Participation in leisure activities after stroke: A survey of community-residing stroke survivors in Nigeria

Abstract

BACKGROUND:

Leisure provides pleasure and relaxation, and has health benefits even after a stressful and life-changing event such as a stroke.

OBJECTIVE:

This study examined leisure participation among a sample of community-residing stroke survivors in Nigeria.

METHODS:

Fifty-five stroke survivors undergoing rehabilitation were consecutively recruited from two government hospitals in Northern Nigeria. Data on pre- and post-stroke participation, and socio-demographic (age, sex, marital, employment, and educational status) and clinical (level of disability, post-stroke duration, stroke type and side of hemiplegia/hemiparesis) attributes of the stroke survivors were obtained. Leisure participation was assessed in four domains of recreational, social, cognitive, and productive/creative activities. Associations between leisure participation and the socio-demographic and clinical variables were examined using bivariate analysis.

RESULTS:

Mean (SD) age of the stroke survivors was 53.55 (14.39) years. Prevalence of leisure participation was 89.1%. Participation in specific leisure domains however varied thus: social (83.6%), cognitive (60%), recreational (41.8%), productive/creative activities (30.9%). Significant associations were observed between participation in cognitive, productive/creative, and recreational leisure activities, and specific socio-demographic and clinical attributes.

CONCLUSIONS:

Leisure participation was high in a general sense but marginal in recreational and productive/creative activities. The observed socio-demographic and clinical associations with post-stroke leisure participation may assist in providing effective leisure rehabilitation strategies.

Keywords

Leisure Nigeria participation stroke

1 Introduction

Leisure is regarded as an enjoyable part of life, an important prerequisite for optimal wellbeing and an essential ingredient for a healthy living (Wang et al., 2012). Although leisure activities are more commonly regarded as avenues for pleasure and relaxation (Pressman et al., 2009), it is important to note that leisure participation is also vital for maintaining good health and wellness and it is therefore considered essential in the prevention of disease conditions and mitigating the effects of the stress that accompanies everyday life (Iwasaki et al., 2006; Pressman et al., 2009). Furthermore, leisure participation has gained some attention in disease (Tomiga et al., 1998) with reports on its beneficial effects in recovery especially following chronic disease conditions including stroke (Boysen & Krarup, 2009).

Stroke is a major cause of mortality and morbidity (Connor et al., 2007), and individuals who survive the disease often have to cope with a spectrum of impaired body functions and structures, activity limitations and participation restrictions (Peters & Hamzat, 2009; Vincent-Onabajo et al., 2013; Vincent-Onabajo, 2013). Increasingly, therapies and interventions capable of ameliorating the consequences of stroke are being discovered and put forth in literature. For instance, there is growing evidence on the positive impact of leisure participation and rehabilitation after stroke on important variables such as quality of life and life satisfaction (Hartman-Maeir et al., 2007), physical fitness (Gordon et al., 2004), and secondary stroke prevention (Billinger et al., 2014). However post-stroke participation in leisure activities is often restricted (Amarshi et al., 2006; Farrow & Reid, 2004) and this prevents the stroke survivor from enjoying the health benefits that are derivable from such participation. It is therefore pertinent to possess an insight into leisure participation after stroke and its correlates which may in turn assist in realistically optimizing stoke survivors’ participation in leisure activities.

Effect of stroke on leisure participation has generated very minimal attention in the literature and in practice compared to other stroke consequences (Wolf et al., 2015). This appears to be even more obvious in low resource countries and settings. For instance in Nigeria, the most populous country in Africa, stroke care often focuses on management of impairments and activity limitations while issues of post-stroke participation in important life domains such as employment, leisure and community activities are seldom addressed. This dearth may be linked to the inadequacy of facilities and personnel for long-term stroke rehabilitation required for addressing post-stroke participation. For instance, regarding personnel, physiotherapists are the main professionals involved in stroke rehabilitation in the country while professionals such as physiatrists, occupational therapists, and recreational therapists are largely unavailable. The lack of emphasis on post-stroke leisure participation is also discernible from the scarcity of studies on post-stroke participation (Peters et al., 2013; Vincent-Onabajo, 2013; Hamzat et al., 2014) and specifically the apparent lack of studies on post-stroke leisure participation in the country.

To provide the impetus needed to integrate leisure rehabilitation into the existing impairment- and disability-based rehabilitation approach in stroke care, research evidence on the leisure participation status of Nigerian stroke survivors is needed. This is more so as leisure participation is culturally sensitive (Karlis, 1992; Stodolska et al., 2014) and findings from the few available studies from developed countries may not be representative of the situation in Nigeria and hence, would not suffice. Similarly, identifying the correlates of post-stroke leisure participation will be required to appropriately address possible restrictions. This study therefore examined leisure participation among community-residing stroke survivors in a metropolitan city in Northern Nigeria and examined the socio-demographic and clinical correlates of leisure participation post stroke.

