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NeuroRehabilitation 34 (2014) 297–304 DOI:10.3233/NRE-141047 IOS Press
Are there gender differences in longitudinal patterns of functioning in Nigerian stroke survivors during the first year after stroke? Grace Oluwatitofunmi Vincent-Onabajoa,∗ , Talhatu Kolapo Hamzatb and Mayowa Ojo Owolabic a Department
of Medical Rehabilitation (Physiotherapy), University of Maiduguri, Maiduguri, Borno State, Nigeria of Physiotherapy, University of Ibadan, Ibadan, Nigeria c Department of Medicine, Neurology Unit, University of Ibadan, Ibadan, Nigeria b Department
Abstract. BACKGROUND: Several studies have examined gender differences in various stroke outcomes. There is however little information on the influence of gender on post-stroke functioning in the context of the International Classification of Functioning, Disability and Health (ICF). OBJECTIVE: Gender differences in selected components of functioning, namely motor performance (body function), activity and participation, were examined in a sample of Nigerian stroke survivors. METHODS: This longitudinal study involved consenting first-incidence stroke survivors who were consecutively recruited from in-patient wards of a University teaching hospital in northern Nigeria. Demographic and clinical data were obtained at recruitment while motor performance, activity and participation were assessed at the 1st, 3rd, 6th, 9th and 12th months using the Simplified Fugl Meyer scale, the Functional Independence Measure Motor Sub-scale and the London Handicap Scale respectively. RESULTS: Participants were thirty-three male (60%) and 22 female (40%) stroke survivors who did not significantly differ in age, stroke sub-type, laterality and initial severity (P > 0.05). There were also no significant differences in motor performance, activity and participation between the male and female stroke survivors across the time points. CONCLUSION: Gender differences were not observed in the components of functioning over the first 12 months post-stroke. Keywords: Activity, functioning, gender, ICF, motor performance, Nigeria, participation, stroke
1. Introduction Stroke is one of the most common chronic conditions that is characterized by a wide array of outcomes (Geyh et al., 2004). With improvement in rates of survival after stroke, post-stroke functioning represents one of the most important outcomes and constitutes the target of ∗ Address for correspondence: Dr. Grace O. Vincent-Onabajo, Department of Medical Rehabilitation (Physiotherapy), University of Maiduguri, Maiduguri, Borno State, Nigeria. Tel.: +2348056614251; E-mail: [email protected].
many rehabilitation efforts (Weimer et al., 2002). This is more so as impaired functioning is experienced by 50 to 75% of all stroke survivors (WHO Report, 2004). The International Classification of Functioning, Disability and Health or ICF, provides a framework for examining the effects of disease conditions on functioning in terms of impairments of body structure and function, activity limitations and participation restrictions (WHO, 2001). These components of functioning not only provide a model for analysing the consequences of disease conditions but could also serve as
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indices of recovery from a condition like stroke. This is especially important as difficulty is often encountered in defining stroke recovery and what it entails (Duncan et al., 2000). Motor performance of the hemiplegic or hemiparetic extremity is closest to the stroke pathology (Feydey et al., 2002) and is therefore regarded as the best indicator of stroke recovery (Desrosiers et al., 2003). The limitation of motor status as an index of recovery after stroke has however been observed (Kwakkel et al., 2004, 2006; de wit et al., 2007). Studies have shown that the ability to carry out activities and engage in higher levels of functioning such as participation after stroke is not fully explained by motor performance, hence the need for holistic evaluation of post-stroke functioning (Kwakkel et al., 2006; de wit et al., 2007). Several physiological, demographic and environmental factors have been reported to be associated with recovery after stroke. While some of these factors are modifiable and amenable to appropriate interventions, demographic factors such as age and gender are not. Gender, and its effect on recovery after stroke has emerged as an important consideration over the years (Wade et al., 1984; Wyller et al., 1997; Di Carlo et al., 2003; Lai et al., 2005; Chong et al., 2006; Gray et al, 2007; Gargano & Reeves, 2007; Wiltz, 2007; Kim et al., 2010). In spite of increasing attention on the influence of gender on stroke outcomes, available findings are inconclusive. While a lack of gender difference in post-stroke recovery of basic activities of daily living and higher level of functioning has been reported (Lai et al., 