Pilot Testing of the WHO Basic Package of Interventions for Rehabilitation (Basic PIR): Acceptability, Appropriateness, and Feasibility Among Primary Care Workers in China, Tajikistan, and Tanzania

Abstract

Introduction

Rehabilitation is essential for Universal Health Coverage, yet access remains limited in low- and middle-income countries. The WHO developed the Basic Package of Interventions for Rehabilitation (Basic PIR) to address this gap through task-sharing with primary care (PC) workers. This pilot study evaluated the acceptability, appropriateness, and feasibility of the Basic PIR clinical resource in China, Tajikistan, and Tanzania.

Methods

A mixed-methods explanatory sequential design was used, involving 53 PC workers. Quantitative data from Likert-scale questionnaires were followed by qualitative focus group discussions.

Results

High median scores (4–5) across all countries indicated strong initial implementation potential within the pilot cohorts. Participants found the resource’s clear visuals and simple interventions superior to existing tools. Qualitatively, the tool fostered professional empowerment, particularly among nurses. However, barriers included time constraints, resource gaps, and cultural preferences for passive treatments over active exercises.

Discussion

The Basic PIR demonstrated high implementation potential across all the pilot sites. Tanzania and Tajikistan had a near-universal agreement on its acceptability and, appropriateness. Although China showed strong feasibility, the PC workers noted cultural preferences for passive treatments and minor challenges with the Basic PIR’s design.

Conclusion

The Basic PIR offers a potentially viable pathway for integrating rehabilitation into PC in these settings. Successful implementation requires addressing systemic barriers and adapting to local cultural contexts to ensure long-term sustainability.

Introduction

Rehabilitation is an integral component of Universal Health Coverage (UHC) and it must be effectively embedded within primary health care (PHC) frameworks to ensure equitable and comprehensive access to essential services.^1,2 PHC represents a whole-of-society approach to health designed to strengthen national health systems by bringing essential services closer to communities.^1,3 The World Health Organization (WHO) defines rehabilitation as a “set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment”. ⁴ Globally, an estimated 2.6 billion people could benefit from rehabilitation at some point in their lives. ⁵ These services are crucial for optimizing functioning, improving well-being, and enhancing the overall effectiveness of healthcare.

However, access to rehabilitation services remains a significant challenge. Particularly in low- and middle-income countries (LMICs), rehabilitation is often inadequately integrated into primary care (PC), the first point of contact within PHC, which provides first-contact, accessible, continuous, comprehensive, and coordinated person-centered care.^6,7 With fewer than 10 skilled rehabilitation practitioners available per million people in PC and low-resource settings,^8,9 the World Health Assembly (WHA) recognized in 2023 this critical gap and adopted a Resolution on “Strengthening Rehabilitation in the Health System,” emphasizing the urgent need to integrate rehabilitation into health system to improve health outcomes for individuals with functioning limitations.^10,11 Importantly, one of the nine action areas of the Resolution urges member states to “expand rehabilitation to all levels of health, from primary to tertiary, … and to develop community-based rehabilitation strategies, which will allow rehabilitation to reach underserved rural, remote and hard-to-reach…” populations.

One promising approach to enhance rehabilitation access in PC settings is task-sharing. Task-sharing, a crucial approach especially in settings where higher-level provider availability is limited, enables the expansion of health service delivery to lay and mid-level healthcare providers without taking tasks away from more highly trained professionals.^12,13 In rehabilitation, it involves training existing non-rehabilitation PC workers (such as doctors, nurses, and community health workers) to deliver basic rehabilitation interventions. To facilitate this, the WHO developed the Basic Package of Interventions for Rehabilitation (Basic PIR). ¹⁴ The Basic PIR’s primary aim is to integrate rehabilitation into the care provided by current PC health workers through a task-sharing methodology. The Basic PIR comprises three key components: a clinical resource, a trainers’ handbook, and a practical guide for implementers. It is structured around eight core functioning domains: mental functions; vision; hearing, speech, and communication; swallowing; respiratory and cardiovascular; motor functions and mobility; pain; and self-care and participation. Within these eight domains, the Basic PIR outlines 20 corresponding intervention targets, which feed into 71 basic rehabilitation interventions that can be delivered by PC workers. It offers guidance on identifying rehabilitation needs, providing PC health workers with a carefully selected set of prioritized, safe, and easy-to-learn evidence-based interventions, and facilitating referrals to specialized rehabilitation services when necessary.

