Developing a theory of change to improve the implementation of communication support for adults with severe learning disabilities in social care settings

Background: Communication partners are crucial for adults with severe learning disabilities, as they recognise, interpret, and respond to non-verbal cues while sharing responsibility for creating a meaningful two-way communication process. Evidence-based strategies such as augmentative and alternative communication (AAC) can enhance interactions; however, their implementation in social care settings is inconsistent, constrained by workforce, organisational, and systemic barriers. This study–which forms part of the Improving Communication with Adults with Learning Disabilities (ICALD) programme–aimed to identify stakeholder-perceived barriers and facilitators to good communication support and to co-develop a Theory of Change (ToC) to guide implementation improvements in social care settings.Methods: Forty-eight stakeholders from diverse backgrounds, including adults with learning disabilities, participated in a total of 15 ToC workshops, one focus group, two interviews, and four supported conversations. Template Analysis based on the Consolidated Framework for Implementation Research (CFIR) was used to identify core themes, barriers, and facilitators across CFIR domains. These key findings informed the iterative, collaborative development of the ToC map.Results: Implementation barriers and facilitators identified across the CFIR domains indicated individual-, organisational-, and system-level factors influencing communication support. Key barriers included limited access to specialist professionals, inconsistent training, fragmented information-sharing systems, and variable staff knowledge of communication needs. Facilitators included strong leadership commitment, collaborative working with speech and language therapists and family carers, and peer mentoring. Supported conversations highlighted the importance of staff responsiveness to non-verbal cues. The resulting ToC map outlines short-, intermediate-, and long-term outcomes through three core pathways: 1) collaborative development of resources and training, 2) improved information sharing and recording, and 3) ongoing skills development, coaching, and supervision.Conclusions: Improving the implementation of good communication support for adults with severe learning disabilities is likely to depend on organisational commitment, leadership engagement, and structured workforce development supported by specialist input. The ToC developed provides a theoretically grounded framework for translating known facilitators into practical, context-specific strategies. It highlights the necessity of capacity-building within teams and organisational alignment with the communication rights of adults with severe learning disabilities to achieve sustainable, consistent and effective practice change.