM, IO, AO, OO) were active developers of the LASC model and activities in Nigeria and key informant themselves, in addition to facilitating the recruitment of other key informants. This may introduce bias, which was partly offset by the study design: two-level triangulated analysis first by the international visitors/experts (SB, JB) and then with an independent thematic and CFIR analysis conducted by two external researchers not involved with the operations or data collection. Fourth, we present a CFIR-base mapping of implementation barriers and facilitators only for a subset of domains and items that were deemed salient here by the analytical team, not for the full set of CFIR items. Fifth, this case study did not involve formal development and study of implementation strategies. A future hybrid effectiveness-implementation study design, including across country contexts, might address this and other current study limitations.
Conclusions
The LASC was purposively designed to be implementable in contexts with human resources, financial, and equipment constraints. Thes grassroots and context-appropriate design and implementation have increased the likelihood of success for the LASC model in a low-resource environment. The identified attributes of its historic and current real-world implementation provide key areas for further study, implementation, scale up, and replication, including elsewhere – with an example already under way in Malawi.
In conclusion, the LASC model is a compelling example of how stroke-rehabilitation service models can focus on local expertise, sustainability, and equity. It shows that when communities are empowered to design and implement their own health solutions, innovations are more likely to be implemented and endure. Global health policies and practices must move beyond a colonial framework that imposes external solutions (whose evidence arises from high-resource contexts) and, instead, support locally driven models that prioritize local responsiveness, engagement, equity, and long-term sustainability.
Declarations
Supplementary Materials
The following supporting information can be downloaded at the website of this paper posted on Preprints.org
Author Contributions
TJ: Conceptualization, study design, data analysis and wrote the main manuscript. SB: Study design, data acquisition, interpretation of the data, critically revised the main manuscript. JB: Conceptualization, study design, data acquisition, interpretation of the data, critically revised the main manuscript. IK: interpretation of the data, critically revised the main manuscript. AO: data acquisition, interpretation of the data, critically revised the main manuscript. OO: interpretation of the data, critically revised the main manuscript. AS: data analysis, critically revised the main manuscript. BRO: interpretation of the data, critically revised the main manuscript. MOA: interpretation of the data, critically revised the main manuscript. RM: Conceptualization, data acquisition, interpretation of the data, critically revised the main manuscript.
Funding
No funding to declare.
Consent for publication
Not applicable.
Ethics approval and consent to participate
The data collection was part of an ongoing quality-improvement and service-development activity occurring through the long-lasting active partnership between the Stroke Action Nigeria running the LASC and the OSCAIL’s international support group that has been technically supporting its development over time. Hence, the data collection was part of an ongoing quality-improvement / service development activity and partnership, not framed as research activity. Furthermore, key informants here were providing their perspectives on the LASC as a service delivery model, not about themselves, while ‘humans subject’ research is defined, according to the 45 CFR 46.102, as addressing individuals “about whom” the research is conducted. This was not the case here. Nonetheless, each of key informants was involved in validating the qualitative data analysis and provided signed, written consent for the publication of this manuscript. Finally, the secondary qualitative-data analysis conducted by external investigators was applied over anonymized field notes and perspectives. Secondary data analysis of de-identified information also is not framed ‘humans subject’ research subject to ethics approval. Nonetheless, a data sharing agreement was established between the OSCAIL group who collected the data as part of the supported quality-improvement process and the external analysts responsible for the secondary data analysis (Ohio State Agreement: OSU ID A205-0015).
Availability of data and materials
The de-identified dataset / field notes are provided in the supplementary appendix 2.
Acknowledgments
We would like to acknowledge the participation of the anonymous key informants that provided input for this manuscript.
Competing interests
None declared.