2005), there are other reports on significant gender disparities in stroke outcomes (Gray et al., 2007; Chong et al., 2006). In the study by Chong et al. (2006), information on stroke survivors’ functional recovery was obtained by self-report and women reported incomplete recovery more than men in spite of objective evidence of recovery. In another study, poorer functional recovery was observed in women, and difference in coping and adaptation patterns between men and women was suggested as being responsible for the disparity (Gray et al., 2007). It is worthy of note that the characterization of gender roles in different cultures and societies could also contribute to the variations in reports on the influence of gender on recovery after stroke. In Nigeria, the most populous country in Africa, the role of the men and women are traditionally distinct and seldom overlap. The established responsibility of men as bread-winners and role models for children and other members of the family is one that often results in self-assertion, unwillingness to exhibit weakness and
dependence, and desire to always be in charge (Omadjohwoefe, 2011). Conversely for the women, being dependent on spouse and family members is considered the norm. Although increasing modernisation and westernisation witnessed in the country have resulted in changes in gender roles with lesser dichotomy between men and women, the influence of culture is still very strong (Omadjohwoefe, 2011). It is worthy of note that in contemporary Nigerian societies, socio-economic challenges appear to be redefining gender roles, especially as it concerns earnings and material provisions for the family (Morrison et al., 2007). The economic trend in the country has resulted in increasing numbers of women contributing substantially to the family income by engaging in income generating ventures while others are solely responsible for providing the livelihood for their families (Morrison et al., 2007). Social issues such as increased rate of divorce and cases of single parenthood have also led to an increase in the number of female breadwinners in the country (Morrison et al., 2007). It therefore follows that the circumstances in different countries and societies would necessitate the assessment of gender differences in the outcome of a major disease such as stroke. Many of the previous studies on the influence of gender on functional outcomes after stroke were however conducted in Western and developed countries, while there is a dearth of data on the subject matter in Nigeria. This is in spite of the possibility that the culturally divergent and well delineated roles of men and women in Nigeria may exert some influence on functional outcome after stroke especially as there is evidence on the interplay between functional activities and role performance (Jongbloed et al., 1993). Furthermore, longitudinal studies are rare in Nigeria, with no record of follow-up of stroke survivors’ status beyond the first six months after stroke (Hamzat & Peters, 2009; Peters & Hamzat, 2009). The aim of this study was therefore to examine gender differences in functioning of stroke survivors in Nigeria over the first 12 months after stroke.
2. Methods 2.1. Study design: A 12-month longitudinal study Study Setting: The study was conducted in the eastern zone of northern Nigeria. Northern Nigeria comprises of 19 states with 6 states in the north-eastern zone. The cultural attributes of northern Nigeria appears
G.O. Vincent-Onabajo et al. / Are there gender differences in longitudinal patterns of functioning in Nigerian stroke survivors
to support gender dichotomy. Apart from improvement in awareness and initiatives that encourage education of the girl child and involvement of more women in politics and different professions, the traditional northern Nigerian culture is patriarchal. Stroke survivors were recruited from the medical wards of a University Teaching Hospital. All stroke survivors were recipients of medical and nursing care, and physiotherapy which are routine stroke management in all tertiary care hospitals in Nigeria. 2.2. Participants Eighty-three first-incidence stroke survivors were consecutively recruited within the first four weeks of stroke onset. Orientation in time, place and person, ability to communicate in either English or Hausa languages and provision of informed consent by the participants or a family member were the eligibility criteria. 2.3. Outcome measures Functioning was operationally defined in terms of motor performance, activity and participation. Motor performance, activity and participation were assessed with the Short-form Fugy-Meyer Assessment (S-FM), motor subscale of the Functional Independence Measure (FIM) and the London Handicap Scale (LHS) respectively. 