2 Methods

This study utilized a cross-sectional design to obtain information on leisure participation of fifty-five community-dwelling stroke survivors receiving outpatient physiotherapy at two government hospitals in Maiduguri, a capital city in North-east Nigeria. The stroke survivors were eligible to participate in the study because they were aged 18 years and above; had suffered stroke for at least 3 months prior to their participation in the study; and expressed willingness to participate in the study through provision of written informed consent. The protocol for the study was approved by the institutional research and ethics committee.

Data collection spanned 3 months (June to August 2014) and was carried out by the second author (CB) at the respective physiotherapy outpatient units where the stroke survivors were recruited from. Data on the socio-demographic and clinical attributes of the stroke survivors and their leisure participation were obtained.

2.1 Socio-demographic and clinical data

Specifically designed data forms were used to obtain information on the stroke survivors’ age, sex, marital, educational and employment status as well as post-stroke duration, side of hemiplegia/hemiparesis, and stroke type.

Level of functional ability of the stroke survivors was assessed with the Modified Rankin Scale (mRS). The mRS assesses global disability on a scale of 0 (no disability/symptoms) to 5 (severe disability). The mRS is a valid and reliable widely used measure in stroke studies (Banks & Marotta, 2007).

2.2 Assessment of leisure participation

The researchers developed a questionnaire to obtain information on leisure participation. The questionnaire requested respondents to provide information on their leisure participation prior to and after stroke. Questions on whether a respondent engaged in leisure participation before and after suffering a stroke which required a “yes” or “no” response were first presented. A ‘yes’ response was required to proceed to the second section of the questionnaire, a section which contained thirty-four leisure activities grouped into 4 leisure domains namely recreational, social, productive/creative, and cognitive. The recreational domain contained eight activities namely ‘playing football’, ‘jogging’, ‘playing of games’, ‘swimming’, ‘cycling’, ‘driving’, ‘walking’ and ‘dancing’. Social leisure domain was made up of thirteen items viz ‘spending time with family’, ‘chatting with friends’, ‘clubbing’, ‘partying’, ‘attending drinking bars’, ‘shopping’, ‘attending social gathering’, ‘attending religious gathering’, ‘attending political gathering’, ‘going to the movies or shows’, ‘listening to music’, ‘listening to radio’ and ‘watching television’. The media-related leisure activities (‘listening to music’, ‘listening to radio’ and ‘watching television’) were included among social leisure activities based on available literature (Al-hassan et al., 2011; Seddon, 2011; Sedo, 2011). Productive/creative leisure domain contained six items namely ‘cooking’, ‘drawing/painting’, ‘writing’, ‘acting drama’, ‘making handicrafts’ and ‘rearing/taking care of animals’. The cognitive leisure domain had seven items which included ‘reading books, Bible or Quran’, ‘using the computer/surfing the internet’, ‘writing/drawing for pleasure’, ‘playing musical instruments’, ‘teaching (tuition/Quranic/Bible classes)’, ‘playing cards’, and ‘attending exhibitions, cultural shows and performances’. Two columns were provided for the ‘yes’ or ‘no’ response; the first column was for pre-stroke participation while the second was for post-stroke participation.

The activities under each domain were complied based on the definition of leisure as activities carried out with freedom and spontaneity (Desrosiers et al., 2007), interviews conducted with stroke survivors, and the usual leisure activities carried out in our settings since leisure engagement is culturally sensitive (Karlis, 1992; Floyd & Stodolska, 2013). Furthermore, it was practically impossible to obtain any consistent format for assessing individual and domain leisure activity from previous studies because of the inconsistent and wide variations in those assessments (Wang et al., 2012). Following the compilation of the leisure activities totaling thirty-four, the questionnaire was pre-tested among a convenience sample of five community-residing stroke survivors. The questionnaire also contained an open-ended question which requested respondents to mention other leisure activities they engaged in which were not available in the questionnaire.

2.3 Statistical analyses

Descriptive statistics were used to summarize the socio-demographic, clinical and leisure participation data. Global and domain-specific rates of leisure participation were presented as percentages.