The development of the Basic PIR clinical resource involved a participatory approach across three phases, incorporating input from a diverse group of rehabilitation and non-rehabilitation experts. ¹⁴ The initial phase, guided by a technical working group, identified relevant rehabilitation interventions for PC settings, narrowing down 297 potential interventions from the WHO’s broader Package of Interventions for Rehabilitation (PIR) ¹⁵ to 71 core interventions across various functioning domains. This participatory process, overseen by the WHO Rehabilitation Programme, ensured the Basic PIR was specifically tailored for use in PC and low-resource settings. The second phase focused on structuring the Basic PIR resource, linking these domains with specific targets and interventions. The final phase involved preliminary field testing of components of the resource in Ghana and Fiji, followed by reviews and refinements, which included revising rehabilitation steps and creating patient handouts. The development of the Basic PIR has been reported in detail elsewhere. ¹⁴

However, studies evaluating the WHO’s Basic PIR in real life settings are pending. The objective of this pilot study is to evaluate the acceptability, appropriateness, and feasibility of the WHO’s Basic PIR clinical resource among PC workers in China, Tajikistan, and Tanzania.

Methods

Study Design

The pilot study used a mixed-methods explanatory sequential design, where quantitative data collection using questionnaires preceded and informed a qualitative phase using structured focus group discussions (FGDs).

Setting

Pilot tests were conducted in China, Tajikistan, and Tanzania. These countries were chosen based on their geographic representation, socioeconomic context, and national commitment to strengthening rehabilitation services, as evidenced by their use of the WHO STARS tool ¹⁶ or the development of national rehabilitation strategic plans, their expressed readiness to the WHO rehabilitation programme to pilot the Basic PIR and the specific aspects described as follows.

China was selected due to its significant demographic trends, particularly a rapidly aging population and a high prevalence of noncommunicable diseases (NCDs). These trends create immense demand for primary and community-based rehabilitation services where substantial unmet needs exist. ¹⁷ The current expansion of aged-care facilities presented a critical opportunity to deliver such services, and China’s efforts aligned well with the Basic PIR’s focus on PC.

Tajikistan, a lower-middle-income country in Central Asia, was selected for its ongoing efforts to address rehabilitation access gaps within a transitional healthcare system. Despite a critical shortage of rehabilitation professionals identified in a 2015 assessment, recent national health strategies and ministerial orders underscored a strong governmental push to improve rehabilitation access, particularly through primary healthcare worker training.^18,19 This ongoing reform environment provided a timely opportunity for the integration of the Basic PIR.

Tanzania, a low-income country in East Africa with a predominantly rural population, faces considerable healthcare challenges including limited infrastructure and a severe shortage of rehabilitation professionals across various disciplines. A 2019 Ministry of Health (MoH) assessment confirmed significant rehabilitation needs and a workforce gap, leading to a strategic plan prioritizing the training of existing primary healthcare workers in rehabilitation. ²⁰ The vital role of PC as the initial point of contact for healthcare in Tanzania made the Basic PIR essential for expanding rehabilitation access in this context.

Participants

In each country, purposive sampling was used by MoH and health facility managers to select PC workers within the same districts or regions. This sampling approach aimed to include PC workers essential in service delivery and the prospective implementation of the Basic PIR rather than to achieve statistical representativeness.

Inclusion and Exclusion Criteria

Participants were eligible if they were PC workers involved in service delivery, including doctors and nurses. As this was a multi-country study, eligibility was adapted to reflect the composition of the PC workforce in each setting. Accordingly, additional cadres were included where relevant (e.g., clinical officers in Tanzania and junior rehabilitation therapists in China).

Recruitment

The MoH in each country, in collaboration with health facility managers, led the participant selection process. External WHO officials, independent of the health facilities, invited selected participants via email or hard copy letters, providing detailed study information, including pre- and post-training assessments, questionnaires and FGDs. Participation was entirely voluntary; participants were informed of their right to decline without consequences and provided written informed consent prior to starting the study. Recruitment aimed for comprehensive inclusion of all eligible individuals to ensure robust and representative data.