1. Short-form Fugyl-Meyer Assessment (S-FM): The S-FM was interviewer-administered to assess participants’ motor performance. It is a 12-item strokespecific scale that is divided into upper limb and lower limb subscales derived from the motor subscale Fugyl-Meyer Assessment (FMA) (Hseih et al., 2007). Each item is scored on a 3-point ordinal scale of 0 to 2 : 0 = cannot perform; 1 = performs partially; 2 = performs fully. The S-FM has high concurrent validity with the motor subscale of the FMA (r = 0.93) (Hseih et al., 2007). 2. The Functional Independence Measure (FIM): The motor subscale of the FIM was used to assess the activity of the stroke survivors. The subscale consists of 13 items and assesses four aspects of function namely: self-care, sphincter control, transfers and locomotion. Each item is scored on a 7-point Likert scale, and the scores indicate the level of assistance required to perform each item (1 = total assistance in all areas, 7 = total independence). Total score is obtained by simple summation and ranges from 13 to 91. The ratings were
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obtained through interview of study participants. The motor sub-scale of the FIM is highly responsive and showed an excellent internal consistency (Cronbach’s alpha of 0.88 at admission and 0.91 at discharge) in a study of stroke patients (Hsueh et al., 2002). 3. The London Handicap Scale: The London Handicap Scale (LHS) was used to assess participation of stroke survivors. The LHS has 6 dimensions; namely: mobility, orientation, occupation, physical independence, social integration, and economic self –sufficiency and each dimension is classified on a six point scale. The un-weighted simple summation scoring system was used to calculate the total participation score with obtainable values ranging from 0 (maximum restriction) to 100 (no restriction) (Jenkinson et al., 2000). The LHS has been previously validated for use among Nigerian stroke survivors (Hamzat & Peters, 2009). 2.4. Procedure Approval for this study was obtained from the relevant Institution Ethics committees. At recruitment within the first four weeks after stroke, verbal informed consent and participants’ demographic and clinical data were obtained, namely age, gender, stroke sub-type, stroke severity and side of hemiplegia or hemiparesis. Information on post-discharge residence and telephone numbers (where available) were also obtained for purposes of follow-up. In Nigeria, it is a common practice for patients who have suffered a stroke to be discharged straight from hospital wards to their places of abode. The Nigerian culture plays a major role in this practice as post-hospital discharge care of an ill individual tends to fall essentially on family members while institutionalized care in nursing homes can be considered alien to many Nigerians. Assessments of motor performance, activity and participation were conducted at the 1st , 3rd , 6th , 9th and 12th month after stroke. Motor performance was assessed through observation while face-to-face interviews were carried out to assess activity and participation. Posthospital discharge follow-up assessments were carried out at the places of abode of the stroke survivors which were either their homes or homes of their relatives. 2.5. Statistical analyses Descriptive statistics of percentages, mean and standard deviation were used to summarize demographic and clinical data, while data from the S-FM, FIM and
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Table 1 Comparison of demographic and clinical characteristics of stroke survivors who completed and those who did not complete the study using one-way ANOVA and Fisher’s exact test (N = 83) Variable
Gender Male Female Type of Stroke Ischemic Hemorrhagic Unknown Side of Hemiplegia/Hemiparesis Left Right Stroke Severity (Stroke Levity Scale) Severe Moderate Mild Age (years) Mean ± SD Range
Completers (55)
Non-completers (n = 28)
Test
P-value
5 (71.4) 2 (28.6)
1.81
0.42
16 (76.2) 2 (9.5) 3 (14.3)
4 (57.1) 2 (28.6) 1 (14.3)
5.88
0.16
33 (60) 22 (40)
8 (38.1) 13 (61.9)
2 (28.6) 5 (71.4)
4.46
0.10
26 (47.3) 20 (36.4) 9 (16.4) 58.0 ± 12.78
11 (52.4) 9 (42.9) 1 (4.8) 54.7 ± 13.7
4 (57.1) 3 (42.9) 0 (0) 63.1 ± 22.3
2.31
0.69
1.03
0.36
31–85
28–75
35–95
n (%)
Attrition (n = 21) n (%)
Died (n = 7) n (%)
33 (60) 22 (40)
16 (76.2) 5 (23.8)
39 (70.9) 14 (25.5) 2 (3.6)
LHS were presented as median scores. Independent t-test and Chi square test were used to compare difference between male and female stroke survivors in terms of age, stroke laterality and sub-type, and baseline stroke severity. Age was computed as a continuous variable while stroke severity was presented as a categorical variable (severity was categorized as mild, moderate, severe) in addition to the other categorical variables. Mann-Whitney U test was used to compare indices of functioning (motor performance, activity and participation) between male and female stroke survivors across 5 time points (1, 3, 6, 9 and 12 months). Level of statistical significance was set at p = 0.05.
