Environmental determinants of participation restriction after stroke: A systematic review of observational and qualitative studies

Abstract

Introduction The International Classification of Functioning, Disability and Health (ICF) was published in 2001 by the World Health Organization (WHO) who defined participation restriction as the difficulty to achieve activities in daily life. The ICF allows to consider an individual in its global functioning then, participation restriction is the combined consequence of disability, activity limitation and contextual factors both personal and environmental. Participation is a major determinant of quality of life and life satisfaction in stroke patients, then for a given deficiency and activity limitation, consequences on participation may be very different depending on these contextual factors. However, there is limited evidence existing. The ICF defined two levels of environmental factors: “individual, direct environment” (interaction between an individual and his direct environment: physical environment, social and familial relationships) and “societal, global environment” (interaction with social, health services, lows and national policies). The aim of this systematic literature review is to better understand the role of environment in stroke patients’ functioning and precisely to identify which environmental determinants could be associated with participation restriction in stroke patients. Methods Searches were conducted in MEDLINE, PsycINFO, and Web of Science. The search algorithms were: for MEDLINE, (‘Stroke’[Mesh]) AND (‘Social Participation’[Mesh]); for PsycINFO and Web of science: ‘stroke and participation restriction’; ‘stroke and social participation’. The quality of observational studies was based on 4 criteria adapted from the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist and quality of qualitative studies was based on four criteria adapted from the COREQ (Consolidated criteria for reporting qualitative research) checklist. Results Forty-one studies were retained for entire reading, full-text assessment of eligibility and quality. We eventually selected 16 articles, among them, 11 were quantitative studies and 5 were qualitative studies. The first level “individual, direct environment” was widely more studied in articles selected than the second level “societal, global environment”. Direct environment conceptualized as social support, attitudes towards the patient and physical environment were the mainly environmental determinant of participation restriction identified and appeared to be a major facilitator of participation. Global environment (access to health services and health policies) was only investigated in one study in the review and showed a significant association with participation, then appeared to be a facilitator of participation. Conclusion This is to our knowledge the first review which gathered evidence regarding environmental determinants of stroke patients’ participation, 16 studies were included. This review shows that two levels of environment: “individual, direct environment” and “societal, global environment” are facilitators of participation and should be considered in clinical practice, in rehabilitation programs and constitute issues for future intervention research.