A total of 13 papers met the eligibility criteria and were included in the present scoping review. Table 1 (Additional file) summarizes the papers. Majority of the paper were conducted in South Africa. We used the ICF framework ("International classification of functioning, disability, and health : ICF," 2001) to thematize and present the review. ICF framework, under the environmental factors, comprises Products and Technology, Natural Environment and Human-Made Changes to Environment, Support and Relationships, Attitudes, and Services, Systems and Policies ("International classification of functioning, disability, and health : ICF," 2001)
Table 1
Study characteristics of all included studies
|
Author(s)
|
year of publication
|
study location
|
Study populations
|
Aims of the study
|
Methodology
|
1.
|
(Cawood & Visagie, 2015)
|
2015
|
South Africa
|
Adult stroke survivors
|
To determine environmental barriers and facilitators to participation experienced
by a group of stroke survivors in the Western Cape province of South Africa.
|
Mixed method
|
2.
|
(Amosun, Nyante, & Wiredu, 2013)
|
2013
|
Ghana
|
Adult stroke survivors
|
To assess the perceived and experienced restrictions in participation and autonomy among adult stroke survivors in Ghana
|
Mixed method
|
3.
|
(Mudzi, Stewart, & Musenge, 2013)
|
2013
|
South Africa
|
Adult stroke survivors admitted to hospital for ischaemic stroke
|
The aim of this study was to establish the level of community participation of patients at 12 months post-stroke and the associated factors impacting on that participation.
|
Mixed method
|
4.
|
(Vincent-Onabajo et al., 2016)
|
2016
|
Nigeria
|
Adult stroke survivors
|
To investigate the impact of social support on participation of stroke survivors in Nigeria.
|
Quantitative
|
5.
|
(Maleka, Stewart, & Hale, 2012)
|
2012
|
South Africa
|
Adult stroke survivors
|
The aim of this study was to establish the experience of people living with stroke in low socioeconomic urban and rural areas of South Africa.
|
Qualitative study
|
6.
|
(Anthea Rhoda, Cunningham, Azaria, & Urimubenshi, 2015)
|
2015
|
South Africa
|
Adult stroke survivors
|
The aim of this paper is to present the provision of in-patient stroke rehabilitation. In addition the challenges experienced by the individuals with participation
post discharge are also presented.
|
Mixed method
|
7.
|
(Elloker, Rhoda, Arowoiya, & Lawal, 2019)
|
2019
|
South Africa
|
Adult stroke survivors
|
The aim of this study is to investigate the factors influencing community participation among community-dwelling stroke survivors in the Western Cape, South Africa.
|
Quantitative method
|
8.
|
(Arowoiya, 2014)
|
2014
|
South Africa
|
Adult stroke patients
|
The aim of this study was to determine and explore the participation restrictions experienced by stroke patients.
|
Mixed methods
|
9.
|
(Elloker, 2016)
|
2015
|
South Africa
|
Adult stroke patients
|
The aim of this study is to determine social support and participation restrictions in patients with stroke living in selected areas in the Western Cape.
|
Quantitative method
|
10.
|
(Ekechukwu, Olaleye, & Hamzat, 2017)
|
2017
|
Nigeria
|
Adult stroke patients
|
This study aims to investigate the clinical and psychosocial predictors of CR among stroke survivors three months post in-hospital discharge.
|
Qualitative method (exploratory study)
|
11.
|
(Urimubenshi, 2015)
|
2015
|
Rwanda
|
stroke patients
|
To explore the activity limitations and participation restrictions experienced by people with stroke in Musanze district in Rwanda.
|
Qualitative method (phenomenological)
|
12.
|
(Soeker & Olaoye, 2017)
|
2017
|
Nigeria
|
stroke survivors
|
The study was aimed at exploring and describing the experiences of rehabilitated stroke survivors and perceptions of stakeholders about stroke survivors returning to work in South-West Nigeria.
|
Qualitative method
|
13.
|
(A Rhoda, 2012)
|
2012
|
South Africa
|
Stroke survivors
|
the aim of the study was therefore to explore the activity limitations and participation restrictions experienced by patients with a stroke.
|
Qualitative method
|
Product and Technology
Product and technology is defined by WHO as "any product, instrument, equipment or technology adapted or specially designed for improving the functioning of a disabled person" ("International classification of functioning, disability, and health : ICF," 2001, p. 180).