3. Results Fifty-five stroke survivors comprising thirty-three males (60%) and twenty-two females (40%) completed the study. There were twenty-eight non-completers of which seven died and twenty-one could not be located for follow-up. Gender of completers and noncompleters were however not significantly different (Table 1). Table 1 also shows the demographic and clinical characteristics of participants in the study. Comparisons of demographic and clinical characteristics between male and female stroke survivors are presented in Table 2. From the univariate analysis, motor performance, activity and participation were not significantly differ-
Table 2 Differences in baseline characteristics between male and female stroke survivors (n = 55) Variable
Male
Age (years) Mean ± SD 60.7 ± 12.4 Stroke Sub-type n Ischemic 22 Hemorrhagic 9 Unknown 2 Side of stroke Right 20 Left 13 Severity of stroke Severe 14 Moderate 14 Mild 5
Female
% 66.7 27.2 6.1
P-value
58.1 ± 12.6 n % 17 77.3 5 22.7 – –
0.06 0.61
60.6 39.4
13 9
59.1 40.9
0.91
42.4 42.4 15.2
12 6 4
54.5 27.3 18.2
0.54
P-value: level of significance. Statistical analyses for difference in age was carried out with the Independent t-test while Chi-square test was used for the other variables.
ent between male and female stroke survivors over the first 12 months after stroke (Figs. 1–3). 3.1. Motor performance Motor performance of the stroke survivors improved across 12 months. Females however had lower median scores on the Short-form Fugyl-Meyer assessment than their male counterparts. The differences in the scores did not attain statistical significance at each time-point with levels of significance (P) equal to 0.28; 0.21; 0.30; 0.36 and 0.41 at the 1st, 3rd, 6th, 9th and 12th months respectively (Fig. 1).
G.O. Vincent-Onabajo et al. / Are there gender differences in longitudinal patterns of functioning in Nigerian stroke survivors
Fig. 1. Longitudinal Patterns of Motor Performance of Male and Female stroke survivors across 12 months as assessed with the Short-form Fugyl Meyer Scale (higher scores denote better motor performance.
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Fig. 3. Longitudinal Patterns of Participation in Male and Female stroke survivors across 12 months as assessed with the London Handicap Scale (higher scores denote better participation).
3.3. Participation Median scores on the LHS for male and female stroke survivors are presented in Fig. 3. Although without statistical significance, participation differed between male and female with males having slightly higher median scores at the 1st, 3rd, 6th and 9th months (P = 0.78; 0.55; 0.96; 0.64; 0.39). However at the 12th month, females had higher participation scores at P = 0.39.
4. Discussion
Fig. 2. Longitudinal Patterns of Activity in Male and Female stroke survivors across 12 months as assessed with the Functional Independence Measure (higher scores denote better activity).
3.2. Activity Differences in the FIM median scores for male and females were not statistically significant although females scored lower than males across 12 months. Figure 2 shows the longitudinal patterns of male and female stroke survivors’ activity at the 1st, 3rd, 6th, 9th and 12th months; with respective P values of 0.45; 0.34; 0.55; 0.93 and 0.65.
