**4.1 Mortality among people who suffer from stroke**

Two-thirds of stroke deaths occur in people living in developing countries and 40% of those with stroke aged less than 70 years [58]. The Inter-stroke phase 1 study 2007–2009 reported that 5.7 million deaths in 2005 were due to stroke and the number is projected to rise to 7.8 million by 2030 and 87% of these will be in low or middle in-come countries. Similar findings were reported when it was estimated that approximately 80% of all deaths by stroke occur in developing countries [59]. However, age adjusted stroke mortality in adults in SSA seemed to be like developed countries [60]. This they attributed to lack of accuracy of longitudinal data collection in different regions.

In Africa, stroke accounts for 0.9–4% of hospital admissions and 2.8–4.5% of total deaths [61]. This is in line with findings elsewhere where it was reported that mortality due to stroke in low- and middle-income countries was the 5th leading cause of death in adults aged 15–59 years [62]. The same study found stroke to be the 7th leading cause of death in SSA with HIV/AIDS at the top. According to UNAIDS, HIV related deaths made up 16% in South Africa, 17% in Nigeria and 6% in Zimbabwe of total death [63]. This makes the need to support survivors of stroke more important so as to reduce mortality in communities.

This high stroke case fatality in Africa was found to be related to limited healthcare facilities and uncontrolled risk factors such as hypertension and diabetes which conditions and resultant death can be prevented [64]. Higher values have been found from community studies where deaths due to stroke contribute 5–10% of deaths in Tanzania [65]. Other studies in Africa have reported between 20 and 45% case fatality rates between admission and one-year post stroke [31, 32]. Stroke has been projected to be the 3rd leading cause of death in low income countries by 2030. Therefore, there is need for vigilance in prevention and care of patients with stroke as previously mentioned.

In South Africa based on an 11-disability adjusted number of life years lost per 1000 of the population, stroke was declared a catastrophic illness as the prevalence of stroke in South Africa was reported to be 3000/100,000 people [66], much higher than the 500/100,000 people living with strokes in developed countries [67]. It may be safe to conclude that Sub-Saharan Africa has relatively low stroke incidence and prevalence but has high mortality rates [17]. This is may be attributed to high prevalence of smoking and other risk factors for stroke. Factors associated with mortality include severity of stroke, being a woman, haemorrhagic stroke, low level of consciousness upon admission and failing a swallow test, irreversible coma, stroke recurrence and other secondary infections and pressure sores, increased age, diabetes mellitus and stroke subtypes as independent predictors of 30-day case fatalities. Similarly, the relative risk of death from stroke was found to be higher for females in Ghana [68].

Ischaemic stroke patients with a National Institutes of Health Stroke Scale (NIHSS) score of less than 10 have a 60–70% chance of a favourable outcome at 1 year compared with only a 4–16% chance if the score is more than 20 [53]. However, ischaemic strokes have better prognosis, but less functional prognosis compared to haemorrhagic strokes [69]. Upon follow up, 23% of patients with ischaemic stroke had died while 65% of the survivors were functionally independent at 1 year [69]. Meanwhile, among the patients with haemorrhagic strokes, 62% had died, and among the survivors, 68% were functionally independent at 1 year. Among those with subarachnoid haemorrhage, 48% were dead and 76% of the survivors were functionally independent. The differences in mortality during the acute phase between the two types of strokes are said to be due to the fact that haemorrhagic strokes are more severe at onset than ischaemic strokes. This results in

increased pressure in the brain with mass shifting of brain which may be the reason for increased fatality. Later, as resolution occurs, swelling and pressure reduce with resultant reduction in mortality. Function is also better in Haemorrhagic strokes because there is less brain damage and once swelling and pressure have resolved, function is restored [70]. In Zimbabwe, not all patients with stroke can afford CT scans for diagnostic purposes, hence comparison is difficult. This also makes it difficult for typing the strokes although this is an important aspect of this study.

## **4.2 Functional outcomes in stroke**

Poor functional recovery is associated with bowel and urinary incontinence, long time between stroke onset and hospital admission, more severe hemiparesis, visuospatial deficits and lower FIM scores [71, 72]. Functional recovery after stroke is also closely related to age, aetiology and severity of neurological deficit, nature of lesion and localization including integrity of collateral blood supply [52, 71]. The authors also reported that factors such as patient's education, motivation and socio-economic level may be important in recovery. Psychosocial and cognitive impairments and other neurological and sociodemographic factors have been seen to affect the functional recovery of stroke survivors [73].