Intervention

A WHO’s Basic PIR training aimed to equip PC workers with the skills needed to deliver essential rehabilitation interventions through task-sharing, supported by rehabilitation specialists. The training was conducted using standardized training materials and guidance to make sure there was consistency across countries. There were however minor contextual adaptations to promote local acceptance such as change of names in case studies. A standardized training-of-trainers approach was followed by a combination of WHO technical staff and local trainers in each country, in the delivery of training. In order to support training alignment, there was at least one WHO trainer consistently present across all three countries. Consistency was maintained by orienting all trainers to the same curriculum and materials, and regular coordination was undertaken to ensure adherence to the core training content across sites. The variation in training scope was a deliberate, context-driven adaptation intended to maximize local feasibility and relevance. Specific functioning domains of the WHO’s Basic PIR were prioritized following consultations and recommendations from the key national institutions and partners overseeing rehabilitation health in each pilot country, ensuring the training addressed recognized service gaps in their respective PC systems. In Tanzania, PC workers underwent a comprehensive 10-day training covering all eight Basic PIR functioning domains. In contrast, China and Tajikistan received condensed 5-day training programs to accommodate workforce availability for training with slight variations in scope: China covered four core domains (Swallowing; Pain; Motor functions and Mobility; and Self-Care and Participation), while Tajikistan covered three (Pain; Motor functions and Mobility; and Self-Care and Participation).

Data Collection

Quantitative Data

A self-reported questionnaire was used to collect quantitative data immediately after the WHO’s Basic PIR training. The questionnaire evaluated the acceptability, appropriateness, and feasibility of the Basic PIR, which are three key implementation outcome constructs (see Table 1 for definitions). The items for this questionnaire were adapted from established measures of implementation outcomes thereby supporting content validity, and presented on a five-point Likert scale (1 = “Completely disagree” to 5 = “Completely agree”),^21,22 modified to specifically reference the “Basic PIR clinical resource” (see Supplementary File 1: Quantitative Questionnaire).

Table 1.

Definition of Acceptability, Appropriateness and Feasibility

Term	Definition
Acceptability	The perception among implementation stakeholders that a given treatment, service, practice, or innovation is agreeable, palatable, or satisfactory
Appropriateness	The perceived fit, relevance, or compatibility of the innovation or evidence-based practice for a given practice setting, provider, or consumer; and/or perceived fit of the innovation to address a particular issue
Feasibility	The extent to which a new treatment or an innovation can be successfully used or carried out within a given agency or setting or problem

Note. Source: Weiner BJ, Lewis CC, Stanick C, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):108. https://doi.org/doi:10.1186/s13012-017-0635-3.

Qualitative Data

Qualitative data were collected through FGDs. Following the completion of the questionnaires, participants in each country were convened into two separate FGDs, each consisting of 6–10 individuals (totaling six groups across the three sites) to gain deeper insight into the quantitative findings. These interviews used a structured guide to explore participants’ views on the Basic PIR’s acceptability, appropriateness, and feasibility within the PC context (see Supplementary File 2: Qualitative Focus Group Discussion Interview Guide). Participant interviews were conducted in English (Tanzania), Mandarin Chinese (China) and Tajik (Tajikistan). All interview guides were translated into these respective languages prior to fieldwork. The interviews also gathered recommendations for future improvements. All interviews were audio-recorded with informed consent, and supplemented with detailed notes. The recordings were subsequently transcribed verbatim and verified for accuracy. Transcripts were translated into English where required to facilitate analysis. To ensure accuracy and preserve meaning, translations were reviewed by bilingual members of the research team familiar with the study context. A common coding framework was developed based on the study objectives and applied across all datasets. Coding was conducted by trained researchers, with regular discussions among the research team to ensure consistency in coding and interpretation across languages and to maintain semantic equivalence. Any discrepancies or disagreements in coding definitions or transcript interpretations were resolved through iterative consensus discussions until full agreement was reached.

Both the questionnaire and the interview guide underwent forward and backward translation and adaptation and were pre-tested during a similar training in Uganda to ensure clarity and relevance.

Data Analyses

Participants’ characteristics were summarized using descriptive statistics. Data from the Likert scales measuring the constructs of acceptability, appropriateness, and feasibility were analyzed descriptively. The median, interquartile ranges, and the percentage of participants who rated “agree” or “completely agree” were calculated for each of the scales.

