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Title: Living with Stroke in Bangladesh: factors influencing Quality of Life (QoL).
Abstract:
This study examined factors that may predict the QoL of stroke survivors in Bangladesh. The
objectives were: to examine the relationship between QoL and health related variables (i.e.
disability status, cognitive status, mobility status, self-care, getting along with people, life
activities, social participation and psychological state); and also to examine the influence of
demographically related variables (i.e. gender, age, level of education, marital status, and
living arrangements) on QoL.
Data were collected from 110 stroke survivors in Bangladesh. Data collection tools included
a semi-structured questionnaire along with WHOQOL-BREF; WHODAS 2.0; and DASS21.
A regression analysis was undertaken to determine the significant independent predictors of
QoL. Post stroke psychological distress was found to be the key predictor of QoL. Therefore,
psychological interventions need to be incorporated in rehabilitation to enhance better QoL
post stroke. Other health and demographically related predictor variables had no influence on
overall QoL post stroke.
Key Words: Stroke; QoL; Rehabilitation; Occupational Therapy; Psychological Distress;Bangladesh.
Introduction:
Stroke is the third leading cause of death in Bangladesh (Islam et al, 2012) and a leading
cause of adult disability (WHO, 2004); survivors are commonly left with significant
impairments, depending on the severity of the lesion and the type of stroke (The Stroke
Association, 2011). Post-stroke disability can include deficits in physical, sensory, cognitive,
and psychological capacity. These can affect survivors’ ability to manage their self-care,
work and leisure occupations. These may, in turn, affect their ability to perform every day
roles within society (Legg, Drummond and Langhorne, 2009). A person’s health condition,
following a stroke, is likely to significantly impact on their quality of life (QoL) (Kim, Choi-
Kwon, Sun, Kwon, Lee, Park, and Seo, 2005). International studies have shown that QoL
post stroke can be predicted by levels of social support, depression, motor impairment,
independence in daily living and demographic factors (Morris, Van-Wijck, Joice, and
Donaghy, 2013).
International studies supports the view that QoL depends on various factors in life and some
of them are the individual’s disability status (Patel, Mckevitti, Lawrence, Rudd and Wolfe,
2007; Carod-Artal, Egido, Gonzalez, and Varela de Seijas, 2000; and Sturm et at., 2004);
social support (Kim, Warren, Madill, and Hadley, 1999; Hilari, Needle, and Harrison,
2012); functional impairments (Nys et al., 2006; Kim et al., 1999; Haley, Roth, Kissela,
Perkins, and Howard, 2011; Hilari, Needle, and Harrison, 2012; Carod-artal et al., 2000 and
Sturm et at., 2004); increased age (Nys et al, 2006 and Sturm et at., 2004); and mobility status
(Patel et al., 2007) . Furthermore, some clinical determinants including cognitive status,
aphasia (Patel et al, 2007 and Nys et al, 2006); and depression (Nys et al, 2006; Patel et al,
2007 and Kim et al, 1999) are important determinants of QoL among the stroke survivors.
However, there is not only one factor that influences QoL but rather combinations of factors
are responsible (Nilsson, Parker, and Kabir, 2004).
To date, no study has been found that focuses on QoL of stroke survivors in Bangladesh.
However, three studies have been identified which were undertaken in Bangladesh, and
which examined QoL for people with a range of health conditions viz.: mental health
problems, leprosy patients and arsenicosis patients. Studies have found some of the important
factors for QoL and these include access to health services and dependence on medical
treatment (Laskar et al, 2010); level of disability (Laskar et al, 2010; Tsutsumia, Izutsub,
Islam, Maksudad, Katoa, and Wakaie, 2007); educational level (Nilsson et al, 2004;
Tsutsumi et al, 2007); financial resources (Tsutsumi et al,2007); home environment (Laskar
et al, 2010, Nilsson et al, 2004); mobility, opportunity for leisure activities, pain and
discomfort, personal relationship, sexual life, safety and security (Laskar et al, 2010); social
participation/ social support (Nilsson et al, 2004); social stigma (Tsutsumi et al, 2007);
support from friends/family and transport facilities (Laskar et al, 2010).