In addition to anatomical, hormonal and role differences between men and women, gender difference could also be seen in the pattern and outcome of disease conditions. This study explored possible differences in motor performance, activity and participation between male and female stroke survivors in Nigeria within the first year after stroke. Although majority of the stroke survivors were males, their age, stroke sub-type, side and severity of stroke were not significantly different from the females. The age similarity between men and women observed differs from earlier reports. The report from a comprehensive review of literature on gender differences in stroke showed that women are usually older than men at onset of stroke (Reeves et al., 2010). However in line with our findings, Reeves et al. (2010) reported similar stroke severity in males and females, especially when stroke subtype and age were taken into
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account. Also similar to our findings, two previous studies reported a lack of gender disparity in the distribution of ischemic and hemorrhagic stroke sub-types, and the location of stroke (Di Carlo et al., 2003; Lai et al., 2005). Motor performance is one of the important components of post-stroke functioning that was assessed in this study. The construct represents the ability to assume, maintain, alter and control voluntary postures and movement patterns. Most commonly impaired in the mirror half of the body (hemiplegia or hemiparesis), motor performance after stroke is regarded as a major indicator of the pathophysiology of the disease (Feydey et al., 2002). Motor performance in male and female stroke survivors in this study did not significantly differ across 12 months after stroke although males had higher scores on assessment. Reports on gender differences in post-stroke motor impairments are rare. One available study however reported better motor function in males at one year after stroke (Wyller et al., 1997). Although stroke survivors and their families tend to place more importance on functional activity and participation than degree of paralysis (Kollen et al., 2006), assessment of motor performance provides a more objective insight into recovery after stroke. Traditionally, many stroke studies focus on activities of daily living although attention has been shifting to higher levels of functioning and quality of life in recent times. There are therefore a number of studies that have examined gender differences in functional activity after stroke. Similar to our findings, some earlier studies observed no gender difference in activities of daily living after stroke (Wade et al., 1984; Lai et al., 2005). However, a more consistent pattern in majority of the available studies is the lower level of functional activities in women (Reeves et al., 2008). In the study of stroke survivors in Kansas City, United States, women reported lower performance in instrumental activities of daily living (IADLs) than their male counterparts (Lai et al., 2005). The authors however suggested that the difference could have resulted from traditional gender roles which shield men from many IADLs and may result in favorable estimation of their capability rather than actual performance of those activities. Similarly in a study of stroke survivors in Germany, perception of stroke impairments was reported to differ between males and females irrespective of actual stroke severity and disability as assessed by Barthel index (Wiltz, 2007). Differences in coping and adaptation patterns between male and female stroke survivors may also be responsible for the gender differences observed in functional outcomes (Gray et al., 2007). In longitudinal
studies that reported gender differences in post-stroke functional activity, there appeared to be no specific pattern in relation to time after stroke, rather, both short (Di Carlo et al., 2003; Kim et al., 2010) and long-term (Kim et al., 2010) trends showed a female disadvantage. Higher level of functioning such as involvement in life roles, also known as participation, did not significantly differ between male and female stroke survivors in this study. Studies that have assessed specific components of participation such as employment (Vestling et al., 2003; Lindstrom et al., 2009), leisure activities (Sveen et al., 2004), and community ambulation (Robinson, 2011) indicated that gender played no significant role in involvement in these life areas after stroke. Similarly in our previous study, rate of return to work after stroke was not significantly different between male and female stroke survivors (Peters et al., 2012). There is however a report on worse outcome in women than in men in terms of post-stroke participation restriction (Di Carlo et al., 2003). Differences in functional recovery after stroke between males and females are seldom attributed solely to gender (Gargano et al., 2007). Rather, many stroke studies that have reported lower levels of functioning in women compared to men provided inconclusive reasons for the observed differences (Reeves et al., 2008). One of the most common explanations for gender differences in stroke outcomes is the older age of women at the stroke onset. This was however not the case in this present study as the age of men and women did not significantly differ. In a one-year follow-up study in Korea, female stroke survivors were reported to be older than males and the fact that older women in that country were likely to be unmarried, and with no caregivers was given as a possible reason for their lower level of functioning (Kim et al., 2010). The converse however tends to be the case in Nigeria where in old age, women are dutifully cared for by family members, especially their children, as a show of appreciation for the care they received in early life. Also, it is culturally unacceptable for children to fail to care for their aged parents, especially the mother. Furthermore, care of older women, especially widows, is often regarded as a religious obligation in Nigeria. Poor physical function prior to stroke and depressive symptoms were the factors attributed to poor physical functioning in women in a United States study (Lai et al., 2005). Although our study did not obtain information on pre-stroke functioning, there are indications of increasing similarity in levels of functioning between genders in Nigeria especially in terms of role