A deductive content analysis ²³ was then conducted on the interviews by two researchers. A detailed reading of the transcripts from all three countries was done. Using the MAXQDA qualitative analysis software tool, codes were developed for each of the constructs. ²⁴ The list of codes was shared with two other researchers for input and clarification. The contents of the transcripts for each country under each construct and code were then compared to identify differences and similarities.

Triangulation was the final step of the data analysis, allowing for a comprehensive understanding of the Basic PIR’s acceptability, appropriateness, and feasibility. Given that the quantitative instruments were adapted and translated without formal psychometric validation, these analyses are strictly descriptive and exploratory in nature. Rather than drawing definitive comparative conclusions between countries, data from the three sites were examined side-by-side to capture a broad, context-specific overview of initial implementation experiences. Quotes from the FGDs were used to illustrate key perceptions of these constructs.

Ethical approval for this study was obtained through a WHO-approved master protocol (ERC.0003985006935/3) covering the multi-country implementation. Additional institutional ethical approvals were obtained in China (TJIRB202404115) and Tajikistan (№1-6/10288). In Tanzania, the study was conducted in collaboration with the Ministry of Health, and an ethics application was submitted in accordance with local requirements prior to the study. The study was implemented under the WHO-approved master protocol, and all participants across all sites provided written informed consent prior to participation. The study was considered to present minimal risk to participants.

Results

The pilot testing occurred over a period of 5 months, from May 2024 to October 2024. Overall, 55 PC workers were invited to take part in the study across the 3 countries and 53 participated (96%) (Table 2). All 53 participants who completed the quantitative questionnaires also participated in the qualitative phase. This phase consisted of six FGDs (two groups per country) with 6–10 participants per group, ensuring that the same cohort of healthcare workers contributed to both sets of data. A notable deviation from the inclusion criteria in China was the deliberate inclusion of junior rehabilitation therapists alongside PC doctors and nurses because of the significant number of rehabilitation personnel trained at the vocational/junior college level who are already working in PC. Another deviation was the selection of clinical officers, who are trained in basic and applied medicine and provide medical care for large and dispersed rural populations in Tanzania. The Basic PIR training upgraded the knowledge of these existing junior therapists and clinical officers to better meet the growing rehabilitation demands, especially in PC.

Table 2.

Participants Characteristics by Country(n=53)

Category	Basic PIR pilot country
	China	Tajikistan	Tanzania	Total n (%)
Gender
Male	3	10	8	21 (39.6%)
Female	16	7	9	32 (60.4%)
Background
Nurses	3	8	9	20 (37.7%)
Clinical Officers	0	0	8	8 (15.1%)
Doctors	4	9	0	13 (24.5%)
Junior rehabilitation therapists	12	0	0	12 (22.6%)
Total participants	19	17	17	53 (100%)

Note. Data are presented as frequency counts. The “Total n (%)” column represents the total number of participants and the corresponding percentage of the total sample (N=53) for each response category.

Evaluation of Acceptability, Appropriateness, and Feasibility

Table 3 presents the descriptive results of participants scoring on the acceptability, appropriateness, and feasibility of the Basic PIR. These scores are presented to illustrate localized trends within each pilot context.

Table 3.

Acceptability, Appropriateness, and Feasibility of the Basic PIR (n=53) by Country

​	China (n=19)	Tajikistan (n=17)	Tanzania (n=17)
Acceptability
The Basic PIR meets my approval	4 (1)/65%	5 (1)/94%	5 (1)/100%
The Basic PIR is appealing to me	4 (1)/71%	5 (0)/100%	5 (1)/100%
I like the Basic PIR	5 (1)/58%	5 (0)/100%	5 (1)/100%
I welcome the Basic PIR	4 (1)/60%	5 (0)/100%	5 (1)/100%
Appropriateness
The Basic PIR seems fitting	4 (1)/76%	5 (1)/100%	5 (1)/100%
The Basic PIR seems suitable	4 (1.25)/65%	4 (1)/94%	5 (1)/100%
The Basic PIR seems applicable	4 (1)/88%	5 (1)/100%	5 (1)/100%
The Basic PIR seems like a good match	4 (1)/71%	4 (1)/94%	5 (1)/100%
Feasibility
The Basic PIR seems implementable	4 (1)/71%	5 (0.5)/100%	4.5 (0.5)/100%
The Basic PIR seems possible	4 (1)/76%	5 (0.25)/100%	5 (1)/100%
The Basic PIR seems doable	4 (1)/76%	5 (0)/100%	4.5 (1)/100%
The Basic PIR seems easy to use	4 (1)/47%	5 (0)/100%	4.5 (1)/100%

Scale: 1 = completely disagree to 5 = completely agree. All columns display Median (IQR) as well as the % of “Agree” and “Completely Agree” response options.