Five studies mentioned how products and technologies facilitate or barriers participation of people living with stroke. In the study, Cawood and Visagie (2015) conducted, 77% of participants identified products and technology as a barrier. Difficulty to use transport appeared frequently as a barrier (Arowoiya, 2014; Cawood & Visagie, 2015; Elloker, 2016; Mudzi et al., 2013). In their study, Mudzi et al. (2013), revealed that 100% of stroke survivors mentioned transport services as mild to moderate barrier to participation. Transport created barrier to community participation and accessing services for 80% of participants (Cawood & Visagie, 2015).
Additionally, it was stated people with stroke need to pay extra to use public transport if they could find a driver who is willing to take them (Arowoiya, 2014; Mudzi et al., 2013). Lack of assets such as money also appeared among stroke survivors as a barrier to participate in social activities (Cawood and Visagie (2015). Cawood and Visagie (2015) stated that stroke survivors were not able to afford phone service. Not only this, but they were also unable to pay for assistive devices (Cawood & Visagie, 2015). In the same vein, Access to and utilization of assistive devices was also found low in the studies (Arowoiya, 2014; Cawood & Visagie, 2015). Cawood and Visagie (2015) stated other than mobility devices people living with stroke struggle to get assistive devices such as bath transfer, grab bars and Ankle foot orthosis. Moreover, they also struggle to use a toilet that is not modified to accommodate their need (Arowoiya, 2014). A Rhoda (2012) mentioned how stroke survivors can benefit from and are dependent on their walking devices.
Also, due to inaccessibility of the public transport, people with stroke need to have someone who can assist to carry and put them on wheelchair as well as in and out of the car in a way that indiginify the people (Arowoiya, 2014).
Natural Environment and Human-Made Changes to Environment
Regarding Natural Environment and Human-Made Changes to Environment, nine articles met the inclusion criteria (Amosun et al., 2013; Arowoiya, 2014; Cawood & Visagie, 2015; Elloker, 2016; Elloker et al., 2019; Maleka et al., 2012; Anthea Rhoda et al., 2015; Soeker & Olaoye, 2017; Urimubenshi, 2015). Almost all studies concluded the natural and human-made environment is inaccessible and creates barrier for participation. Amosun et al. (2013) stated in their article that environmental barriers led to self-imposed restriction as stroke survivors would prefer to stay at home than go out and experience the environmental difficulty. Elloker et al. (2019) also asserted how mobility, in a fully accessible environment facilitates participation.
Inaccessibility of the environment also hindered people living with stroke from participating in rehabilitation therapy (Anthea Rhoda et al., 2015; Soeker & Olaoye, 2017). This further complicated their condition and deteriorate their recovery and ability to participate. Soeker and Olaoye (2017) concluded home to clinic distance was a major factor not to adhere to therapy. On the other hand, some people changed their home address to live near hospitals where they get therapy (Urimubenshi, 2015) This led them to lose their previous social contact (Urimubenshi, 2015).
We also found in the articles that the home and the surrounding environment were inaccessible and a barrier to participation (Amosun et al., 2013; Arowoiya, 2014; Cawood & Visagie, 2015; Maleka et al., 2012; Anthea Rhoda et al., 2015; Urimubenshi, 2015). Cawood and Visagie (2015) found in their study that 65% of public buildings were inaccessible. Walking or pushing a wheelchair on sandy and uneven pavements creates huge inaccessibility and result in hindered social participation (Cawood & Visagie, 2015). Stairs to get in and out of their home, and the sandy and the uneven way in the neighbourhood make mobility with or without a wheelchair very difficult (Cawood & Visagie, 2015; Urimubenshi, 2015). Arowoiya (2014) also asserted that among their study participants about 21% face severe difficulty to deal with the physical environmental barriers in their society. Anthea Rhoda et al. (2015) also found stones on the way, stairs and uneven grounds create a barrier to use wheelchair and hinder social participation of stroke survivors. The home environment was also inaccessible. Maleka et al. (2012) revealed that the homes where stroke survivors were living in small, and cluttered homes.
