Improving Community Stroke Rehabilitation Using Enriched Environment Activities (EEAs) - the VOCALS study

(Developing strategies for improVing OutComes And Living well with people living at home with Stroke)

Stroke survivors often face gaps in community rehabilitation services, so use self-initiated, everyday activities like jigsaw puzzles or laundry-folding to aid recovery. The VOCALS study explores how these "Enriched Environment Activities" (EEAs) can be optimised to enhance functional recovery, independence, and quality of life at home.

Stroke affects 113,000 people annually in the UK, with many experiencing long-term disability. Current rehabilitation services often end after six months, leaving survivors to develop informal EEAs at home. VOCALS identifies these activities, evaluates their effectiveness, and co-designs an accessible toolkit to bridge service gaps. Aligning with NHS Long Term Plan priorities, the study empowers stroke survivors through low-cost, scalable strategies to improve recovery outcomes and reduce recurrent stroke risk.

This 18-month study combines documentary analysis, interviews with 20 stroke survivors, and real-world testing of EEAs with 12 participants. Co-produced with patient advocates (PPI), it addresses health inequalities by focusing on diverse populations, including rural/urban and minority ethnic groups. The project supports UN Sustainable Development Goal 3 (Ensure healthy lives and promote well-being for all at all ages ) and NHS England’s stroke rehabilitation targets.

Background

Stroke survivors frequently rely on self-devised activities (e.g. jigsaws, virtual boxing) to supplement limited rehabilitation services. These EEAs – linked to improved cognitive, physical, and social recovery – are understudied in home settings. VOCALS fills this gap by amplifying survivor voices to shape practical, inclusive solutions.

Methods

Work Package 1 (Months 1–3)

  • Documentary analysis of stroke discharge guidance across England.
  • Co-design of data collection tools with PPI group.

Work Package 2 (Months 4–8)

  • Interviews with 20 stroke survivors (10 urban/London, 10 rural/Essex) to identify EEAs.
  • Thematic analysis using The Silences Framework to uncover EEAs in use.

Work Package 3 (Months 9–16)

  • Testing and iterating 10–15 EEAs with 12 survivors using the Model for Improvement.
  • Co-production of an EEA toolkit and enhanced discharge guidelines.

Work Package 4 (Months 17–18)

Dissemination via roadshows, social media, and partnerships, e.g. Stroke Association, Royal College of Occupational Therapists.

Patient and Public Involvement (PPI)

Two PPI co-applicants (Shani Shamah and Ernest Dunlop) ensured lived experience shapes all aspects of the study. Focus groups with stroke survivors and carers informed design, recruitment, and dissemination plans.

Anticipated impact

  • Short-term: Improved survivor agency and functional recovery.
  • Long-term: Evidence-based guidelines for NHS policymakers.
  • Outputs: Accessible EEA toolkit, academic papers, and a feasibility study protocol.

Funding and timeline

Funded by NIHR Research for Patient Benefit (NIHR207877), the study runs from April 2025 to October 2026.

1. Documentary review (Month 3)

Analysis of current hospital discharge guidance following a stroke.

2. Identification of stroke survivor-initiated EEAs in use at home (Month 9)

Interview study.

3. Data-driven iteration of EEAs and co-design of study outputs (Month 14)

  • EEA toolkit for use at home.
  • Good practice recommendations for hospital discharge guidelines.

Dissemination and impact (Month 15 onwards)

Project updates and final report published on NIHR project page.

We are seeking partnerships with community stroke groups to inform the development and testing of the EEA toolkit. Contact Joint Study Lead Prof Gillian Janes at [email protected] for more information.

Project team

  1. Prof Gillian Janes (Joint Study Lead) – Improvement science
  2. Prof Calvin Moorley (Joint Study Lead) – Stroke equity research
  3. Dr Paul Sugarhood – Occupational Therapy/rehabilitation practice
  4. Mrs Shani Shamah – Stroke survivor advocacy
  5. Mr Ernest Dunlop – Stroke survivor advocacy
  6. Prof Laura Serrant – Inclusive and community practice, health policy
  7. Dr Sivakumar Ramachandran – Stroke medicine
  8. Dr Audley Graham – Mixed methods research

External Partners