Functional prognosis is better among the patients with haemorrhagic stroke in the long term compared to patients with ischaemic stroke even when someone is caring for them [74–81]. This is however different from findings that report worse functional outcomes among haemorrhagic strokes [82]. In line with the study by Bamford et al. [69], Kelly et al., had comparable results when they used the Functional Independence Measure (FIM) and found that among 1064 patients with stroke, 871 had ischaemic stroke and these had better functional abilities at admission compared to those with haemorrhagic stroke [81]. However, at follow up, the patients with haemorrhagic stroke had better recovery in comparison to those with ischaemic stroke. However, the treatment they received was not standardised. Unfortunately there are not many studies where comparison of functional outcomes was done after training in Africa. In South Africa poor functional outcomes were found to be associated with female gender, and more severe stroke and poor physical condition when patients were followed up at 6 weeks, 6 months and 1 year [32]. This was also the case later in Malawi [31]. Stroke has both psychosocial and physical impact upon both the survivors of stroke and their caregivers and it is important to discuss this area. These are aspects that affect quality of life.

## **4.3 Participation**

Participation restriction means that survivors are unable to take part in areas of life such as usual roles and hobbies. They are the challenges individuals would have 'in involvement in life situations' [83]. Achieving independent ambulation within the community post stroke is not easy [84]. This has an impact on community reintegration post stroke as the survivors may not be able to take part in their former activities and may become isolated [85]. It is therefore important to assess stroke survivor's participation post stroke to get a complete picture of caregiver burden [86]. The relationship between participation and the environment was also highlighted elsewhere where the authors reported that perceptions of danger in the environment may make survivors increase speed for safety as seen when crossing roads [87]. In some cases, fear and the terrain may not be conducive for mobility. This is because there may be stones around and the terrain may be hilly thus reducing wheelchair mobility [6, 87]. Rehabilitation

**321**

*Supporting Survivors of Stroke in Low Resource Settings DOI: http://dx.doi.org/10.5772/intechopen.86900*

action as survivors try to move about [6].

**5. Rehabilitation and caregiving of stroke survivors**

play the sick role.

professionals may face difficulties in trying to equip stroke survivors with the skills for community mobilisation in different terrains. Further, survivors may not be able to manoeuvre wheelchairs given for mobilisation as the environment plays a role in the outcome of rehabilitation and the patient's recovery after stroke as it may act as a barrier [6, 87, 88]. This is more so because the objects, their position and orientation in the environment drives the motor pattern in an

Inability to ambulate within the community by survivors of stroke directly affects their community participation [87]. Reduced ambulation leads to poor accessibility of community facilities and this in turn causes poor social integration of survivors of stroke [89]. Once the survivors cannot access facilities, integration into community becomes poor, leading to non-compliance with medications [85]. This is further compounded by the fact that about 66% of community dwelling survivors of stroke will need help with at least one activity of daily living (ADL) [90]. Availability of support from family, acquaintances, peers, colleagues, neighbours and personal care providers are facilitators to activity participation but these are not always available as they have other roles to play [91]. The impact of stroke on ADLs, emotions, cognition, and participation in social activities therefore significantly compromises survivor well-being and inevitably alters their and caregiver's quality of life [67]. However, stroke survivors generally function better in activities of daily living than they do in social activities [92]. This is because stroke survivors are dependent on their caregivers for single and multiple tasks for up to one-year post stroke thus further compromising social integration [91]. Unfortunately, this need for help may cause dependency as they may continue to

The occurrence of stroke is devastating and overwhelming for both the survivor who becomes disabled suddenly and the family who are not prepared for the changes brought about in their lives when managing the multiple problems of a patient post stroke [7]. This is because they may face financial worries and are not prepared for the long care-giving hours and emotional stress which are predominant factors in increasing caregiver stress when one is caring for stroke survivors [93]. Caregivers should therefore be involved early on in the rehabilitation phase so that they understand and deal with the problems and prepare for after discharge life. The quality of rehabilitation, timing of treatment and amount of time spent in hospital have a bearing on the functional outcomes of the patients [6, 94–96]. Success of rehabilitation is also determined by emotional and physical challenges that the patient faces post stroke [97]. It is therefore important to identify barriers to an efficient rehabilitation service [6, 98, 99]. This is because availability of resources will affect the standard of stroke rehabilitation that patients receive [6, 100]. Effective rehabilitation initiated early after stroke can help enhance the recovery process and minimise functional disability which in turn improves quality of life of both the patient and the caregiver [42, 43, 97, 101–103]. Caregivers need to be well prepared for the emotional and physical challenges that the survivor faces as they may become barriers to care or even have a bearing on caregiver burden.