Abbreviations
| CFIR | Consolidated Framework for Implementation Research |
| LASC | Life After Stroke Center |
| OSCAIL | Organized Stroke Care Across Income Levels |
References
- Gouda, H.N.; Charlson, F.; Sorsdahl, K.; Ahmadzada, S.; Ferrari, A.J.; Erskine, H.; Leung, J.; Santamauro, D.; Lund, C.; Aminde, L.N.; et al. Burden of non-communicable diseases in sub-Saharan Africa, 1990-2017: results from the Global Burden of Disease Study 2017. Lancet Glob. Health 2019, 7(10), e1375–e1387. [Google Scholar] [CrossRef]
- Arokiasamy, P. India’s escalating burden of non-communicable diseases. Lancet Glob. Health 2018, 6(12), e1262–e1263. [Google Scholar] [CrossRef] [PubMed]
- Jesus, T.S.; Landry, M.D.; Brooks, D.; Hoenig, H. Physical Rehabilitation Needs Per Condition Type: Results From the Global Burden of Disease Study 2017. Arch. Phys. Med. Rehabil. 2020, 101(6), 960–968. [Google Scholar] [CrossRef]
- Abissegue, G.; Yakubu, S.I.; Ajay, A.S.; Niyi-Odumosu, F. A systematic review of the epidemiology and the public health implications of stroke in Sub-Saharan Africa. J. Stroke Cerebrovasc. Dis. 2024, 33(8), 107733. [Google Scholar] [CrossRef]
- Chukwudelunzu, F.E.; Mbonde, A.A. Stroke care in sub-Saharan Africa: Evaluating the present landscape and proposing strategies for improving outcomes. AN 2024, 3(2). [Google Scholar] [CrossRef]
- Jesus, T.S.; Arango-Lasprilla, J.C.; Kumar Kamalakannan, S.; Landry, M.D. Growing physical rehabilitation needs in resource-poor world regions: secondary, cross-regional analysis with data from the global burden of disease 2017. Disabil. Rehabil. 2022, 44(19), 5429–5439. [Google Scholar] [CrossRef]
- Prvu Bettger, J.; Liu, C.; Gandhi, D.B.C.; Sylaja, P.N.; Jayaram, N.; Pandian, J.D. Emerging Areas of Stroke Rehabilitation Research in Low- and Middle-Income Countries: A Scoping Review. Stroke 2019, 50(11), 3307–3313. [Google Scholar] [CrossRef]
- Bright, T.; Wallace, S. Kuper H: A Systematic Review of Access to Rehabilitation for People with Disabilities in Low- and Middle-Income Countries. Int. J. Env. Res. Public Health 2018, 15(10). [Google Scholar]
- Kamenov, K.; Mills, J.A.; Chatterji, S.; Cieza, A. Needs and unmet needs for rehabilitation services: a scoping review. Disabil. Rehabil. 2019, 41(10), 1227–1237. [Google Scholar] [CrossRef] [PubMed]
- Kumurenzi, A.; Richardson, J.; Thabane, L.; Kagwiza, J.; Musabyemariya, I.; Bosch, J. Provision and use of physical rehabilitation services for adults with disabilities in Rwanda: A descriptive study. Afr. J. Disabil. 2022, 11, 1004. [Google Scholar] [CrossRef]
- Urimubenshi, G.; Cadilhac, D.A.; Kagwiza, J.N.; Wu, O.; Langhorne, P. Stroke care in Africa: A systematic review of the literature. Int. J. Stroke 2018, 13(8), 797–805. [Google Scholar] [CrossRef]
- Kumurenzi, A.; Jesus, T.S.; Richardson, J.; Thabane, L.; Kagwiza, J.; Cockburn, L.; Langhorne, P.; DePaul, V.; Melifonwu, R.; Hamilton, L.; et al. A description of functional needs of community-dwelling stroke survivors in Rwanda: a prospective observational cohort study. Disabil. Rehabil. 2025, 1–8. [CrossRef] [PubMed]
- Jesus, T.S.; Landry, M.D.; Dussault, G.; Fronteira, I. Human resources for health (and rehabilitation): Six Rehab-Workforce Challenges for the century. Hum. Resour. Health 2017, 15(1), 8. [Google Scholar] [CrossRef]
- Agho, A.O.; John, E.B. Occupational therapy and physiotherapy education and workforce in Anglophone sub-Saharan Africa countries. Hum. Resour. Health 2017, 15(1), 37. [Google Scholar] [CrossRef] [PubMed]
- Louw, Q.; Grimmer, K.; Berner, K.; Conradie, T.; Bedada, D.T.; Jesus, T.S. Towards a needs-based design of the physical rehabilitation workforce in South Africa: trend analysis [1990-2017] and a 5-year forecasting for the most impactful health conditions based on global burden of disease estimates. BMC Public Health 2021, 21(1), 913. [Google Scholar] [CrossRef]
