Barriers and facilitators to telerehabilitation adherence in young and middle-aged stroke survivors: a qualitative COM-B analysis

Objective To explore the barriers and facilitators to telerehabilitation adherence among young and middle-aged stroke survivors using the Capability, Opportunity, Motivation–Behavior (COM-B) model. Methods A qualitative descriptive study was conducted with 15 stroke survivors aged 18–60 years recruited from a tertiary hospital in China. Data were collected via one-on-one semi-structured interviews and analyzed using directed content analysis, with iterative mapping of codes to COM-B sub-domains. Results Fourteen themes were identified across the six COM-B dimensions, comprising eight barriers and six facilitators. Capability barriers included post-stroke physical exhaustion and low digital confidence, while facilitators were perceived functional recovery and movement self-correction. Opportunity barriers encompassed physical space limitations, unstable internet connectivity, and social isolation; facilitators were family support and therapist supervision. Motivational barriers included efficacy skepticism, digital fatigue, and re-injury anxiety; facilitators were return-to-work aspiration and routine integration. Adherence was shaped by dynamic interactions among these factors rather than isolated determinants. Conclusion Telerehabilitation adherence in young and middle-aged stroke survivors is influenced by a complex interplay of physical, cognitive, environmental, social, and motivational factors. Multi-component interventions that simultaneously target capability, opportunity, and motivation—such as fatigue management, digital skills training, home environment optimisation, family involvement, vocational goal-setting, serious games, and peer support—are warranted to enhance engagement and improve long-term outcomes. The COM-B model provides a useful framework for designing such tailored strategies.