G.O. Vincent-Onabajo et al. / Are there gender differences in longitudinal patterns of functioning in Nigerian stroke survivors
performance. In some instances, due to contemporary socio-economic realities, women take up roles that were previously male-dominated such as providing family income. Increasing rates of single parenthood leading to women taking up roles that were previously regarded as paternal could also be contributory to transition in gender roles in the Nigerian society. Although there were also variations among previous reports, the socio-cultural differences between an African country such as Nigeria, and Western and Asian countries where previous studies were conducted could have contributed substantially to the dissimilarities between our findings and those of the other studies. There are however no available data from other African countries with which to compare our findings. The fact that stroke survivors in this study were recruited from acute hospital settings might have resulted in selection bias which limits the generalizability of our findings. A community–based study might therefore provide a more representative sample although the 12-month follow-up design of our study enabled us compare functioning between male and female stroke survivors from the time they were on hospital admission till they returned to the community. Also, the rate of drop-out and the small size of the sample of stroke survivors that completed the study constitute limitations although there were no significant differences in the clinical and demographic attributes between those who completed the study and those who dropped out. 5. Conclusion Functioning in the group of Nigerian stroke survivors studied did not significantly differ by gender over the first 12 months after stroke. These findings are indicative of a lack of difference in post-stroke functioning in male and female Nigerian stroke survivors and thus imply the need for parity in provision of health care and support for all stroke survivors irrespective of gender. Furthermore, interventions and strategies needed to enhance motor performance, activity and participation in the first year of stroke should be provided without gender inequality or bias in order to ensure optimal outcomes in both male and female stroke survivors. Declaration of interest The authors report no conflict of interest
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NeuroRehabilitation 34 (2014) 297–304 DOI:10.3233/NRE-141047 IOS Press
Are there gender differences in longitudinal patterns of functioning in Nigerian stroke survivors during the first year after stroke? Grace Oluwatitofunmi Vincent-Onabajoa,∗ , Talhatu Kolapo Hamzatb and Mayowa Ojo Owolabic a Department
of Medical Rehabilitation (Physiotherapy), University of Maiduguri, Maiduguri, Borno State, Nigeria of Physiotherapy, University of Ibadan, Ibadan, Nigeria c Department of Medicine, Neurology Unit, University of Ibadan, Ibadan, Nigeria b Department
Abstract. BACKGROUND: Several studies have examined gender differences in various stroke outcomes. There is however little information on the influence of gender on post-stroke functioning in the context of the International Classification of Functioning, Disability and Health (ICF). OBJECTIVE: Gender differences in selected components of functioning, namely motor performance (body function), activity and participation, were examined in a sample of Nigerian stroke survivors. METHODS: This longitudinal study involved consenting first-incidence stroke survivors who were consecutively recruited from in-patient wards of a University teaching hospital in northern Nigeria. Demographic and clinical data were obtained at recruitment while motor performance, activity and participation were assessed at the 1st, 3rd, 6th, 9th and 12th months using the Simplified Fugl Meyer scale, the Functional Independence Measure Motor Sub-scale and the London Handicap Scale respectively. RESULTS: Participants were thirty-three male (60%) and 22 female (40%) stroke survivors who did not significantly differ in age, stroke sub-type, laterality and initial severity (P > 0.05). There were also no significant differences in motor performance, activity and participation between the male and female stroke survivors across the time points. CONCLUSION: Gender differences were not observed in the components of functioning over the first 12 months post-stroke. Keywords: Activity, functioning, gender, ICF, motor performance, Nigeria, participation, stroke
1. Introduction Stroke is one of the most common chronic conditions that is characterized by a wide array of outcomes (Geyh et al., 2004). With improvement in rates of survival after stroke, post-stroke functioning represents one of the most important outcomes and constitutes the target of ∗ Address for correspondence: Dr. Grace O. Vincent-Onabajo, Department of Medical Rehabilitation (Physiotherapy), University of Maiduguri, Maiduguri, Borno State, Nigeria. Tel.: +2348056614251; E-mail: [email protected].