- Jesus, T.S.; Mani, K.; Bhattacharjya, S.; Kamalakannan, S.; von Zweck, C.; Ledgerd, R. Situational analysis for informing the global strengthening of the occupational therapy workforce. Int. J. Health Plan. Manag. 2023, 38(2), 527–535. [Google Scholar] [CrossRef]
- Bernhardt, J.; Urimubenshi, G.; Gandhi, D.B.C.; Eng, J.J. Stroke rehabilitation in low-income and middle-income countries: a call to action. Lancet 2020, 396(10260), 1452–1462. [Google Scholar] [CrossRef]
- Jesus, T.S. Hoenig H: Crossing the Global Quality Chasm in Health Care: Where Does Rehabilitation Stand? Arch. Phys. Med. Rehabil. 2019, 100(11), 2215–2217. [Google Scholar] [CrossRef]
- van Zyl, C.; Badenhorst, M.; Hanekom, S.; Heine, M. Unravelling ‘low-resource settings’: a systematic scoping review with qualitative content analysis. BMJ Glob. Health 2021, 6(6). [Google Scholar] [CrossRef] [PubMed]
- Kim, J.Y.; Farmer, P.; Porter, M.E. Redefining global health-care delivery. Lancet 2013, 382(9897), 1060–1069. [Google Scholar] [CrossRef]
- Bhattacharjya, S.; Curtis, S.; Kueakomoldej, S.; von Zweck, C.; Russo, G.; Mani, K.; Kamalakannan, S.; Ledgerd, R.; Jesus, T.S. Developing a Global Strategy for strengthening the occupational therapy workforce: a two-phased mixed-methods consultation of country representatives shows the need for clarifying task-sharing strategies. Hum. Resour. Health 2024, 22(1), 62. [Google Scholar] [CrossRef]
- Kumurenzi, A.; Richardson, J.; Thabane, L.; Kagwiza, J.; Urimubenshi, G.; Hamilton, L.; Bosch, J.; Jesus, T. Effectiveness of interventions by non-professional community-level workers or family caregivers to improve outcomes for physical impairments or disabilities in low resource settings: systematic review of task-sharing strategies. Hum. Resour. Health 2023, 21(1), 48. [Google Scholar] [CrossRef] [PubMed]
- Melifonwu R: Clinical stroke research in resource limited settings: tips and hints. Int. J. Stroke 2019, 14(5), Np13–np14. [CrossRef]
- Damschroder, L.J.; Reardon, C.M.; Widerquist, M.A.O.; Lowery, J. The updated Consolidated Framework for Implementation Research based on user feedback. Implement Sci. 2022, 17(1), 75. [Google Scholar] [CrossRef]
- O’Brien, B.C.; Harris, I.B.; Beckman, T.J.; Reed, D.A.; Cook, D.A. Standards for reporting qualitative research: a synthesis of recommendations. Acad. Med. 2014, 89(9), 1245–1251. [Google Scholar] [CrossRef]
- Carter, N.; Bryant-Lukosius, D.; DiCenso, A.; Blythe, J.; Neville, A.J. The use of triangulation in qualitative research. Oncol. Nurs. Forum 2014, 41(5), 545–547. [Google Scholar] [CrossRef] [PubMed]
- Braun, V.; Clarke, V. Using thematic analysis in psychology. Qual. Res. Psychol. 2006, 3(2), 77–101. [Google Scholar] [CrossRef]
- Feo Istúriz, O.; Basile, G. Maizlish N: Rethinking and Decolonizing Theories, Policies, and Practice of Health from the Global South. Int. J. Soc. Determ. Health Health Serv. 2023, 53(4), 392–402. [Google Scholar]
- Zakumumpa, H.; Diop, N.; Alhassan, R.K. Decolonizing global health: an agenda for research. BMC Health Serv. Res. 2023, 23(1), 832. [Google Scholar] [CrossRef]
- Büyüm, A.M.; Kenney, C.; Koris, A.; Mkumba, L.; Raveendran, Y. Decolonising global health: if not now, when? BMJ Glob. Health 2020, 5(8). [Google Scholar] [CrossRef]
- McCoy, D.; Kapilashrami, A.; Kumar, R.; Rhule, E.; Khosla, R. Developing an agenda for the decolonization of global health. Bull. World Health Organ 2024, 102(2), 130–136. [Google Scholar] [CrossRef]
- Malla, C.; Aylward, P.; Ward, P. Knowledge translation for public health in low- and middle- income countries: a critical interpretive synthesis. Glob. Health Res. Policy 2018, 3, 29. [Google Scholar] [CrossRef] [PubMed]
