Stroke rehabilitation in coastal Eastern England: a qualitative study of intersectional inequalities.

Abstract

Disparities in stroke incidence, outcomes and access to healthcare are increasingly reported-including in relation coastal status-yet a health-systems perspective is rarely applied to examine root causes. This study utilises a health-systems approach to explore how rehabilitation models of care may exacerbate or mitigate health inequalities, in an organisation serving rural and coastal communities in England. A multi-faceted theoretical framework drawing on seminal health-systems concepts was derived, to guide this qualitative study. Focus group discussions with stroke professionals were conducted. Data were analysed thematically, and iteratively, <i>via</i> operationalisation of the theoretical framework. Rehabilitation systems exacerbated health inequalities, which was related to unresponsiveness to personal and social determinants, geographical factors and system-level factors. Bottlenecks were identified in accessibility and effective health coverage, which were associated with multiple aspects of a health system, including service delivery, financing, workforce, health information systems and leadership/governance. Four recurrent intersectional high‑risk profiles emerged. There are significant, system-derived challenges in the current stroke rehabilitation and life-after-stroke provision in the region studied, which may exacerbate health inequalities for those who are already marginalised by society. Applying an intersectional framework to develop solutions for equality in rehabilitation systems is required.