many rehabilitation efforts (Weimer et al., 2002). This is more so as impaired functioning is experienced by 50 to 75% of all stroke survivors (WHO Report, 2004). The International Classification of Functioning, Disability and Health or ICF, provides a framework for examining the effects of disease conditions on functioning in terms of impairments of body structure and function, activity limitations and participation restrictions (WHO, 2001). These components of functioning not only provide a model for analysing the consequences of disease conditions but could also serve as
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indices of recovery from a condition like stroke. This is especially important as difficulty is often encountered in defining stroke recovery and what it entails (Duncan et al., 2000). Motor performance of the hemiplegic or hemiparetic extremity is closest to the stroke pathology (Feydey et al., 2002) and is therefore regarded as the best indicator of stroke recovery (Desrosiers et al., 2003). The limitation of motor status as an index of recovery after stroke has however been observed (Kwakkel et al., 2004, 2006; de wit et al., 2007). Studies have shown that the ability to carry out activities and engage in higher levels of functioning such as participation after stroke is not fully explained by motor performance, hence the need for holistic evaluation of post-stroke functioning (Kwakkel et al., 2006; de wit et al., 2007). Several physiological, demographic and environmental factors have been reported to be associated with recovery after stroke. While some of these factors are modifiable and amenable to appropriate interventions, demographic factors such as age and gender are not. Gender, and its effect on recovery after stroke has emerged as an important consideration over the years (Wade et al., 1984; Wyller et al., 1997; Di Carlo et al., 2003; Lai et al., 2005; Chong et al., 2006; Gray et al, 2007; Gargano & Reeves, 2007; Wiltz, 2007; Kim et al., 2010). In spite of increasing attention on the influence of gender on stroke outcomes, available findings are inconclusive. While a lack of gender difference in post-stroke recovery of basic activities of daily living and higher level of functioning has been reported (Lai et al., 2005), there are other reports on significant gender disparities in stroke outcomes (Gray et al., 2007; Chong et al., 2006). In the study by Chong et al. (2006), information on stroke survivors’ functional recovery was obtained by self-report and women reported incomplete recovery more than men in spite of objective evidence of recovery. In another study, poorer functional recovery was observed in women, and difference in coping and adaptation patterns between men and women was suggested as being responsible for the disparity (Gray et al., 2007). It is worthy of note that the characterization of gender roles in different cultures and societies could also contribute to the variations in reports on the influence of gender on recovery after stroke. In Nigeria, the most populous country in Africa, the role of the men and women are traditionally distinct and seldom overlap. The established responsibility of men as bread-winners and role models for children and other members of the family is one that often results in self-assertion, unwillingness to exhibit weakness and
dependence, and desire to always be in charge (Omadjohwoefe, 2011). Conversely for the women, being dependent on spouse and family members is considered the norm. Although increasing modernisation and westernisation witnessed in the country have resulted in changes in gender roles with lesser dichotomy between men and women, the influence of culture is still very strong (Omadjohwoefe, 2011). It is worthy of note that in contemporary Nigerian societies, socio-economic challenges appear to be redefining gender roles, especially as it concerns earnings and material provisions for the family (Morrison et al., 2007). The economic trend in the country has resulted in increasing numbers of women contributing substantially to the family income by engaging in income generating ventures while others are solely responsible for providing the livelihood for their families (Morrison et al., 2007). Social issues such as increased rate of divorce and cases of single parenthood have also led to an increase in the number of female breadwinners in the country (Morrison et al., 2007). It therefore follows that the circumstances in different countries and societies would necessitate the assessment of gender differences in the outcome of a major disease such as stroke. Many of the previous studies on the influence of gender on functional outcomes after stroke were however conducted in Western and developed countries, while there is a dearth of data on the subject matter in Nigeria. This is in spite of the possibility that the culturally divergent and well delineated roles of men and women in Nigeria may exert some influence on functional outcome after stroke especially as there is evidence on the interplay between functional activities and role performance (Jongbloed et al., 1993). Furthermore, longitudinal studies are rare in Nigeria, with no record of follow-up of stroke survivors’ status beyond the first six months after stroke (Hamzat & Peters, 2009; Peters & Hamzat, 2009). The aim of this study was therefore to examine gender differences in functioning of stroke survivors in Nigeria over the first 12 months after stroke.