Acceptability

Median scores for acceptability ranged from 4 to 5 across all participating countries. Tanzania and Tajikistan reached near-universal agreement, with median scores of 5 for all items. In China, median scores ranged from 4 to 5; specifically, while 58% of participants completely agreed with the statement “I like the Basic PIR” (Median: 5), the proportion of those who agreed or completely agreed that “The Basic PIR meets my approval” was 65% (Median: 4).

In the interviews, content analysis confirmed widespread acceptability of the Basic PIR across participants from all three countries. There was general agreement that the interventions within the Basic PIR matched patient needs. Particularly, participants in Tajikistan were happy with the simplicity and effectiveness of interventions.

“Yes, simple things, we did not ever think of will help our patients” (Doctor 1, Tajikistan)

However, they also highlighted contextual challenges for some rural areas alongside local preferences for traditional treatments.

“It is necessary to consider people's attitudes. Some people might not want to change anything. They may not like it if we do not give medicines or electrophoresis” (Doctor 2, Tajikistan)

Participants also noted some specific design issues including navigation difficulties and a need for clearer labelling in China, as well as a desire for larger pictures in Tajikistan to aid older users. There was also a strong demand for videos demonstrating exercises and patient progress in Tajikistan, and a suggestion for guidance on managing high patient rehabilitation expectations in China.

“I think we need to know how to manage a patient with high rehabilitation expectation” (Junior therapist 1, China)

While the language and professional fit of the Basic PIR were generally considered appropriate, Tajikistan showed mixed reactions; doctors felt the language was too simple, preferring more medical terminology, whereas nurses considered the language too formal or high level.

“The language needs to be more medical” (Doctor 1, Tajikistan)

“I think the language is too formal” (Nurse 1, Tajikistan)

Importantly, participants from all countries highlighted the Basic PIR’s superior usability compared to existing PC resources, noting its clearer explanations, better pictures, and simpler assessment forms.

“The Basic PIR is more clear with explanations and pictures” (Nurse 3, Tanzania)

Appropriateness

Median scores for appropriateness ranged from 4 to 5 across the three pilot countries. Tanzania recorded the highest results, with a median score of 5 and 100% agreement across all appropriateness items. In China, median scores were consistently 4; for example, 65% of Chinese participants rated the item “The Basic PIR seems suitable” as agreed or completely agreed (Median: 4). Tajikistan reported median scores of 4 to 5, with agreement ranging from 94% to 100%.

FGDs generally confirmed the appropriateness of the tool, but also identified specific potential implementation boundaries mainly centered around resource and behavioral constraints. In China and Tajikistan, significant issues included time limitations for staff.

“It will be more time consuming especially to select the interventions but willing to do it” (Junior rehabilitation therapist 3)

Participants in Tajikistan added patient travel distances and costs for multiple visits as well as the lack of dedicated rooms with necessary equipment and visual materials as resource constraints. In Tanzania, participants also reported the lack of specific spaces in PC clinics to provide the interventions.

In China, participants noted patient preferences for passive treatments like electrotherapy, over exercise.

Feasibility

Median scores for feasibility items ranged from 4 to 5 across all participating countries. In Tanzania and Tajikistan, agreement on items related to implementability, possibility, and doability ranged from 71% to 100% (Median: 4–5). Similarly, participants in China reached 100% agreement on the items “implementable,” “possible,” and “doable” (Median: 4.5–5). However, the item “easy to use” in China recorded an agreement rate of 47% (Median: 4).

In all three countries, interview participants widely perceived the Basic PIR as beneficial for professional development and productivity, fostering increased professional confidence, particularly among nurses, and facilitating easier explanation of exercises and better patient assessment.

