Background
Stroke is a major burden in developing African countries [
1,
2]. An estimated 75 000 strokes occur in South Africa each year. Of these 25 000 stroke survivors die within the first month [
3]. In Tanzania the overall crude yearly incidence of stroke was reported as 94 · 5 per 100 000 (95 % CI 76 · 0–115 · 0) and 107 · 9 per 100 000 (88 · 1–129 · 8) in the Hai and Dar-es-Salaam Regions respectively [
4] Specific information about the burden of stroke in Rwanda is lacking. A recent study reported the rate of disability in adults as 10.4 % in the Bugesera Distrct and 19.6 % for the Muzanza District. Although the incidence and mortality of stroke have increased in these countries evidence-based management strategies have not been implemented [
5]. This further increases the burden of the disease in these countries affecting the quality of life of the individuals who have experienced a stroke.
Rehabilitation post stroke has been found to be beneficial in facilitating recovery and improving quality of life [
6,
7]. A multidisciplinary approach [
8] which includes, physiotherapy, occupational therapy and speech therapy has been found to improve functional outcomes of individuals post stroke. Various lengths of hospital stay post stroke have been documented in the literature [
9,
10] although the factor that has been found to improve outcomes relates not specifically to the length of stay but to the intensity of the rehabilitation received. When a greater intensity of treatment is provided early post stroke, it results in improved outcomes and recovery [
8]. In developing African countries, the availability of health services is poor and inadequate [
11]. The majority of stroke patient receiving out-patient rehabilitation at Community Health Centres in South Africa, only received between 1–5 Physiotherapy sessions which equated to a median number of 1.8 hours over a 6 month period [
12]. Stroke patients who are admitted to in-patient rehabilitation facilities in South Africa [
13] and Tanzania [
14] also have limited follow-up treatment and contact with a Physiotherapist although they could benefit from these services [
14]. According to the authors no published literature is available about the rehabilitation services provided to stroke patients in Rwanda. This limited availability and access to therapy services impacts on the quality of life and participation of people with disabilities which includes those who have experienced a stroke.
The challenges experienced by stroke patients after being discharged can be conceptualised within the World Health Organisation’s framework of functioning disability and health (ICF). The ICF is seen as a comprehensive framework and classification which provides a common language for all stakeholders including policymakers and persons who have become disabled [
15]. The ICF is therefore useful for analysing the patient’s problems post stroke as well as assisting in enabling a systematic analysis of rehabilitation interventions [
16].
Within the ICF framework, impairments and activity limitations are known to influence participation and quality of life which are seen as the ultimate goal of rehabilitation. The ICF could further be used to monitor rehabilitation outcomes from admission to reintegration into the community [
17]. Included in this process is the identification of personal and social obstacles, as well as the management of interventions and measuring the effectiveness of rehabilitation interventions [
17]. Although addressing participation restrictions is an important goal of rehabilitation, a number of barriers to participation have been identified. These include attitudes of others towards disabled people, lack of provision and access to services, problems with service delivery and inadequate financial resources [
18].
The current paper focusses on the provision of inpatient rehabilitation and the post discharge challenges of stroke survivors in specific African countries.
Methods
The study presents data collected in three African countries, namely South Africa, Tanzania and Rwanda. The settings for the different studies were all public hospitals which are funded by the state. The South African setting was the Eastern Cape with a population of 6 562 053 and reported the second lowest household income in the country. The study was conducted at the Provincial Hospital in the Eastern Cape with a bed capacity of 250 beds. The stroke patients are managed by a multidisciplinary team of professionals, ranging from the medical doctor, a neurologist (when available), nursing staff, and rehabilitation professionals which include the physiotherapist, occupational therapist and speech therapist. These rehabilitation professionals also provide outpatient sessions for those that require it.
The Tanzanian study was conducted in the Mbulu District in the Manyara Region, in the Northern Province of Tanzania. The setting for the Tanzania study was a referral hospital in the Northern Province of Tanzania. The hospital has a 450-bed and serves about 600,000 people who reside mainly in the Mbulu, Hanang and Babati Districts in the Manyara Region, and the Iramba district in the Singida regions which are mostly rural. Patients only receive institution-based physiotherapy services at the hospital as inpatients and at the time of data collection no other rehabilitation services were provided.
The setting for the Rwandese study was a district hospital, located in the Northern Province of Rwanda. It has a capacity of 409 beds. Stroke patients receive rehabilitation in the form of physiotherapy. There is neither outreach nor community-based rehabilitation services that are provided to stroke patients and these patients get institution-based rehabilitation services only as inpatients or outpatients. All interviewees, discharged from the district hospital lived in Musanze District, an area which is mainly rural, and where at least 91 % of the population is engaged in agriculture [
19]. Musanze District has a total population over 380,000 having the highest density in the country: 770 persons per km2 [
20]. Most families (about 65 %) live below poverty line [
21]. Musanze is the most mountainous district in Rwanda [
22], and there is therefore difficult geographical access and transport.