- MacDonald, N.E.; Bortolussi, R.; Kabakyenga, J. A long-term process for decolonizing and democratizing community-focused research: the case for MicroResearch in East Africa and in Canada. Can. J. Public Health 2023, 114(1), 147–151. [Google Scholar] [CrossRef] [PubMed]
- Ghaffar, A.; Bachani, A.M.; Hyder, A.A.; Cieza, A.; Bhangu, A.; Bussières, A.; Sanchez-Ramirez, D.C.; Gandhi, D.B.C.; Verbunt, J.; Rasanathan, K.; et al. : Role and promise of health policy and systems research in integrating rehabilitation into the health systems. Health Res. Policy Syst. 2024, 22(1), 143. [Google Scholar] [CrossRef] [PubMed]
- Jesus, T.S.; Hoenig, H.; Landry, M.D. Development of the Rehabilitation Health Policy, Systems, and Services Research field: Quantitative Analyses of Publications over Time (1990-2017) and across Country Type. Int. J. Env. Res. Public Health 2020, 17(3). [Google Scholar] [CrossRef]
- Oliveira Hashiguchi, L.; Conlin, M.; Roberts, D.; McGee, K.; Marten, R.; Nachuk, S.; Mukti, A.G.; Nigam, A.; Ahluwalia, N.; Nagpal, S. Enabling cross-country learning and exchange to support universal health coverage implementation. Health Policy Plan 2024, 39 (Supplement_1), i125–i130. [Google Scholar] [CrossRef]
Table 1.
Facilitators for implementing the Life After Stroke Centre (LASC): themes (first column) and respective codes and synthesis of the coded content.
Table 1.
Facilitators for implementing the Life After Stroke Centre (LASC): themes (first column) and respective codes and synthesis of the coded content.
| themes | Codes | Synthesis of the underlying coded content |
| Context-sensitive approach driven by local champions | The LASC emerged out of local grass-roots movement and champions that have been key agents of change |
|
| The LASC model has gained local traction because it is tailored to fit the local context, culture, needs and resources |
|
|
| International technical support helps build the capacity without dictating the approach. |
|
|
| Holistic approach to addressing stroke survivors’ needs | LASC addresses rehabilitation needs that are unable to be met by local service-delivery alternatives |
|
| Stroke survivors want to attend the LASC because it addresses a range of stroke rehabilitation & recovery needs vs limited available alternatives |
|
|
| Efficiencies and affordability lead to patient attendance, including equitable | Stroke survivors can attend the LASC because the costs are a small fraction of the alternatives. |
|
| LASC’s lower operating costs have been partly driven by the ‘task-sharing’ workforce model |
|
|
| LASC’s lower operating costs has been partly driven by the sustainable personnel’ remuneration, recruitment, retention |
|
|
| LASC’s lower operating costs has been partly driven by the group activities |
|
|
| LASC’s lower costs have been partly driven by no or low costs with facilities and equipment, including donated infrastructure |
|
|
| Provision of transportation and lunch to improve attendance | Stroke survivors can reliably attend the LASC because transportation facilities have been provided, including preference-sensitive |
|
| Lunches and water are provided |
|
|
| Referral mechanisms direct stroke survivors to the LASC and increase demand | Referral pathways have been progressively established |
|
| Referral and recruitment pathways have been recently strengthened |
|
|
| Community and policy stakeholders’ engagement increases understanding of the purpose of the LASC | Political support has been sought and growing |
|
| Continuous advocacy for government-level programmatic integration and toward sustainability leads to some fruition |
|
|
| Buy in and active engagement of key health agents and respected community leaders |
|
Table 2.
Synthesis of the perceived Barriers and respective Strategies for implementing and sustaining the Life After Stroke Centre (LASC) in Onitsha, Nigeria.
Table 2.