“…patients do not go to nurses. Doctors do not ever refer patients to nurses. This is clearly stipulated in our work orders. But after getting this course certificate nurses will have the capacity to change what we do.” (Nurse 7, Tajikistan)

Regarding workflow integration, while concerns about increased workload and data recording were expressed in Tanzania and Tajikistan, participants also highlighted the potential for simplified work due to new knowledge gained from the Basic PIR, reduced patient travel costs through home exercises, and anticipated increases in referrals and improved patient outcomes.

“My work will be easy due to the new knowledge gained and the home exercises will reduce the clients’ cost of travelling”. (Clinical Officer 2, Tanzania)

Overall, participants across all three countries reported that utilizing the Basic PIR would lead to simpler work processes, better patient outcomes, reduced client costs, and more streamlined clinical tasks. Nurses in the focus groups specifically highlighted that the training would allow them to take a more active role in patient motivation and to facilitate rehabilitation services within home settings. They further stated that these changes would expand their current professional activities and the perceived value of their role within the PC team.

“…our patients will have better outcomes so the work will be easier”. (Nurse 3, China)

A descriptive subgroup analysis was conducted to determine if professional background influenced implementation ratings. In China, median scores across all three constructs (acceptability, appropriateness, and feasibility) were consistent between junior rehabilitation therapists (Median range: 4-5) and PC doctors/nurses (Median range: 4-5). Similarly, in Tanzania, no substantial differences were observed between clinical officers and nurses, with both groups reporting high median scores (Median: 4.5-5) for the core implementation outcomes. These data suggest that the Basic PIR resource was perceived similarly across the diverse professional roles represented in the pilot.

Discussion

In this mixed-methods pilot study, the WHO Basic PIR clinical resource, a tool to integrate rehabilitation into the care provided by current PC health workers through a task-sharing methodology, was perceived as acceptable, appropriate, and feasible among the participating PC workers across China, Tajikistan, and Tanzania. The findings provide promising preliminary evidence regarding the potential integration of basic rehabilitation services into similar low-resource settings via task-sharing using a standardized tool, while also highlighting key contextual factors that must be addressed for successful uptake and scale-up. This first pilot study shows that the Basic PIR provides a viable, task-sharing approach to addressing the action areas of the WHA resolution on “Strengthening Rehabilitation in the Health System” and tackling the global rise in rehabilitation needs worldwide.^25,26

The Basic PIR’s pilot model closely aligns with other WHO PC resources, specifically the WHO Package of Essential Noncommunicable Disease Interventions (PEN) ²⁷ and the Mental Health Gap Action Programme (mhGAP). ²⁸ Whereas WHO PEN and mhGAP manage mainly the medical aspects of NCDs and mental disorders respectively, the Basic PIR serves as a necessary complement by targeting the associated functional limitations. Like the Basic PIR pilot, similar feasibility and implementation studies have been conducted for PEN and mhGAP in several countries (e.g., Bhutan, Korea, Fiji, Myanmar, Moldova, Ghana, Tajikistan, and Sri Lanka), consistently assessing implementation outcomes and PC worker experiences.^29,30 Some studies for PEN also included patient perspectives, ³¹ and mhGAP pilots provided feedback on cultural relevance. ³⁰

The consistently high median scores across all three pilot sites demonstrate that the Basic PIR is strongly acceptable to PC workers. This positive perception was reinforced by the widespread qualitative agreement that the interventions were relevant and matched patient needs. This finding aligns with studies in South Africa and Zimbabwe, where PC workers also expressed considerable interest in integrating similar rehabilitation guidance tools, citing potential benefits in promoting collaborative learning and knowledge exchange. ³² Participants in this study favored the Basic PIR’s clear visuals and simple explanations over existing, more complex PC tools. This preference aligns with a systematic review by Reddy et al (2024), which identifies pictorials as key predictors of adherence and successful tool integration in low-resource settings. By applying these design principles, the Basic PIR likely overcomes common literacy and comprehension barriers among non-specialist PC workers. ³³ It is however important to note that prior validation of the Basic PIR does not necessarily ensure uniform acceptability across countries. Furthermore, because the evaluation tools used in this pilot were not formally validated psychometrically for cross-cultural comparison, the descriptive differences observed across the three countries should be interpreted carefully. Variances in median scores or agreement rates likely reflect structural realities, such as resource availability, workforce composition, and existing scopes of practice, rather than baseline comparative differences in tool performance across health systems. The high perception of appropriateness across all three countries indicates that PC workers view the Basic PIR as highly relevant and compatible for integration into their practice setting, which is a critical precursor to successful scaling up. However, qualitative findings identified clear implementation boundaries that challenge practical appropriateness. The concerns regarding staff time limitations observed in China and Tajikistan mirror findings from similar task-sharing pilots, such as the WHO mhGAP. ³⁴ However, participants also expressed willingness to use the tool, which points out that the high perceived appropriateness and acceptability of the Basic PIR may help mitigate the common resistance associated with time limitation and increased workload. ³⁵ Furthermore, task-sharing can lead to better job satisfaction among healthcare workers due to feelings of empowerment. ³⁶