Support and Relationships
Eleven articles out of thirteen discussed support and relationships in stroke survivors. We found a contradicting result. Five articles (Cawood & Visagie, 2015; Ekechukwu et al., 2017; A Rhoda, 2012; Soeker & Olaoye, 2017; Vincent-Onabajo et al., 2016) discussed people living with stroke are getting positive social support that is facilitating participation. Conversely, five articles (Amosun et al., 2013; Arowoiya, 2014; Elloker, 2016; Anthea Rhoda et al., 2015; Urimubenshi, 2015) stated that social support and relationships were low and eventually negatively affecting stroke survivors.
Mudzi et al. (2013) assessed the support and relationship in terms of immediate family; personal care providers friends; acquaintances, peers, colleagues, neighbours, and community members. They found immediate family and personal care providers were supportive and facilitators to participation (Mudzi et al., 2013). However, stroke patients saw the support from their friends as a barrier to social participation (Mudzi et al., 2013). Cawood and Visagie (2015) also found that majority (88%) of stroke survivors’ immediate families were supportive. Stroke survivors need social support and assistance for ADL and IADL activities from family members (A Rhoda, 2012). By the same token, they also get positive support in the workplace to resume their previous work (Soeker & Olaoye, 2017). Ekechukwu et al. (2017), while assessing the clinical and psychosocial predictors of community reintegration of stroke survivors, revealed stroke survivors who received good social support were better in reintegrating into the community. Vincent-Onabajo et al. (2016) also asserted that a high level of social support is associated with better social participation and economic self-sufficiency.
However, we also understood from the articles that as time passes the support and relationship diminishes (Anthea Rhoda et al., 2015). In the study done in Rwanda, to assess activity limitations and participation restrictions, Urimubenshi (2015) revealed that the social interaction of stroke survivors decreased from time to time. One reason stated was people with stroke changed to more accessible and near to hospital residency (Urimubenshi, 2015). Others also could not maintain their relationship with friends due to financial restrain (Arowoiya, 2014). Elloker (2016) assessed the social support and participation restrictions in patients living with stroke in South Africa. He revealed that nearly 90% of stroke survivors have low social support (Elloker, 2016). Amosun et al. (2013) discussed how low family support leads to family-imposed participation restrictions. Similarly, Anthea Rhoda et al. (2015) also discussed how lack of support barriers stroke survivors from participation. For people who were receiving support, the majority indicated they are very satisfied with the support given (Elloker, 2016). Based on the result, Elloker (2016) concluded that despite the low level of social support, stroke survivors valued the support they received.
Attitudes
Four articles discuss how the attitude towards stroke survivors is positively or negatively determining participation (Amosun et al., 2013; Arowoiya, 2014; Cawood & Visagie, 2015; Mudzi et al., 2013).
Cawood and Visagie (2015) found in their study that majority of immediate families have positive attitudes towards stroke survivors. Additionally, the attitude of health professionals was a facilitator for participation (Cawood & Visagie, 2015). However, the societal attitude was found negative and created a barrier for participation (Arowoiya, 2014; Cawood & Visagie, 2015). Mudzi et al. (2013) also revealed in their study that majority of friends’ attitudes were a barrier for stroke survivors to participate in their community.
We also understood from the articles that people see the stroke survivor as pity and support from the sense of duty (Arowoiya, 2014; Cawood & Visagie, 2015). The negative attitude does not always come from another person, but stroke survivors have also a perceived negative attitude that hinders participation (Amosun et al., 2013). Amosun et al. (2013) concluded that stroke survivors experienced both self and enacted stigma.
Services, Systems and Policies
We could not find much about services, systems and policies and how it is affecting the participation of stroke survivors. Three articles (Cawood & Visagie, 2015; Mudzi et al., 2013; Soeker & Olaoye, 2017) discussed services, systems and policies regarding participation. Results from the articles showed services, systems and policies are barriers to participation for stroke survivors. For example, Cawood and Visagie (2015) revealed that nearly half of their study’s participants indicated that they did not receive assistance from associations or organizations. Cawood and Visagie (2015) and Mudzi et al. (2013) presented that housing services were a barrier. Stroke survivors experienced difficulties to get government subsidised houses (Cawood & Visagie, 2015). Housing policies were also a barrier (Mudzi et al., 2013). Additionally, the paperwork to process disability grants took too long which led the stroke survivors to financial strain (Cawood & Visagie, 2015). In another study, Soeker and Olaoye (2017) indicated stroke survivors struggle from financial constraints that led them to opt-out from therapy. This indicates that there was no or minimum support to help them continue their therapy.