Synthesis of the perceived Barriers and respective Strategies for implementing and sustaining the Life After Stroke Centre (LASC) in Onitsha, Nigeria.
| Themes | Codes |
Synthesis of the coded content: Barriers |
Synthesis of the coded content: Strategies to address the barriers (action taken, desirable or planned to be taken) |
| Further evidence needed on effectiveness and implementation | Evidence-informed, locally tailored model pragmatically developed and implemented for a decade but lacking rigorous, context-specific evidence of feasibility and effectiveness |
|
Action taken: Standardized the service delivery procedures and data collection and management before conducting an effectiveness and implementation trial Action planned to be taken: A full-scale trial on the effectiveness and implementation (e.g., type 1 hybrid trial), in this context and possibly across other low-resource contexts and countries. |
| Further funding support might benefit from the more solid evidence on the feasibility, effectiveness and implementation in low-resource contexts |
|
Action planned to be taken: Local effectiveness and further implementation evidence, including costing, and future trials are planned to be translated (e.g., into policy briefs) and used in local, regional, national and international venues as an evidence-based advocacy tool to help further fund, sustain, or expand on this context sensitive service delivery model. That evidence base would facilitate all other actions here described. | |
| Variable funding affects long-term planning and operations. | Intermittent funding and partial reliance on partly unpredictable donations |
|
Desirable: The ability to secure sustainable funding and integration with the health sector and solutions on long-term financing and sustainability (beyond membership fees and partial reliance on donations), including in the integration with public financing |
| Variable levels of funding, including from the grants, prevent stable structure, scale, and operations |
|
Desirable: Same as above. Action planned to be taken: Applying for a full-scale trial may avoid de-escalation for a while, whereas the maintenance of historical funding support might partly assure the baseline levels of LASC activity. |
|
| Further integration into the health system and its priorities is needed | Further integration with the health system is required |
|
Action taken: Stroke Action Nigeria is renewing a Memorandum of Understanding (MoU) with Federal Ministry of Health. This provides a base to leverage support (financial, in kind) from national/state health institutions and to explore integration with outpatient services. Action taken: Stroke Action Nigeria is exploring with high-level national officer further developments such as including stroke contents in Community Health Worker training and for the development of a stroke management and care guide as part of office’s activities. It is also exploring stroke training for community health workers (CHWs) and joint World Stroke Day campaign with the Non-Communicable Diseases Department nationally & Asaba. These are opportunities to raise the profile of stroke unmet needs. |
| Policy awareness and recognition have not been translated into priorities, plans and action yet |
|
Action taken: Stroke Action Nigeria has continuously built relationships and advocacy locally, nationally and internationally with policy and research collaborators to help make service delivery for stroke a greater priority. Action taken: New MoU at national and state level is being pursued with a view to greater specificity in deliverables and roles and responsibilities for a continuum of stroke care within the health system that includes the LASC |
|
| Expansion opportunities for more physical sites and extended outreach, in addition to integrate the service with the health system |
|
Action taken: Discussions at surrounding hospitals and medical centers indicate the potential to utilize extant space in hospitals for LASC activities. This has the potential to: increase the number of locations where life-after-stroke services are delivered, to enhance the accessibility to service users, to increase referrals from the hospital and integrate the model with inpatient and outpatient hospital services. Action planned to be taken: Restart of LASC activities (stopped during the COVID 19) at the National Hospital Abuja and to explore expansion in different locations. |
|
| Ongoing staff training and development is needed | Need to systematically support staff on the new challenges: learning curves in the context of multi-task (e.g. service delivery; study project tasks) and increased workloads from enhanced recruitment. |
|
Action taken: Hands-on training as well as audit and feedback. The professional and non-professional staff have received guidance, including from OSCAIL team (e.g., through an initial site visit and then weekly guidance in online meetings), on areas such as: Randomization data; Anthropometric Measurements; Date of medical clearance; Data Collection practice and considerations (further details on the Supplementary Appendix 2, page 2). Action taken: A paper-based data entry with a posteriori digital scanning and automatic reading was taken as an option to prevent untraceable error/amendments and the dependency on the continuous functioning of local internet and digital facilities (further details on the Supplementary Appendix 2, page 2). Planned to be taken: In addition to hands-on training, audit and feedback and the overall support from the OSCAIL team , there is a need for developing and deploying detailed, standardized staff manuals for their training, roles and procedures. These staff manuals may inform and complement the verbal input from the OSCAIL team (or other facilitators/implementers), and can be relevant for staff training, development, and consultation as needed. |
| Detailed, systematized manuals of LASC modular activities under development but available yet |
|
Action taken: The OSCAIL team are creating rehabilitation and recovery modules for a standardized LASC manual. | |
| Space and technological constraints require consideration | Space and layout not always allowing for privacy or for universal accessibility |
|
Desirable: Accommodations like the ability to install handrails in ramps and turn toilets wheelchair accessible. Desirable: Layout with two enclosed office spaces. This would be in addition to the existing spaces: one multi-purpose room (e.g. for group activities), another large room (gym, with no need to relocate equipment after use) and a smaller room of other interventions. |
| Dated information technology |
|
Desirable: Up to date information technology. |
Table 3.