Inferential statistics of chi-square was utilized to examine the socio-demographic and clinical variables that were associated with leisure participation (global and domain-specific) among the stroke survivors. For the purpose of Chi-square analyses, age in years was categorised into ‘20–40’, ‘41–64’, and ‘≥65’ while post-stroke duration in months was categorised as ‘within the first 6 month’ (3–6 months), ‘7–12 months’, ‘>12–<36 months’ and ‘≥36 months’. Level of statistical significance was set at alpha equals 0.05.

3 Results

Fifty-five stroke survivors participated in the study and their mean (SD) age and mean (SD) post-stroke duration was 53.55 (14.39) years and 15.07 (21.02) months respectively. The majority of the stroke survivors were males (63.6%), married (81.8%) and presented with left-sided hemiplegia/hemiparesis (52.7%) following ischaemic stroke (50.9%). The majority (89.1%) of the stroke survivors engaged in leisure activities (Table 1)

3.1 Participation in specific leisure domains

Based on the questionnaire used in this study, four leisure domains were assessed for pre-stroke and post-stroke leisure participation and they were: recreational, social, productive/creative and cognitive leisure activities. Pre-stroke participation was highest in the social domain (87.3%), and lowest (65.5%) in productive/creative leisure activities. Although the rate of leisure participation post-stroke was lower compared to pre-stroke participation, a similar decreasing prevalence pattern in the four leisure domains of social, cognitive, recreational and productive/creative leisure activities at 83.6% , 60% , 41.8% and 30.9% respectively was observed(Fig. 1).

In terms of specific leisure activities, two activities in the social leisure activities namely spending time with family (81.8%) and having a chat with friends (70.9%) predominated, while dancing (1.8%) in the recreation domain and drawing/painting (1.8%) in the creative/productive domain were the least preferred leisure activities. Five (14.7%) out of the thirty-four leisure items in the questionnaire namely ‘swimming’, ‘acting drama’, ‘making handicrafts’, ‘playing musical instruments’ and ‘attending exhibitions, cultural shows and performances’ were however not selected by any of the stroke survivors. Two stroke survivors utilized the provision in the questionnaire for mentioning leisure activities they engaged in which were not captured in questionnaire, and both indicated that cigarette smoking constituted their leisure activities.

3.2 Associations between leisure participation and stroke survivors’ socio-demographic and clinical attributes

There was no significant association between global leisure participation and the socio-demo-graphic and clinical attributes of the stroke survivors.

There were however significant associations between three (recreation, cognitive, and productive/creative) out of the four leisure domains, and some socio-demographic and clinical attributes. For the recreational leisure domain, the employed (70.6%) and those with moderate disability (60%) had the highest rate of participation at P < 0.01 and P < 0.05 respectively. Similarly, educational qualification of the stroke survivors had a significant association (P < 0.01) with the productive/creative leisure domain and a higher proportion of those with secondary education qualification (57.1%) engaged in the domain activities. Participation in cognitive leisure activities had the highest number of associations having being found to be associated with employment status, educational qualification, type of stroke and post-stroke duration. Table 2 provides details of the results of the chi-square analyses utilized to examine associations between leisure participation domains and socio-demographic and clinical attributes of the stroke survivors.

4 Discussion

Leisure participation contributes substantially to well-being even after a debilitating condition like stroke. The majority of the community-dwelling stroke survivors assessed in this study engaged in leisure activities albeit at varying degrees based on the specific activities. Although these variations in domain-specific leisure participation were not unique to the post-stroke period – since they mirrored pre-stroke participation trend – rates of participation were considerably lower post stroke across all the leisure domains. This observed trend is indicative of a negative spiral in leisure participation which is line with previous findings (Amarshi et al., 2006; Farrow & Reid, 2004) and reflects the adverse effect of stroke and its sequelae on leisure participation.

4.1 Participation was highest in social leisure activities

Participation in social activities such as spending time with family, and chatting with friends predominated and this finding has implications. On the one hand, engagement in such activities may serve to boost family ties and bond, and enhance the availability of social support to the survivors, all of which will impact positively on the stroke survivors’ emotional and mental wellbeing (Vincent-Onabajo et al., 2015). On the other hand, the predominance of these largely sedentary leisure activities, coupled with low participation in leisure time recreational physical activities, will ultimately have its downside. These two scenarios (sedentariness and physical inactivity) constitute well-known behavioral risk factors for obesity (Swaka et al., 2012) and obesity appears to adversely affect recovery of motor function and functional status after stroke (Sheffler et al., 2012; Burke et al., 2014).