The high feasibility scores in Tanzania and Tajikistan, coupled with participants’ anticipation of efficiency gains, suggest that the Basic PIR has the potential to be successfully integrated within these resource-limited PC settings. The high quantitative perception that the Basic PIR is “implementable,” “possible,” and “doable” demonstrates a clear appraisal among PC workers that the intervention can be successfully carried out within their existing settings. This positive outlook stems from perceived workflow benefits, as participants anticipated considerable efficiency gains and lower client costs. The reported potential for reduced client travel costs aligns with previous studies indicating that patients strongly prefer home-based programs to minimize logistical burdens.^37-39 Furthermore, the Basic PIR appeared to foster a positive shift in professional identity, empowering PC workers, especially nurses, to expand their scope of practice. This empowerment and increased professional confidence, which one study linked to successful intervention implementation by improving personal development and self-worth ⁴⁰ are key drivers for sustaining complex interventions in task-sharing models. ³⁶

The future successful implementation and scale-up of the Basic PIR rely on acknowledging and adapting to diverse contextual and cultural preferences. The necessity for adaptation is showcased by specific rehabilitation traditions in countries like China, where healthcare policy focuses on a system with “Chinese characteristics”. This is driven by the historical significance, proven efficacy, low cost, and minimal side effects of Traditional Chinese Medicine (TCM) rehabilitation. ⁴¹ This strong cultural and political support for TCM contributes significantly to the population’s preference for passive treatments, which contrasts with the active exercise methodology of the Basic PIR. Acknowledging this is imperative, as it requires country-specific implementation strategies to bridge the gap between traditional practices and the Basic PIR’s task-sharing approach, ensuring local relevance and buy-in. The pilot also highlighted a positive initial shift among participants in Tajikistan. The Basic PIR training challenged a health culture for these participants, which had historically defined nurses mechanistically as technical assistants restricted to administering drugs and injections, severely limiting their autonomous practice. ⁴² Within this pilot cohort, the training acted as a catalyst for change, empowering nurses and enabling them to envision an expanded scope of practice beyond previous restrictive work orders. These findings highlight that successful scale-up requires mitigating local resistance through tailored strategies and harnessing professional empowerment to ensure the task-sharing model persists over time.

While the Basic PIR was developed through a rigorous, multi-phase process including prior field testing and validation, this does not guarantee uniform acceptability across different country contexts. Implementation outcomes such as acceptability, appropriateness, and feasibility are inherently context-dependent and may vary according to health system characteristics, workforce composition, scope of practice, and resource availability. The differences observed across China, Tajikistan, and Tanzania should therefore be interpreted in light of these structural and contextual factors, rather than as solely reflecting intrinsic properties of the Basic PIR.

Key lessons for other countries highlight the utility of using Implementation Research (IR) frameworks during the pilot phase to move beyond purely technical evaluations toward a comprehensive understanding of the delivery system.^21,22 By adopting a mixed-methods IR approach, countries can systematically evaluate initial implementation outcomes, acceptability, feasibility, and appropriateness, while preparing to measure the patient-level outcomes necessary to establish long-term clinical effectiveness.^21,29 Our findings underscore that success is driven not only by the resource’s technical merit but also by the social nature of the implementation process. Specifically, IR reveals that professional empowerment and the mitigation of systemic barriers, such as patient travel costs, are as critical to feasibility as the design of the resource itself.^36,38,40