CFIR-based mapping of the salient implementation facilitators and barriers for the LASC during its historical pragmatic implementation and the current pilot study on feasibility. Note: the mapping displays only the most salient constructs and here was not exhaustive of all CFIR constructs and domains or of those that apply to the LASC but to a lesser or not so salient extent; for instance, the CFIR's Implementation Support domain was not included here as it refers to formal implementation studies or activities which may occur after the pilot study in the LASC, Nigeria.
Table 3.
CFIR-based mapping of the salient implementation facilitators and barriers for the LASC during its historical pragmatic implementation and the current pilot study on feasibility. Note: the mapping displays only the most salient constructs and here was not exhaustive of all CFIR constructs and domains or of those that apply to the LASC but to a lesser or not so salient extent; for instance, the CFIR's Implementation Support domain was not included here as it refers to formal implementation studies or activities which may occur after the pilot study in the LASC, Nigeria.
| I. INNOVATION DOMAIN | Facilitator | Barrier | Notes on how elements of the construct have been a facilitator, barrier or both |
| A. Innovation Source | The innovative model arises primarily from the local sources, agents and needs, integrating and adapting evidence-based interventions from high-resource contexts to the local low-resource requirements. That has led to substantive local traction | ||
| B. Innovation Evidence-Base | As a whole LASC program and specifically in low-resource contexts, there is still a need to build a solid, generalizable evidence base of the LASC feasibility, implementation, and effectiveness; that is beginning to be done with the current pilot study and its accomplishment will facilitate other subsequent developments | ||
| C. Innovation Relative Advantage | Important relative advantages in cost, availability, accessibility and holistic needs met, plus transportation and other facilities provided, all of them unmatched compared to the few discipline-specific community-based options | ||
| D. Innovation Adaptability | Albeit the core components of the LASC model are identified (e.g., task-sharing, day-based center, group activities), operationalization details are tailorable to local needs and resources | ||
| F. Innovation Complexity | The multiple modules that make the LASC model holistic, the need to consider multiple structural, operational, financing and other determinants for setting or upscaling a day-based community center model, further combined with the need to enhance data collection, management and other study activities compound toward the complexity of the model and its implementation. | ||
| G. Innovation Design | The LASC model was locally designed | ||
| H. Innovation Cost | The LASC model has been designed to be resource-efficient, including in operational costs and in the out-of-pocket costs for patient attendance which are much lower than the few extant alternatives | ||
| II. OUTER SETTING DOMAIN | Facilitator | Barrier | Notes on how elements of the construct have been a facilitator, barrier or both |
| B. Local Attitudes | The staff, patient, local community and broader local stakeholders have expressed engagement, gratitude and both implicit and explicit support to the LASC model, its mission, implementation, and expansion | ||
| D. Partnerships & Connections | Partnership and connection have been continuously established over time with multiple local, regional, national, and international stakeholders to advance the LASC model and its continuous operation and improvement. | ||
| F. Financing | Although philanthropy, research grants, and membership fees for patient attendance have been financing operations, there are no long-term or established funding with temporary variations for example when research grants go away there is a need for de-escalation. Public funding has not been available to partly operate the LASC and supplement the other financing sources | ||
| III. INNER SETTING DOMAIN | Facilitator | Barrier | Notes on how elements of the construct have been a facilitator, barrier or both |
| 1. Physical Infrastructure | The main physical space is donated, repurposed and rent-free, which reduces operational costs, builds efficiencies and reduces costs for patients toward enabling attendance. As a trade-off, this makes the space usable but not always a perfect fit (one or more enclosed offices and wheelchairs-accessible toilets would be needed) | ||
| 2. Information Technology Infrastructure | Some of the hardware used is outdated and affects the efficiency and workflow | ||
| 3. Work Infrastructure | Organization of the multiple staff's tasks is still being systematized, but with a specified time allocation for each type of task and a degree of flexibility | ||
