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.

References:

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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***