The influence of socio-demographic variables including age, gender, marital status, living
arrangements and educational levels have been studied and varying results have been found
in terms of QoL of people living with stroke. Kim et al., (2005) found that young people
living with stroke (15-45 years of old; n=96) had significantly better QoL compare with older
people (above 45 years of old; n=160). Similarly, other robust studies have found that
increased age was an independent predictor of reduced QoL of stroke survivors (Nys et al.,
2006; Deborah et al., 2005; Singhpoo et al., 2011 and Dayapoglu and Tan, 2010). However,
Jaracz and Kozubski (2003) and Kim et al., (1999) conducted quality of life studies among 72
Polish and 50 Canadian stroke survivors respectively and they did not find any significant
correlation between age and QoL. There is therefore inconsistency in results relating to the
impact of age on QoL post stroke. In terms of gender, Jonsson, Lindgren, Hallstrom,
Norrving, and Lindgren, (2005) found female stroke survivors (n=182) had higher QoL
scores than male (n=234) survivors. However, Dayapoglu and Tan, (2010) found men had
higher QoL scores post stroke than females. Kim et al., (1999) did not find any association
between gender and QoL when they conducted a quality of life study among the stroke
survivors. Marital status is another socio-demographic variable which may affect QoL of
people living with stroke. Being married has been found to have a positive correlation (r =
0.30, p<0.05) with QoL for stroke survivors (Kim et al., 1999). However, Jaracz and
Kozubski (2003) did not find any association between marital status and quality of life post
stroke. Level of education may also influences QoL of stroke survivors. Some evidence
supports the notion that low education level is a significant predictor of poor QoL (Deborah
et al., 2005). Singhpoo et al., (2011) conducted a study among the 237 stroke survivors and
found that patients with higher bachelor degrees had better QoL than who had low
educational levels. However, Jaracz and Kozubski (2003) and Kim et al., (1999) found that
levels of education and living arrangements were not significantly correlated with QoL.
In summary, it is clear that QoL is a holistic view of health where different domains are
included such as physical well-being, psychological well-being, social well-being and
emotional well-being (Carod-Artal et al., 2000). QoL is a very complex (Lau, Mckenna,
Chan, and Cummins. 2003) and multi multidimensional concept (Kim et al, 1999; Cummins,
1997; and Hughes, 1990) that particularly relates to variety of aspects of individuals’ life
(Nilsson et al, 2004). A precise definition of QoL is yet to be developed based on its
conceptual aspects. Some authors believe QoL embraces both subjective components (e.g.
individuals’ functional status, wellbeing, social support etc) and objective components (e.g.
culture, religion, values, age, gender, race etc) (Cummins, 1997; Kuchler, Kober, Brolsch,
Henne-Bruns, and Kremer, 1991). On the other hand, some authors believe that individual
perception is the key in relation to QoL. They believe that subjective experiences of
individuals are more important in regards to QoL rather than objective conditions of their
lives (i.e. income, religion) (Schipper, Clinch, and Powell, 1990). QoL could be affected by
various life factors including physical (functional impairments, health and disability status,
mobility status, working capacity, bodily pain and degree dependency etc), psychological
(positive and negative feelings, lack of meaningful activities, degree of self-esteem), social
relationship (personal relationship, support from family and friends, sexual life, social stigma,
lack of social participation, social status and network etc) and environmental (financial status,
level of education, access to health service, home environment, and information need for day
to day life etc). These include some clinical determinants like cognitive status, aphasia,
anxiety, depression etc. However, these are not unique factors that are always responsible for
poor levels of QoL of stroke survivors and research findings are mixed in some of these
domains. These factors may differ in importance from person to person, culture to culture and
territory to territory, as the QoL concept is such a subjective issue.
WHO defines QoL as a broad-ranging concept, which is mostly subjective in nature; the
perception of the individual characterizes the person’s QoL (WHO, 1998). Stroke
rehabilitation services tend to be narrowly focused on neurological symptoms (Doyle, 2002)
and the main aim is to regain and maintain physical aspects of functioning (Shih, Rogers,
Skidmore, Irrgang, and Holm, 2009 ; Doyle, 2002 and Richard, & Zorowitz, 1999) and
other important aspects of health such as quality of life are rarely supported (Doyle, 2002).