| D. Culture | Local culture and shared values have been accounted for in the design, operationalization | ||
| 1. Human Equality-Centeredness | Multiple mechanisms exist to try to make the LASC affordable for all attending patients and, as funding allows, with waived fees for those who are unable to pay those fees or for transportation | ||
| 2. Recipient-Centeredness | There are strong shared values beliefs of the LAS staff, leaders and other related stakeholders about the LASC model as one capable of addressing the community-based rehabilitation needs and welfare of stroke survivors in holistic, context-sensitive and holistic manner. | ||
| H. Incentive Systems | Patient incentives (waivers of membership fees, reimbursement of travel for a patient's preferred travel method) during the pilot trial, along with the reinforced activities for obtaining hospital-derived referrals, were able to increase the patient enrollment | ||
| I. Mission Alignment | The LASC has been designed and delivered to reflect the overarching commitment, purpose, or goals of the LASC stakeholders about equitably and feasibility meeting the holistic needs of stroke survivors in the community versus little to no alternatives. | ||
| J. Available Resources | The community has provided donated resources, either financial or in-kind, to support the LASC operations and equitable patient attendance. | ||
| 1. Funding | Research funding has been available to study the feasibility of the LASC with upscaled patient recruitment but no funding is yet secured for maintaining operations at that level of activity or for a study of implementation strategies for the current site or expansion | ||
| 3. Materials & Equipment | Basic gym equipment donated from the UK has been sufficient for the LASC program activities that were not designed to be high-tech or reliance on expensive equipment | ||
| K. Access to Knowledge & Information | Supportive material and guidance have been made available on evidence-based assessment and intervention resources, but a detailed 'one-stop-shop' manual for staff training, guidance, role description, and ongoing consultation would be beneficial, as well. | ||
| IV. INDIVIDUALS DOMAIN | Facilitator | Barrier | Notes on how elements of the construct have been a facilitator, barrier or both |
|
ROLES SUBDOMAIN Project Roles: [Document the roles applicable to the project and their location in the Inner or Outer Setting.] | |||
| A. High-level Leaders | Policymakers and other high-level leaders are increasingly aligned with the need to develop health and community-based responses for stroke survivors but not yet fully translated into actual policies and plans. | ||
| D. Implementation Facilitators | Individuals with subject matter and methodological expertise, including international, are actively supporting the development, implementation and conduct of a systematized LASC model, data collection, and data management. | ||
| E. Implementation Leads | A local champion and Principal Investigator, along with other local supporters, is taking charge of the operational, strategic, research, social entrepreneurship, and advocacy activities. | ||
| G. Other Implementation Support | The local champion has the support of a large international group with varying levels of expertise who contribute to technical tasks (e.g., evidence-informed modules) and to overall support through periodic meetings; however, there is also a need for a written tool for supporting staff, their training and their role performance. | ||
| CHARACTERISTICS SUBDOMAIN | |||
| A. Need | Population unmet needs, enhanced levels of patient recruitment, attendance, and reference to the holistic benefits of the model | ||
| B. Capability | Learning curve for the new staff facing challenges in role performance but with adaptive capability including for the required multi-tasking; enhanced supports needed for their enhanced capability, including in study-related procedures | ||
| C. Opportunity | The increasing recognition of the growing burden of stroke and unmet needs in low-resource contexts provides the awareness and opportunity to support the study, development and implementation of service-delivery solutions such as the LASC | ||
| D. Motivation | The local agents of change, staff, and overall community showed high levels of proactive commitment, engagement, and alignment with the LASC model and its mission. Patients were also motivated to attend and benefit from the differential LASC attributes relative to alternatives, when these exist. | ||
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2026 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Copyright: This open access article is published under a Creative Commons CC BY 4.0 license, which permit the free download, distribution, and reuse, provided that the author and preprint are cited in any reuse.