Building on these lessons, we recommend that countries planning to scale up the Basic PIR conduct a proactive assessment of local contextual determinants to guide early preparation. Implementation planning must specifically address the logistical and time constraints identified as primary barriers in China and Tajikistan; such workload concerns are well-documented challenges in the deployment of WHO task-sharing tools. ³⁴ Furthermore, specific strategies must be designed to mitigate cultural resistance to active rehabilitation, particularly in regions where passive treatments are historically preferred. ⁴¹ This should involve tailored patient education and community advocacy to bridge the gap between traditional practices and evidence-based interventions. Finally, to ensure the long-term sustainability of the task-sharing model, countries must move beyond training to formally redefine the scope of practice for PC personnel. Legitimizing the expanded role and autonomy demonstrated by workers such as the nurses in Tajikistan is essential to align national policy with the demonstrated capabilities of the PC workforce.^36,42

Study Limitations

This pilot study has several limitations, including a small sample size (n=53) and the resulting limited generalizability due to purposive sampling. Participants were selected by MOH and health facility managers, which may have introduced selection bias by favoring more motivated or higher-performing staff, potentially leading to an overestimation of acceptability. In addition, detailed data on participants’ years of experience, prior rehabilitation training, and workload were not consistently collected, limiting further characterization of the sample. Furthermore, the non-standardized nature of the intervention ranging from a 10-day, full-scope training in Tanzania to a condensed 5-day version in China and Tajikistan on 5 and 4 domains respectively may have introduced bias and confounded cross-country comparisons. Specifically, these differences in intervention exposure (scope and duration) may have likely influenced participants’ perceptions, potentially confounding the acceptability, appropriateness, and feasibility ratings across the different sites. Furthermore, there was inconsistent participant inclusion; the deliberate addition of junior rehabilitation therapists in China and clinical officers in Tanzania, while reflecting local PC workforces, complicates the evaluation of pure task-sharing with existing doctors and nurses. To mitigate this, we performed a descriptive comparison of scores across professional groups within each country. The analysis revealed that ratings for acceptability, appropriateness, and feasibility remained stable regardless of professional background, suggesting that the resource is broadly applicable across different levels of PC providers. Nonetheless, the lack of a large, standardized sample remains a constraint, and future research should utilize stratified sampling to formally test for differences in implementation outcomes between generalist and specialized PC personnel. Formal psychometric validation of the adapted, multilingual survey instruments was not conducted. Consequently, findings must be viewed as exploratory and descriptive, serving as an initial proof-of-concept. Additionally, outcomes were assessed immediately following training, meaning the findings reflect initial perceptions and cannot capture how the acceptability, appropriateness, or feasibility of the Basic PIR may evolve with sustained clinical use over time. Finally, the study focused on implementation outcomes among healthcare workers, meaning it did not measure patient-level outcomes or long-term sustainability.

In conclusion, this pilot study provides a promising proof of concept for the WHO Basic PIR as a highly acceptable, appropriate, and feasible task-sharing resource. By demonstrating that essential rehabilitation can be successfully integrated into PC, the tool offers a promising framework that may help strengthen PHC and advance UHC across similar, diverse, low-resource settings, aligning with the objectives of the World Health Assembly’s mandate. Successful scale-up, however, necessitates moving beyond technical implementation to address the social and systemic determinants of health, specifically by mitigating cultural resistance to active interventions and leveraging the professional empowerment of non-specialist personnel. To ensure these gains are sustained, we recommend that future studies utilize Implementation Research and Health Policy and Systems Research frameworks. Such approaches are critical for evaluating the long-term sustainability, clinical effectiveness, and broader health system impact of the Basic PIR as it transitions from pilot testing to large-scale clinical use.

ORCID iD

Abena Yeboaa Tannor https://orcid.org/0000-0002-0580-9736

Ethical Considerations

Ethical approval for this study was obtained through a WHO-approved master protocol (ERC.0003985006935/3) covering the multi-country implementation. Additional institutional ethical approvals were obtained in China (TJIRB202404115) and Tajikistan (№1-6/10288). In Tanzania, the study was conducted in collaboration with the Ministry of Health, and an ethics application was submitted in accordance with local requirements prior to the study. The study was implemented under the WHO-approved master protocol, and all participants across all sites provided written informed consent prior to participation. The study was considered to present minimal risk to participants.

Consent to Participate

Informed written consent was obtained from all participants included in the study.

Consent for Publication

No identifiable human data is published in this manuscript.