Impact of culture on rehabilitation services for stroke patients in developing countries: Jordanian perspective
Saleh AL-Oraibi, V. L. Dawson, S. Balloch and A. P. Moore
Aims: This study explored the perceptions stroke survivors had of rehabilitation services received by them in the Jordanian community. A secondary aim was to explore the impact of culture on providing appropriate services for stroke survivors.
Methods: Eighteen stroke survivors were recruited from an outpatient stroke rehabilitation programme. All 18 participants had been discharged from hospital for between one and six months. Semi-structured interviews were performed either in the physiotherapy outpatient clinic where the stroke patient was attending a clinic or in their homes. Transcription of interviews carried out in Arabic and thematic analysis was also carried out in that language by transcribers who were fluent in Arabic and English, using a back-translation method. Necessary measures were taken to ensure the accuracy, reliability and validity of the data collection and analysis.
Findings: Following thematic analysis, themes arising out of the data included physiotherapy and occupational therapy support in the community, out-patient rehabilitation clinic services, community clinic services and support from families, friends and neighbours. Participants expressed satisfaction with their therapists but there were large areas of unmet rehabilitation need for stroke survivors in the Jordanian community such as a limited availability of occupational therapy services, insufficient amount of therapy services and poor medical support.
Conclusion: This study presents a unique contribution to knowledge relating to the experiences of stroke survivors in a developing country and shows how care systems are dependent on cultural contexts, cultural beliefs and practises.
Worldwide, stroke is a leading cause of death and, for those who survive a stroke; the condition being a major cause of functional disablement (Broeks, Lankhorst, Rumping, & Prevo, 1999; Pan, Lien, Yen, Lee, & Chen, 2008). In developed countries including Jordan, despite service provisions that include physical assistance and rehabilitation services, the literature indicates that there are large areas of unmet need for stroke survivors (Lutz, Chumbler, & Roland, 2007; Daniel, Wolfe, Busch , & McKevitt, 2009; Legg & Langhorne, 2004). These studies however were largely carried out in developed countries, where social and economic situations differ in significant ways from those in developing countries. In developing countries, there is a paucity of information about stroke survivors and their life experiences after stroke and the health and social services that are available to stroke survivors and other people with severe disability are extremely under developed.
The primary aim of this study was to explore the perceptions of stroke survivors of rehabilitation in the community in Jordan. A secondary aim was to explore the impact of culture on providing appropriate community services for stroke survivors.
The study was conducted over a period of 12 months and ethical approval was received from the Hashemite University Ethics Committee in Jordan and that of the School of Health Professions at the University of Brighton in the UK. A total of 21 potential participants were identified as eligible for inclusion in the study during the data collection period. The researchers approached all 21 participants to explain the purpose of the study and 18 consented to participate. One survivor was readmitted to hospital and two survivors declined to participate without giving reasons. After providing informed consent, each participant completed a semi-structured interview which lasted between 60 to 90 minutes using audio taped and later transcribed verbatim prior to thematic content analysis. Measures were taken to ensure the accuracy of transcripts and the reliability and validity of the data analysis.
In total, 18 participants were interviewed as part of the study, 14 participants were interviewed at home and 4 at a Rehabilitation Centre. Seven of survivors were female and 11 were male and ages ranged from 55 to 73 years. They had been discharged from hospital for between one and six months and the average time post stroke for the participants was 12.33 weeks ± 5.29 weeks.
Perceived Formal Support in the Community
a) Physiotherapy and Occupational therapy
Many survivors received physiotherapy in hospital, in out-patient clinic, or at home and they were overall satisfied with their therapists. Most participants were satisfied with the therapists who visited them at their homes.
Out-patient rehabilitation clinics were provided for patients, including stroke survivor’ patients in need of physiotherapy and occupational therapy. Survivors showed satisfaction with the rehabilitation outpatient services they received but stated that they preferred to have their therapy at home. When asked about follow-up after discharged from hospital, all survivors responded that there were no follow-ups at all from their doctors or other health professionals after treatment had stopped. They also reported that no explanation as to why the help was stopped was ever given.
c) Community Clinic Services
All survivors reported that they had community clinics in the area where they lived and that they used the general practitioner (GP) services in the clinic services to provide them with medication, mainly for high blood pressure and diabetes. They identified two types of community clinic: one run by the Ministry of Health; the other by non-governmental organisations ((NGOs). None of the survivors mentioned having had a home visit from a GP from the local community clinic.
Impact of Culture on the Provision of Rehabilitation Services
In any culture there are both positive and negative features. The majority of Jordanians are Muslims and the influence of Islam affects every aspect of society. A main finding from our interviews was that gender of stroke survivor had a substantial impact on the provision of rehabilitation services, in particular for women with stroke. Interviewees consistently agreed that there was clear discrimination against women survivors of stroke. Customs around physical contact between men and women in Islam influence the care given to female stroke survivors. In general, only male therapists work with survivors in their homes in Jordan, so the therapy available in their homes to women survivors will be limited, resulting in the treatment being terminated or the patient seeking help from traditional healers. In either case the possibility of further complications or the slowing of progress is possible. Women with disabilities face less favourable treatment than men in the same situation. There is an urgent need to address the implications of gender issues in Jordan, to identify unmet needs and to change cultural attitudes. One way of improving the situation of women with disabilities could be by increasing the number of female therapists and making it possible for them to work in the community.
The current study elicited a new body of evidence about the life experiences of Jordanian stroke survivors after discharge from hospital. The findings will inform service providers and planners about the needs of stroke survivors and will contribute to the development of appropriate formal community care for these people. This study also shows how rehabilitation services are very dependent on cultural contexts, cultural beliefs and practices.
Broeks JG, Lankhorst GJ, Rumping K, Prevo AJ. (1999). The long-term outcome of arm function after stroke: Results of a follow-up study. Disability Rehabilitation 21:357-364.
Daniel K, Wolfe CD, Busch MA, McKevitt C. (2009). What Are the Social Consequences of Stroke for Working-Aged Adults? Stroke 40:431-440
Legg L, & Langhorne P. (2004). Outpatient Service Trialists. Lancet 1; 363(9406):352-6
Lutz B, Chumbler N, Roland K. (2007). Aftermath of Stroke: Care in the Home. Reviews in Clinical Gerontology 17:277-292
Pan SL, Lien IN, Yen MF, Lee TK, Chen THH. (2008). Dynamic aspect of functional recovery after stroke using a multistate model. Arch Phys Med Rehabili 9:1054-60.
Saleh AL-Oraibi, PhD, MSCP, MHPC
Associate Professor, Applied Medical Sciences College
Physiotherapy Department, University of Hail, KSA
Professor, Director Clinical Research Centre for Health Professions
University of Brighton
International Journal of Disability, Community &
Volume 10, No. 1