Journal of Rehabilitation Medicine 51-5 | Page 43

Sexuality after stroke on sexual activity (16–18). However, the 18 items prioritized by our panel as core content for inclusion in post-stroke sexual rehabilitation curricula reflect a much broader understanding of sexuality. The ad- ditional 27 content areas that achieved a high level of consensus, but a lower level of priority, potentially point to the need for a stepped care (32) approach to sexual rehabilitation. Using a stepped care model, the majority of stroke survivors and their partners could be offered a core programme during the first stage (Step 1) of a sexual rehabilitation curriculum. In the second stage (Step 2), those who need additional support could select other content areas based on individual need and preference. This stepped care approach would need evaluation, but potentially offers a method of addressing sexuality within existing stroke rehabilita- tion services. Participants in this study did not exclude sexuality from any stage of the stroke rehabilitation continuum. However, there was high level of consensus for the subacute and chronic stages of stroke recovery as key points when intervention should be offered. It is perhaps not surprising that participants did not believe sexual rehabilitation should be prioritized during the earliest stages of stroke recovery, given that, for many, the acute phase is focused on achieving medical sta- bility and preparing for rehabilitation. This finding also reflects previous research, where most stroke survivors want counselling about sexuality between 3 and 12 months post-stroke (5). However, there was a high level of consensus that access to sexual rehabilitation services should be available throughout the continuum. Clinicians and researchers therefore need to be mindful of the individual nature of stroke recovery and recognize that individuals will require support to adjust to post-stroke sexuality at different times in their recovery journey. Previous research indicates that stroke survivors, their partners and health professionals struggle to openly discuss sexuality (1). However, despite this struggle, participants in our study prioritized face-to- face delivery by health professionals over other modes. Given the high levels of discomfort reported by stroke professionals regarding sexuality (11), this finding suggests an urgent need for education and training to support professionals as they assume this new role. Further work is also needed to explore how stroke survivors and their partners might be supported to take on roles as peer counsellors, including their training and education needs. Participants prioritised rehabiltiation physcians, nur- ses with specialist knowledge in stroke and sexuality, psychologists, physiotherapists and sexologists/sex educators/ counsellors as the preferred service provi- ders. Previous research has also identified physicians 359 and nurses as key providers of sexual rehabilitation counselling (5), but limited attention has been given to the roles of allied health professionals in addres- sing sexuality after stroke. Our study suggests a need to adopt a multidisciplinary approach to sexual reha- bilitation. Although sexologists may not be routinely available for referrals by stroke rehabilitation teams, our findings suggest that there is a need to develop onward referral pathways for stroke survivors and their partners when needs cannot be met by traditional stroke rehabilitation professionals. Furthermore, stroke survivors with communication difficulties need access to speech pathologists who can support communication about sexuality. While the Delphi methodology allowed consensus to be reached on the content and delivery of sexual rehabilitation following stroke, there are some study limitations. First, although we attempted to recruit a diverse panel of experts, our panels were largely composed of people who identified as heterosexual, and who, for the most part, came from white Austra- lian backgrounds. If their backgrounds had been more diverse, different aspects of sexuality may have been prioritized. Secondly, while we successfully recruited stroke survivors with self-reported communication difficulties, the nature of the survey meant that in- depth description and assessment of communication was not conducted. Thus, we may not have provided a comprehensive description of all aspects of their communication presentation. Readers should note this limitation when considering how representative our participants are of people with communication impairment following stroke. Finally, although there were high levels of consensus among panel members regarding inclusion of content, timing and mode of service delivery, panel members failed to exclude any of the original content areas pre- sented in the first round of data collection. This lack of discrimination may reflect their limited exposure to, and experience with, sexual rehabilitation. The majority of stroke survivors and their partners in our study did not receive any information or advice from health professionals regarding sexuality. Therefore, it could be argued that the knowledge of these experts was limited, and responses represent their best judge- ment on what content might be helpful. Despite this limitation, we believe that the inclusion of open-ended questions throughout the survey allowed panellists to comment and express their views, resulting in greater ecological validity of results. In conclusion, there is a need for informed, evidence- based interventions to address sexuality after stroke. This study presents the opinions of stroke survivors, their partners, clinicians and researchers. Inclusion of stroke survivors with self-reported communication J Rehabil Med 51, 2019