4.2 Participation in other leisure domains

Physical activity after stroke is known to enhance recovery of functional activity, promote fitness, prevent recurrent stroke and enhance quality of life (Saunders & Crieg, 2014; Billinger et al., 2014). Whilst the physical disability that accompany stroke may serve as a major restriction to leisure participation, especially participation in physical activities engaged in prior to stroke, a stroke does not preclude participation in enjoyable physical activities. Several studies have reported diminished physical activity after stroke (Vahiberg et al., 2013). Information in the Healthy People 2010 document also showed that 56% of adults with disability in the United States did not engage in leisure physical activity (US Department of Health and Human Services, 2002) similar to the 58.2% of the stroke survivors in our study who did not engage in recreational leisure activities, a domain which comprised of physical activity items. Incorporating physical activity regimen into traditional stroke rehabilitation programme constitutes an important means of ensuring participation in recreational leisure activities. The consideration of, and engagement in smoking as a leisure activity by two participants in this study is worrisome especially in terms of secondary stroke prevention and may be considered as a reflection of the findings by Teo et al. (2013) on the low rate of smoking cessation post stroke in low-incomecountries.

4.3 Associations between leisure participation and socio-demographic and clinical attributes of stroke survivors

While there were no significant associations between global leisure participation and the stroke survivors’ socio-demographic and clinical attributes, a different picture was observed for specific leisure domains; with the cognitive, productive/creative and recreational domains having significant associations with some of the assessed socio-demographic and clinical attributes.

Engagement in cognitive leisure activities such as reading, writing, using the computer, teaching Bible or Quranic classes, was found to be associated with more socio-demographic and clinical attributes compared to the other leisure domains. Those with ischemic stroke, and tertiary education, who were employed, and who had suffered stroke for between 1 and 3 years prior to the study, had a higher prevalence of engagement in these activities. Hemorrhagic stroke has often been associated with marked cognitive impairment compared to ischemic stroke (Nys et al., 2007), and little wonder ischemic stroke survivors in our study had a significantly higher level of participation in cognitive leisure activities. The high level of engagement of stroke survivors who had tertiary education in cognitive leisure activities also came as no surprise especially as many of the activities require a certain level of intelligence and educational exposure. It is important to state that higher level of education has been associated with more leisure participation (Caspersen et al., 1986). Furthermore, the significant association between participation in cognitive leisure activities and the pair of being employed and possessing a tertiary education qualification, both indicators of high socio-economic status, appear to be in line with the marginality framework of understanding differences in leisure participation (Floyd & Stodolska, 2013). Educational status was also found to be associated with participation in productive/creative leisure activities. All of these associations have implications for planning and providing appropriate interventions to enhance post-stroke leisure participation. In line with stroke practice guidelines, appropriate rehabilitation interventions are required to address restrictions in leisure participation (Lindsay et al., 2010). Such interventions have been reported to include leisure education programmes (Desrosiers et al., 2007; Lindsay et al., 2010).

Additionally, environmental factors (Amarshi et al., 2006), access to transportation (Morgan & Jongbloed, 1990; Amarshi et al., 2006), financial implication of leisure participation (Amarshi et al., 2006), cognition (Amarshi et al., 2006), and availability of social support (Morgan & Jongbloed, 1990; Amarshi et al., 2006) are some of the most frequently reported determinants of leisure participation after stroke. Our study however focused on the associations of leisure participation with socio-demographic and clinical attributes, and further studies would be required to explore the impact of these documented factors on leisure participation of stroke survivors in our environment. Future studies should also examine the impact of leisure participation on important stroke outcomes such as motor and functional recovery and quality of life among Nigerian stroke survivors.

4.4 Limitations of the study

The small size of the sample of stroke survivors in this study constitutes a limitation. Independent determinants of leisure participation could not also be ascertained because of the size of the sample as more complex analyses such as regression could not conducted. The hospital-based design of the study also limits generalizability of our findings. The assessment of leisure participation in this study was carried out using an unstandardized measure and has implications for comparability of this study with others. To our knowledge, our study is the first to explore leisure participation in Nigeria and the fact that leisure activities tend to be unique to different cultural situations rendered the use of some of the existing measures inappropriate. The availability of standardized leisure assessment instruments that are suitable and appropriate for our African setting will therefore be required.

5 Conclusion

Leisure participation was generally high among stroke survivors in this study although it varied across the four domains assessed with the highest rate in the social leisure domain and lowest in the productive/creative leisure domain. Participation in cognitive, recreational and productive/creative leisure activities was significantly associated with some of the socio-demographic and clinical attributes of the stroke survivors such as level of education, employment status, level of disability, post-stroke duration and type of stroke. These associations may have implications for planning appropriate rehabilitation strategies capable of enhancing leisure participation after stroke.

Conflict of interest

None.

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