Renwick, Brown, and Nagler (1996) also highlighted that those therapeutic interventions
after stroke, which merely focused on physical restoration, can still isolate the person from
their psychosocial environment. This isolation can have an impact on QoL. A narrow
approach to stroke rehabilitation mainly focused on symptomatic treatment and which
focuses on the individual rather than taking a holistic and social view of disability (Jongbloed
and Crichton, 1990) is common. Accordingly, even though the modern stroke rehabilitation
approach has recently introduced an emphasis on improving QoL, where functional status or
health status are affected, they are usually used as the only criteria to measure QoL (Renwick
et al., 1996). This narrow approach is likely to be neglect psychosocial, social and
environmental influences towards becoming independent. Therefore, it could affect stroke
survivors’ ability to cope with stroke related psychological symptoms, which include stress,
anxiety and depression and also with their ability to cope with environmental barriers.
Importantly, some studies have found that a significant number of stroke survivors, who have
little or no physical problems, still faced deterioration in their QoL over an extended period
of time (Niemi, Laaksonen, Kotila, and Waltimo, 1988; and Ahlsio, Britton, Murray, and
Theorell, 1984). Functional limitations in different domains (self-care, productivity and
leisure) are a frequent effect of stroke (Doyle, 2002). Increased dependency in day to day
self-care, mobility and locomotion places significant burdens on stroke survivors (Clarke,
Black, Badley, Lawrence and Williams, 1999; and Kim et al, 1999). Although some receive
help from formal or informal caregivers to manage everyday life (Kim et al., 1999),
persisting disability as a result of stroke can still impact on QoL (Nys et al., 2006). So, it
seems that physical health and sufficient care are not the key determinants for improved QoL.
Physical health and care could be some of the determinants of a persons’ QoL but others must
be considered. In Bangladesh, people with stroke risk being left with substantial disability,
due to the vast gap in stroke knowledge and poor acute and long term stroke care, which
creates an enormous burden on society. Stroke rehabilitation has just begun in Bangladesh
and is only available in the main cities (Wasay, Khatri, and Kaul, 2014). In terms of stroke
rehabilitation in Bangladesh, the country of the principal author of this paper, emphasis is
placed on the physical aspects of stroke recovery such as functional status, mobility, and tone
management after stroke. However, this approach has tended to neglect other aspects of
health such as psychological, socio-cultural and environmental issues which could potentially
affect an individual’s QoL (Nydevik and Hulter-Asberg, 1988).
In the past few decades, the incidence of stroke in developing countries has grown to
epidemic proportions. Indeed, two-thirds of strokes now happen in low and middle-income
countries (Pandian, Padma, Vijaya, Sylaja, and Murthy, 2007). One country where no
published peer reviewed research on QoL post stroke has been conducted is Bangladesh. This
study, which examines factors that impact on QoL in stroke survivors in rehabilitation
services in Bangladesh, could assist health professionals (such as occupational therapists,
physiotherapists and speech and language therapists) and the families of stroke survivors, by
informing them of factors that have an effect on QoL. Health practitioners, including
occupational therapists, could make constructive treatment plans and families could support
stroke survivors to manage those factors that have an effect on QoL. The findings of this
study would be useful to services such as the Centre for the Rehabilitation of the Paralysed
(CRP) in Bangladesh, by providing information about QoL status and the factors that have an
effect on the QoL of stroke survivors. Eventually, the CRP could use this study’s findings to
improve health care services for stroke survivors by managing those factors that have an
effect on QoL of stroke survivors in Bangladesh. Moreover, such data could be helpful to
manage stroke patients, especially in terms of their QoL, for those who are working with
stroke survivors in community and national level. Therefore, the aim of this current study was
to identify key factors that could predict the QoL of stroke survivors in Bangladesh.
The primary objectives were-
To examine the influence of the following health conditions on QoL: disability status,
cognitive status, mobility status, self-care, getting along with people, life activities,
social participation and post stroke psychological distress.
To examine the influence of the following socio-demographic variables on QoL:
gender, age, level of education, marital status, and living arrangements.
Method:
A retrospective, cross-sectional survey was selected for the study design in order to measure
the influence that the predictor variables have on QoL post stroke.
A convenience sampling approach was used to select participants who fulfilled the inclusion
criteria (over the age of 18; have experienced either ischemic or hemorrhagic type of stroke;
attending rehabilitation services; sufficient cognitive and communication capacity to be able
to give informed consent). The minimum acceptable sample size required for a regression
model study is 50 to 75 (Field, 2009). This study included 110 participants from Centre for
the Rehabilitation of the Paralysed (CRP)-Bangladesh.