Moreover, organised respite care services that are available in developed countries may not be available in Zimbabwe to help with care of stroke survivors. This means that caregivers who have to look after survivors for long periods of time in most cases have no respite support. Disability benefits or allowances and voluntary support services to assist people living with disabilities and their caregivers may

#### *Supporting Survivors of Stroke in Low Resource Settings DOI: http://dx.doi.org/10.5772/intechopen.86900*

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

**4.2 Functional outcomes in stroke**

to affect the functional recovery of stroke survivors [73].

increased pressure in the brain with mass shifting of brain which may be the reason for increased fatality. Later, as resolution occurs, swelling and pressure reduce with resultant reduction in mortality. Function is also better in Haemorrhagic strokes because there is less brain damage and once swelling and pressure have resolved, function is restored [70]. In Zimbabwe, not all patients with stroke can afford CT scans for diagnostic purposes, hence comparison is difficult. This also makes it difficult for typing the strokes although this is an important aspect of this study.

Poor functional recovery is associated with bowel and urinary incontinence, long time between stroke onset and hospital admission, more severe hemiparesis, visuospatial deficits and lower FIM scores [71, 72]. Functional recovery after stroke is also closely related to age, aetiology and severity of neurological deficit, nature of lesion and localization including integrity of collateral blood supply [52, 71]. The authors also reported that factors such as patient's education, motivation and socio-economic level may be important in recovery. Psychosocial and cognitive impairments and other neurological and sociodemographic factors have been seen

Functional prognosis is better among the patients with haemorrhagic stroke in the long term compared to patients with ischaemic stroke even when someone is caring for them [74–81]. This is however different from findings that report worse functional outcomes among haemorrhagic strokes [82]. In line with the study by Bamford et al. [69], Kelly et al., had comparable results when they used the Functional Independence Measure (FIM) and found that among 1064 patients with stroke, 871 had ischaemic stroke and these had better functional abilities at admission compared to those with haemorrhagic stroke [81]. However, at follow up, the patients with haemorrhagic stroke had better recovery in comparison to those with ischaemic stroke. However, the treatment they received was not standardised. Unfortunately there are not many studies where comparison of functional outcomes was done after training in Africa. In South Africa poor functional outcomes were found to be associated with female gender, and more severe stroke and poor physical condition when patients were followed up at 6 weeks, 6 months and 1 year [32]. This was also the case later in Malawi [31]. Stroke has both psychosocial and physical impact upon both the survivors of stroke and their caregivers and it is important to discuss this area. These are aspects that affect

Participation restriction means that survivors are unable to take part in areas of life such as usual roles and hobbies. They are the challenges individuals would have 'in involvement in life situations' [83]. Achieving independent ambulation within the community post stroke is not easy [84]. This has an impact on community reintegration post stroke as the survivors may not be able to take part in their former activities and may become isolated [85]. It is therefore important to assess stroke survivor's participation post stroke to get a complete picture of caregiver burden [86]. The relationship between participation and the environment was also highlighted elsewhere where the authors reported that perceptions of danger in the environment may make survivors increase speed for safety as seen when crossing roads [87]. In some cases, fear and the terrain may not be conducive for mobility. This is because there may be stones around and the terrain may be hilly thus reducing wheelchair mobility [6, 87]. Rehabilitation

**320**

quality of life.

**4.3 Participation**

professionals may face difficulties in trying to equip stroke survivors with the skills for community mobilisation in different terrains. Further, survivors may not be able to manoeuvre wheelchairs given for mobilisation as the environment plays a role in the outcome of rehabilitation and the patient's recovery after stroke as it may act as a barrier [6, 87, 88]. This is more so because the objects, their position and orientation in the environment drives the motor pattern in an action as survivors try to move about [6].

Inability to ambulate within the community by survivors of stroke directly affects their community participation [87]. Reduced ambulation leads to poor accessibility of community facilities and this in turn causes poor social integration of survivors of stroke [89]. Once the survivors cannot access facilities, integration into community becomes poor, leading to non-compliance with medications [85]. This is further compounded by the fact that about 66% of community dwelling survivors of stroke will need help with at least one activity of daily living (ADL) [90]. Availability of support from family, acquaintances, peers, colleagues, neighbours and personal care providers are facilitators to activity participation but these are not always available as they have other roles to play [91]. The impact of stroke on ADLs, emotions, cognition, and participation in social activities therefore significantly compromises survivor well-being and inevitably alters their and caregiver's quality of life [67]. However, stroke survivors generally function better in activities of daily living than they do in social activities [92]. This is because stroke survivors are dependent on their caregivers for single and multiple tasks for up to one-year post stroke thus further compromising social integration [91]. Unfortunately, this need for help may cause dependency as they may continue to play the sick role.