Qualitative and qualitative approaches were used to collect data [
23]. The data relating to the provision of care was collected using a quantitative approach while the outcome data was collected using a qualitative approach. Information relating to the process of care was collected using a retrospective record review of a conveniently selected sample of patients admitted to the three hospitals. Records were reviewed where the diagnosis of stroke was made by a medical doctor based on the WHO definition of stroke [
24]. Patients who had a hemiplegia as a result of a brain injury or tumour were excluded. To ensure sufficient data for statistical analysis, the South African charts were reviewed for a two year period, 1 January 2008 to 31 December 2009, the Rwandese charts for a four year period, 1 January 1st, 2005 and December 31st, 2008 and the Tanzanian charts for a 7 year period,1st January 2004 to 31st December 2010.
A validated document template was used to collect the quantitative data. Documented information that was captured included demographic characteristics (age, gender, marital status and employment status), medical characteristics (documented risk factors), stroke onset–admission interval, length of hospital stay, commencement of physiotherapy since admission, duration of physiotherapy and the total number of physiotherapy sessions.
Once ethical clearance and permission was obtained from the relevant parties, stroke patients who could be included in the studies were identified by reviewing hospital records. The data was collected by perusing the hospital and physiotherapy records of the patients. The data was collected by the main researchers, together with trained research assistants in their respective countries. Descriptive data was presented in the form of tables and figures displaying means, frequencies, percentages and standard deviations. A Pearson correlation between the number of physiotherapy sessions and the length of length of hospital stay was done. The significance level was set at p < 0.05.
Challenges experienced by the participants post in-patient rehabilitation
The challenges experienced by the participants were determined qualitatively with a sample of those patients whose folders were reviewed as part of the quantitative part of the study. Although purposive sampling was planned for all the settings, the sample for the qualitative component for the South African setting was done conveniently because the initial purposively selected sample could not be recruited. The sample for the two other settings was recruited purposively. It was necessary to only consider subjects who were able to articulate their experiences and feelings, and therefore exclude individuals with communication or cognition problems. Participants, who needed assistance with at least one activity of daily living, as determined by the researcher, were interviewed.
Those participants, who were part of the quantitative retrospective study and were selected, were contacted telephonically to ascertain their willingness to be interviewed. The qualitative interviews were conducted at times and places convenient to the participants. Many participants preferred to have the interview conducted at their homes. The qualitative interviews were recorded by means of a digital voice recorder, but where the patients did not give their consent for the recording, detailed field notes were made during and immediately after the interview.
An interview guide was used to guide the interviews. The interview guide was developed based on the literature consulted [
25‐
27]. The interview guide consisted of questions aiming to collect data which explored the challenges experienced by stroke patients while in the home or community setting. The interviews were conducted in a language in which the participant was fluent. The data was translated into English as part of the analysis process.
Trustworthiness of qualitative data
Member-checking was the form of verification used. The stories shared by participants during the interviews were summarised and then retold by the researcher to the participants, in order to ensure that the researcher correctly understood the information provided during the interview. To enhance credibility of the qualitative data, the themes presented were illustrated with representative quotations from the transcribed texts [
28]. To ensure that the qualitative data was confirmable, a peer examination was used by the researcher discussing the research process and findings with colleagues and experts with experience in qualitative research methods. For the same purpose, the study supervisor checked transcriptions, data reduction and analysis products (condensed notes), data reconstruction and synthesis products (thematic categories, interpretations) [
29].
Qualitative data analysis
The data was analysed thematically. The tape-recorded interviews were transcribed verbatim by the researchers. The transcriptions were read and compared to the audio tape recordings and field notes several times to verify accuracy [
30]. Where necessary, a trained, multilingual translator translated the transcriptions into English and the researchers analysed those transcriptions to identify main patterns. Concepts were coded and then grouped into common themes. The analyses were conducted by the main researchers (NC, GU, SA) and peer reviewed to confirm themes by an independent person (AR).
Ethical clearance was obtained from the University of Western Cape, the Department of Health in the Eastern Cape, Tanzania Ministry of Health and Director of Haydom Lutheran Hospital respectively and the Rwanda National Ethics Committee. The participants were all given an information sheet which explained the aim of the study. Written informed consent was sought from all the participants. Participation was voluntary and participants were given the opportunity to withdraw from the study at any time. Participants were endured that information provided was handled confidentially and that pseudonyms will be used to protect participants' identities when results are published. The ethics number for the SA study was 10/1/23, the TZ study 10/9/25 and the Rwandan study was RW: No. 09/RNEC/2009.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AR drafted the article and was the senior researcher involved in facilitating the development of the study proposal. NC collected the data for the SA component, AZ was the Tanzanian researcher and GU collected the data for the Rwandese study. All three of these authors also contributed to the analysis of the data and writing the article. The authors have all agreed to publication of the manuscript.