Recruitment
Participants were recruited from CRP-Bangladesh which provides the most comprehensive
rehabilitation services in Bangladesh; occupational therapy, physiotherapy, and speech and
language therapy are all offered (Centre for the Rehabilitation of the Paralysed, 2010).
Participants come from all regions of Bangladesh to receive the rehabilitation service.
The staff invited all patients who fitted the recruitment criteria to contact the researchers
should they wish to participate (n=180). They received a research invitation letter,
information sheet, and consent form. Initially 119 participants expressed a wish to take part.
The researchers screened all potential participants to identify their level of cognitive capacity
and communication skills prior to inclusion in the study; those not able to answer some
simple orientation questions were excluded (n=9) as they would have difficulty giving
informed consent and taking part of the whole interview process. The study thus recruited
110 participants; this number was deemed sufficient to proceed with the research.
Data collection
Socio demographically related predictor variables
Demographic data including age, gender, marital status, living arrangement and educational
level were collected face to face via individual semi-structured interviews.
Health condition related predictor variables
The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) was
used to measure health related predictor variables, including disability status, cognitive status,
mobility status, self-care, getting along with people, life activities and participation. It is split
up into six domains: cognition, mobility, self-care, getting along with people, life activities,
and participation. Scores are assigned to each of 36 items and range from a minimum of 1
(none) to 5 (extreme or cannot do). The possible total score ranges from a minimum,
36×1=36 to maximum 36×5=180 for each respondent. Higher scores indicate greater
difficulties (WHO, 2010)
Post stroke psychological distress (depression, anxiety and stress) was measured using the
Depression Anxiety Stress Scale 21 (DASS-21). It consist of 21 questions each scored from 0
(Did not apply to me at all) to 3 (Applied to me very much or most of the time). The possible
total score ranges from a minimum, 21×0=0 to a maximum, 21×3=63. Higher scores indicate
increasing severity of psychological distress (Psychology Foundation of Australia, 2011).
Outcome variable- QoL
The World Health Organization Quality of Life-BREF (WHOQOL-BREF) was used to
measure the outcome variable QoL. It consists of four domains: Physical, Psychological,
Social relationships and Environment. Scores on each item range from 1 to 5. This scale
consists of 26 questions and the first two questions were warm up questions for the interview.
These two warm up questions did not use in score calculation. Therefore, 24 items were
considered for score calculation and possible scores ranges from a minimum, 24×1=24 to a
maximum, 24×5=120 for each respondent. Higher scores indicated better QoL (WHO, 1998).
Instrument translation: At first the English version of WHOQOL-BREF, WHODAS 2.0
and DASS21 were translated into Bengali and then read out by a colleague and suggestions
made about translation. Then the translated copy (in Bengali) was translated back into
English; this was then compared with the original English version. There were some
contradictions particularly regarding questions no D1.3 and D6.6 of WHODAS 2.0. This was
resolved through discussion and by referring to the original English version; the agreed
amendment was made to the translated copy.
Data collection procedure and analysis: Face to face individual interviews were carried out
at the rehabilitation centre. Socio demographic data were collected first, prior to
administration of the three standardised measures: WHOQOL-BREF, DASS21 and
WHODAS 2.0. Each interview lasted no more than 60 minutes.
Firstly descriptive analysis was undertaken. Following this, multiple regression analysis
(MRA) was used to determine the amount of variance in QoL explained by the possible
predictors’ variables (Pallant, 2010).
Ethical Consideration:
Ethical approval was obtained from the School of Health Sciences and Social Care Research
Ethics Committee (12/05/MOT/07), Brunel University, London and CRP-Bangladesh
(RE/0401/46); the research was undertaken in accordance with the Data Protection Act
(1998). All participants gave informed signed consent.
Results:
The participants’ mean age was 49.57 (SD, 13.958) years and ranged from 19 to 81 years.
The participants’ ages spread over different age groups, but most (69%) were in the middle
and late middle age group (>30 to 65years) and only 19% in the older age group (>65years).
Participants were 61% male and 38% female. Most of the participants were married (82%)
and rest of the participants were single (18%). Participants lived with family (80%) and living
alone (20%). Participants’ educational level had been categorised as 0 = none, 1 = primary, 2
= secondary, 3 = tertiary and mean educational level was 1.85 (SD, 1.135).
The total QoL mean score was 44.40 (SD, 6.011). The maximum score that could be
achieved was 120; a poor score indicating a lower quality of life. Physical factors had the
highest sub domain mean at 14.26 (SD, 2.145) among the four subdomains of WHOQOL-
BREF; and the social relationships had the lowest mean at 5.17 (SD, 1.164). The mean of
other two subdomains: psychological and environmental was 11.51 (SD, 1.775) and 13.45
(SD, 2.768) respectively. Post stroke psychological distress mean score, measured by
DASS21, was 44.78 (SD, 6.032). The participants’ disability status mean score, measured by
WHODAS was 128.88(SD, 9.104). The maximum score that could be achieved was 220 with
a higher score representing a greater degree of disability. The disability domain in which
participants had the most problems was in ‘Participation’ (mean, 33. 85; SD, 3.785); and least
problems in managing ‘Self-care’ (mean, 16.82; SD, 2.351). The mean of other disability
domains: cognitive (mean, 22.32; SD, 3.667); mobility (mean, 20.89; SD, 3.209); getting
along with people (mean, 17.90; SD, 3.337); and life activities (mean, 17.10; SD, 2.763).
Simultaneous linear regressions were run to assess QoL predictors. See Table 1. A strong
negative association was found between post stroke psychological distress (DASS21) and
total QoL (β= -0.61, p= <.001***), so as post stroke psychological distress levels increased,
QoL decreased. Negative correlations were also found to be present between post stroke
psychological distress (DASS21) and the QoL subscales ‘Physical’ (β= -0.54, p= <.001***),
‘Psychological’ (β= -0.50, p= <.001***) and ‘Environmental’ (β= -0.52, p= <.001***),
which are combination to make the total OoL. However, no significant correlation was found
between post stroke psychological distress and the subscale of the QoL measure labelled
‘Social relationship’ (β= -0.17, p=>0.05).
Insert Table-1 about here.
Being female had a positive relationship with psychological subscale of QoL (β= 0.20, p=
<.05*), which indicates that females had slightly better psychological QoL (i.e. bodily image
and appearance, self-esteem, spirituality, thinking, learning, memory and concentration) than
males, post stroke. Similarly, being unmarried had a positive relationship with the
environmental subscale of QoL (β= 0.21, p= <.05*), which indicates that being unmarried
was associated with slightly better environmental QoL (i.e. physical environment, home
environment, financial resources, freedom, physical safety and security) than being married,
post stroke.
No significant associations were found between QoL and the subscales of the WHODAS 2.0
disability scale: cognitive, mobility, self-care, getting along with people, life activities and
participation.
Discussion:
The majority of the participants in the study were male (61%); this is not surprising as the
incidence of stroke is generally higher in men than in women worldwide (Appelros,
Stegmayr, and Terént, 2012). The mean age of stroke survivors in this study population was
49.57 (SD13.958); this was consistent with the fact that stroke is common in the middle aged
group (Grimaud, Béjot, Heritage, Vallée, Durier, Giroud, and Chauvin, 2011) and is
similar to participants who have taken part in other research studies (Aidar, Oliveira, Silva,
Matos, Carneiro, Nuno, Garrido, Hickner, and Reis, 2011). The sample was therefore
representative of stroke survivors in terms of gender and age. However, Nys et al, 2006 and
Carod-Artal, et al, 2000 conducted a study among Dutch and Spanish stroke survivors and
they found the mean age 61.6 and 68.19 respectively. This could be due to the fact of
variance of life expectancy between Bangladesh and developed countries, and it also may be
related to risk of stroke with diabetes, which is becoming more prevalent in Bangladesh
(Akter, Rahman, Krull, and Sultana, 2014).
Post stroke psychological distress (depression, anxiety and stress) was the only predictor of
QoL among the stroke survivors in Bangladesh. This finding was in keeping with the findings
of Kim et al 1999, who found that psychological distress was the key predictor of QoL; other
stroke studies have also found psychological distress to be an influential factor (Nys et al,
2006; Hilari, Needle and Harrison, 2012; Howitt, Jones, Jusabani, Gray, Aris, Mugusi, Swai,
and Walker, 2011; Patel, Mckevitti, Lawrence, Rudd, and Wolfe, 2007) Therefore, it may be
helpful for rehabilitation professionals to incorporate psychological assessment, medication
and counseling services to assist with the reduction of psychological distress when treating
stroke patients. A complete adjustment to stroke can also take longer than the time given to
the rehabilitation phase (Kim et al, 1999); additional long-term psychological support may be
needed post discharge. Long term psychological treatment may sustain help the stroke
survivor to regain emotional stability, reduce psychological distress, with the resulting effect
of improved QoL.