2. Methods 2.1. Study design: A 12-month longitudinal study Study Setting: The study was conducted in the eastern zone of northern Nigeria. Northern Nigeria comprises of 19 states with 6 states in the north-eastern zone. The cultural attributes of northern Nigeria appears
G.O. Vincent-Onabajo et al. / Are there gender differences in longitudinal patterns of functioning in Nigerian stroke survivors
to support gender dichotomy. Apart from improvement in awareness and initiatives that encourage education of the girl child and involvement of more women in politics and different professions, the traditional northern Nigerian culture is patriarchal. Stroke survivors were recruited from the medical wards of a University Teaching Hospital. All stroke survivors were recipients of medical and nursing care, and physiotherapy which are routine stroke management in all tertiary care hospitals in Nigeria. 2.2. Participants Eighty-three first-incidence stroke survivors were consecutively recruited within the first four weeks of stroke onset. Orientation in time, place and person, ability to communicate in either English or Hausa languages and provision of informed consent by the participants or a family member were the eligibility criteria. 2.3. Outcome measures Functioning was operationally defined in terms of motor performance, activity and participation. Motor performance, activity and participation were assessed with the Short-form Fugy-Meyer Assessment (S-FM), motor subscale of the Functional Independence Measure (FIM) and the London Handicap Scale (LHS) respectively. 1. Short-form Fugyl-Meyer Assessment (S-FM): The S-FM was interviewer-administered to assess participants’ motor performance. It is a 12-item strokespecific scale that is divided into upper limb and lower limb subscales derived from the motor subscale Fugyl-Meyer Assessment (FMA) (Hseih et al., 2007). Each item is scored on a 3-point ordinal scale of 0 to 2 : 0 = cannot perform; 1 = performs partially; 2 = performs fully. The S-FM has high concurrent validity with the motor subscale of the FMA (r = 0.93) (Hseih et al., 2007). 2. The Functional Independence Measure (FIM): The motor subscale of the FIM was used to assess the activity of the stroke survivors. The subscale consists of 13 items and assesses four aspects of function namely: self-care, sphincter control, transfers and locomotion. Each item is scored on a 7-point Likert scale, and the scores indicate the level of assistance required to perform each item (1 = total assistance in all areas, 7 = total independence). Total score is obtained by simple summation and ranges from 13 to 91. The ratings were
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obtained through interview of study participants. The motor sub-scale of the FIM is highly responsive and showed an excellent internal consistency (Cronbach’s alpha of 0.88 at admission and 0.91 at discharge) in a study of stroke patients (Hsueh et al., 2002). 3. The London Handicap Scale: The London Handicap Scale (LHS) was used to assess participation of stroke survivors. The LHS has 6 dimensions; namely: mobility, orientation, occupation, physical independence, social integration, and economic self –sufficiency and each dimension is classified on a six point scale. The un-weighted simple summation scoring system was used to calculate the total participation score with obtainable values ranging from 0 (maximum restriction) to 100 (no restriction) (Jenkinson et al., 2000). The LHS has been previously validated for use among Nigerian stroke survivors (Hamzat & Peters, 2009). 2.4. Procedure Approval for this study was obtained from the relevant Institution Ethics committees. At recruitment within the first four weeks after stroke, verbal informed consent and participants’ demographic and clinical data were obtained, namely age, gender, stroke sub-type, stroke severity and side of hemiplegia or hemiparesis. Information on post-discharge residence and telephone numbers (where available) were also obtained for purposes of follow-up. In Nigeria, it is a common practice for patients who have suffered a stroke to be discharged straight from hospital wards to their places of abode. The Nigerian culture plays a major role in this practice as post-hospital discharge care of an ill individual tends to fall essentially on family members while institutionalized care in nursing homes can be considered alien to many Nigerians. Assessments of motor performance, activity and participation were conducted at the 1st , 3rd , 6th , 9th and 12th month after stroke. