Content and Effectiveness of Interventions Focusing on Community Participation After Stroke: A Systematic Review

PURPOSE: Stroke survivors' satisfaction with rehabilitation is low when therapy is overly focused on physical outcomes without addressing the social implications of stroke (Peoples, Satink, & Steultjens, 2011). Sole focus on physical improvement is only preparatory to community participation and does not address the complexity of potential barriers, difficulties, and needs that individuals might face outside the hospital and in the community. Increasing emphasis is being placed on community integration and community participation outcomes in stroke rehabilitation. However, only a few systematic reviews are available to guide these interventions (Graven et al., 2011; and Warner et al., 2015; Wolf et al., 2015). Yet, existing systematic reviews have not examined interventions directly addressing post stroke community participation and the content of such interventions. This systematic review aims to investigate the content and effectiveness of interventions that address post-stroke community participation.

METHODS: Bibliographic databases including EMBASE, PsycINFO, Ovid-PubMed, and CINAHL were searched using a combination of three indexing terms and respective thesaurus: stroke, social participation, and randomized control trial. Search was also extended to checking references from relevant systematic reviews. Selected studies were conducted with adults who have had a stroke, evaluated interventions addressing community participation, had comparison groups, and reported at least one of the following outcomes: participation, depression, and health related quality of life. Articles retrieved through searches were screened based on title, abstract, and full text. Data were then independently extracted based on characteristics of participants, key elements of intervention, comparator, outcome measures, and results were extracted. Intervention contents were categorized based on 11 categories from the International Classification of Functioning, Disability, and Health (ICF) Activities and Participation domains.

RESULTS: Four community participation intervention categories were identified: community resources and information, leisure participation, community integration, and community mobility. Three leisure and four community integration interventions showed significant group differences favoring the intervention group in at least one of the participation, depression, and health related quality of life outcomes. One community mobility intervention showed effectiveness in particular skills and self-efficacy in using the transit system. The majority of interventions addressed ICF categories such as moving around, interpersonal relations, economic life, community life, and recreation and leisure. Very few interventions focused on human rights, political life and citizenship, education, assisting others, and religion and spirituality.

CONCLUSIONS: Potential bias in research designs and heterogeneity of interventions, samples, and outcome measures limit definitive conclusions about the effectiveness of community participation-focused interventions. However, comprehensive interventions addressing environmental influences on participation with opportunities for individualized interventions, strategies, or goals were more likely to be effective. The systematic review provides evidence supporting the effectiveness of individualized and comprehensive approaches to addressing post-stroke community participation and suggests that interventions for people with stroke also include the sociopolitical aspects of community participation.

References

Graven, C., Brock, K., Hill, K., & Joubert, L. (2011). Are rehabilitation and/or care co-ordination interventions delivered in the community effective in reducing depression, facilitating participation and improving quality of life after stroke? Disability and Rehabilitation, 33(17–18), 1501–1520. https://doi.org/10.3109/09638288.2010.542874

Peoples, H., Satink, T., & Steultjens, E. (2011). Stroke survivors’ experiences of rehabilitation: A systematic review of qualitative studies. Scandinavian Journal of Occupational Therapy, 18(3), 163–171. https://doi.org/10.3109/11038128.2010.509887

Warner, G., Packer, T., Villeneuve, M., Audulv, A., & Versnel, J. (2015). A systematic review of the effectiveness of stroke self-management programs for improving function and participation outcomes: self-management programs for stroke survivors. Disability and Rehabilitation, 37(23), 2141–2163. https://doi.org/10.3109/09638288.2014.996674

Wolf, T. J., Chuh, A., Floyd, T., Mclnnis, K., & Williams, E. (2015). Effectiveness of occupation-based interventions improve areas of occupation and social participation after stroke: An evidence-based review. American Journal of Occupational Therapy, 69(1), 1–11. https://doi.org/10.5014/ajot.2015.012195