The study suggested that females had slightly better scores in the psychological domain of
QoL than males, post stroke. The findings were inconsistent with studies from other parts of
the world which did not find any significance difference between male and female stroke
survivors in terms of their QoL (Akinpelu, and Gbiri, 2009; Owolabi, 2008; Fatoye,
Komolafe, Eegunranti, Adewuya, Mosaku, and Fatoye, 2007). The study also found that
being unmarried had a positive relationship with the environmental subscale of QoL, which
indicates that being unmarried is associated with slightly better environmental QoL (i.e.
physical environment, home environment, financial resources, freedom, physical safety and
security) than being married, post stroke. However, Kim et al (1999) conducted a study with
Canadian stroke survivors and found being married was positively correlated with QoL. The
inconsistent findings of these two studies might be due to socio-cultural differences, such as
beliefs, values, life style, social context etc between participants in Bangladesh and Canada.
Limitations of the study:
This study was conducted with the stroke survivors who received services from the major
rehabilitation centre in Bangladesh; data would not be representative of those stroke survivors
who do not attend a rehabilitation centre. Financial status could not be included as all
participants had to be on low or no income in order to qualify for the rehabilitation service.
Implications of the findings:
To date, no previous study has been found on QoL of stroke survivors in Bangladesh.
Therefore, this study could provide useful knowledge for people who are dealing with stroke
survivors including rehabilitation professionals, care givers, family members and perhaps
stroke survivors themselves.
This study provides further knowledge about QoL, which will assist rehabilitation staff in
CRP in guiding the planning and provision of services valued by people living with stroke in
Bangladesh, to help them achieve a maximum QoL. This study will help by giving
information about the impact of stroke on QoL in Bangladesh. From this study, the identified
factors that have an effect on QoL of stroke survivors could be considered by the
rehabilitation professions when supporting people living with stroke in their recovery. This
knowledge could be used to support more comprehensive rehabilitation service
developments.
Furthermore, the findings of this study could help to draw the attention of family members
and care givers of stroke survivors by providing information about the factors that have an
effect on QoL of stroke survivors. Therefore, family members and care givers could support
stroke survivors to manage those identified factors that have an effect on QoL of stroke
survivors in Bangladesh.
As Bangladeshi rehabilitation goals focus more on physical aspects, this study contributes in
identifying several other factors including psychological, social and environmental aspects,
which are important and need to be considered in rehabilitation for stroke survivors to
enhance their QoL. These include early treatment of post stroke depression, support from
friends and family, social engagement, engaging in meaningful activities and getting along
with people. Focusing on occupational therapy treatments of this aspect, the therapist could
encourage and facilitate stroke survivors to engage in different occupations that are
meaningful to the individual, rather than only focusing on physical and functional
rehabilitation to help individuals to enhance their QoL. According to WFOT (2010),
occupational therapy enabling individuals, through focusing on physical, cognitive,
psychological, psychosocial and environmental issues or combination of those, to enrich
occupational participation, eventually enhances QoL.
This study’s findings will also help to determine the rationale for selecting appropriate QoL
measures for use with target populations in context of Bangladesh. Based on the findings of
this study, the WHOQOL-BREF appears to be an appropriate measure for the adult
population living with stroke in Bangladesh as it considers the different domains of health,
including the physical, psychological, social and environmental.
Questions for further research:
As the concept of QoL is highly subjective, the nuances of the experience of the individuals
would be useful to explore at the individual level through such qualitative methods as
interpretative phenomenological analysis.
Conclusion:
In adult stroke survivors in Bangladesh, health condition related predictor variables such as
disability status, cognitive status, mobility status, functional impairment and social
participation were not associated with overall QoL. Similarly, demographically related
predictor variables, including age, living arrangements and educational level did not
influence either subscale of QoL (physical health, psychological, social relationships and
environmental) or overall QoL post stroke. However, being female had a positive
relationship with the psychological subscale of QoL which indicates that females had slightly
better psychological QoL (i.e. bodily image and appearance, self-esteem, spirituality,
thinking, learning, memory and concentration) than males, post stroke. Similarly, being
unmarried had a positive relationship with the environmental subscale of QoL which
indicates that being unmarried was associated with slightly better environmental QoL (i.e.
physical environment, home environment, financial resources, freedom, physical safety and
security) than being married, post stroke.
This study found that psychological distress was the key predictor in post stroke QoL. To
enhance QoL for stroke survivors in Bangladesh, services could be developed more
extensively to help alleviate patients’ psychological distress (depression, anxiety and stress).
Therefore, rehabilitation professions should emphasize rehabilitation for psychological
factors like depression, anxiety and stress in their rehabilitation programme as early as
rehabilitation starts, in order to reduce the impact of psychological distress on the QoL of
stroke survivors. Stroke rehabilitation involves combined and coordination use of medical,
therapeutic, educational, social and vocational measure to retraining individual to reach their
maximum physical, psychological, social and vocational potential (Shakoor, Rahman,
Jaigirdar, Nahar, and Moyeenzaman, 2006). Multidisciplinary approaches should take place
for proper rehabilitation post stroke. Early psychological distress post stroke interferes with
stroke recovery, because with psychological distress, stroke survivors lack the motivation to
participate in rehabilitation. In the long run, those who are in psychological distress fail to
engage in daily activities, leisure and social activities , have increased health care use and are
more likely to die earlier (Williams et al, 2004). Occupational therapy ensures routine
assessment is in place for mood and cognition for people living with stroke (The Stroke
Association, 2012). Occupational therapists work using active listening to patients, exploring
and supporting the impact of the stroke. Occupational therapists help individuals to
understand adjustment after stroke, identify psychological difficulties and provide
compassionate care by giving advice and information for adjustment, goal setting and
problem solving. Similarly, occupational therapists provide open and close groups to provide
support and achieve therapeutic goals. Open groups comprise stroke survivors and their
families and aim to educate people on the impact of stroke and on coping strategies; whereas,
the aim of close groups is to share problems and ideas to find solutions (Gillham et al, 2011).
People with strokes can reduce the likelihood of psychological issues through active
participation in life roles (Gillham et al, 2011). Occupational therapists make sure every
individual engages in active roles following stroke, through befriending, volunteering,
creative activities, group attendance, participating in meaningful leisure pursuit and daily
living activities (The Stroke Association, 2012). Occupational therapists need to incorporate
psychological issues as soon as they start rehabilitation for people living with stroke. This
study suggests that psychological distress, such as being stressed, anxious and depressed, can
affect attention, remembering and learning new things, which hinder rehabilitation.
Occupational therapists can help people living with stroke to improve their
mood/psychological issues through life style modification. For instance, occupational
therapists can advise stroke survivors to have regular gentle exercise to improve mood, to
undertake simple relaxation techniques that may help to reduce some symptoms of post
stroke distress, to engage in some of the activities or hobbies that they enjoyed in the past,
to learn to pace their activities so they have a balance of how much they can do, and to find
local support groups where they can share their own experience with others who have had
similar problems. These activities can all enrich QoL for people living with stroke (Booth and
Berry, 2014).
In conclusion, Occupational Therapists play a vital role along with other professionals,
including counsellors and clinical psychologists for psychological rehabilitation post stroke.
Therefore, it is highly recommended to Occupational Therapists to start psychological
rehabilitation as soon as possible after stroke to lessen the likelihood of psychological issues
and so enhance QoL.
Acknowledgements:
Thank you to the staff of CRP-Bangladesh for giving permission to conduct the study and for
providing assistance with the screening for recruitment.
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Table-1: Regression summary: Standardized Betas (β), *=p<0.05, ***=p<0.001
QoL Subscales
Predictors Total QoL Physical Psychological Social Rel Environmental
Age .04 .00 .21 -.01 -.02
Gender .10 .01 .20* -.11 .12
Marital St .15 -.02 .13 .10 .21*
Living arrang .10 .02 .07 -.14 .02
Educ level .00 -.02 .07 .00 -.04
Cognitive -.06 -.02 -.12 -.04 -.03
Mobility .04 .00 -.14 .04 .16
Self care .08 .03 .04 .07 .08
Getting along -.04 -.00 -.18 .02 .02
Life activities .18 .14 .14 .01 .19
Participation -.11 -.06 -.08 .07 -.17
Psychological distress
(DASS21)
-.61*** -.54*** -.50*** -.17 -.52***