Generalisability
non-fluent aphasia, depressed, depressed ABI, depression, aphasia
RECRUITMENT
Generalisability has benefitted from using a mixed-methods design, in accordance with MRC recommendations [A study strength is that circumstances necessitated a variety of recruitment routes, from clinician referrals in NHS services, through charities and from social media self-referrals that can be useful to use in future trials. The blocked randomisation ensured that potential participant differences due to recruitment route would not have a disproportionate impact on any group. Whilst underpowered to examine quantitative outcome differences, the qualitative data at least suggest that both interventions were well-received.Participants were mainly in the chronic stages of ABI. Earlier stages are associated with greater frequency of impairments and impact on function, which can limit intervention engagement [It is likely that improvements in group outcomes in part rely on the degree of cohesion among BA group members. Our trial conducted randomisation at the individual level and therefore pre-selection of similar participants to either group (e.g., in terms of demographics and ABI severity/type of impairments) was not possible. However, our qualitative data indicated that some participants preferred groups comprised of individuals with similar experiences/needs. Future trials should therefore evaluate whether alternative randomisation methods (e.g., cluster randomisation) may be appropriate and incorporate measures of group cohesion as an outcome mediator. Of course, in clinical settings, there is often a balance between using waiting lists to accumulate group participants with similar needs and imposing unduly long waiting times. For this reason, individual therapy provision, or the use of rolling admissions into formerly “static” BA groups to ensure earlier access to an intervention, may be more practical in some cases. Groups such as the Experiential BA group may lend itself to rolling recruitment better than a Traditional BA group that could perhaps be used as a method of positive benefit until a more static Traditional BA group begins.In protocols for future trials, it may be worth explicitly incorporating how to manage participant delays between baseline assessment and intervention start that strikes a balance between internal and external validity. In clinical practice, participant delays in starting groups (e.g., due to illness, personal circumstances, or return to work dates) may occur occasionally and sometimes intentionally (i.e., in pre-selecting participants who are likely to have good group cohesion). Given we observed three such delays due to personal circumstances within our study, it is likely that a definitive trial will encounter similar situations. One solution could be to pre-specify fixed time windows between baseline assessments and intervention start.With a mild to moderately depressed sample, it is unknown whether results extend to those with severe depression and therefore further evaluation in severely depressed ABI samples may be warranted. Some participants stated that discussing highly personal and emotionally challenging content was not well-suited to groups. One-to-one support may be preferred in those with more severe depression [Based on data from participants with aphasia, dedicated groups for those with non-fluent aphasia are likely to have greater acceptability [Generalisability must be considered in light of in-person vs. remote delivery. For the former, transport was a considerable barrier for many participants. Transport and access-related barriers relate to community integration and well-being in ABI [For online sessions, trading-off limitations (e.g., creating a cohesive group atmosphere online) against higher attendance was preferred by many. Participants with greater physical disabilities and those who found travel too cognitively demanding/tiring particularly benefited. Some online participants, due to service provision differing across regions, could 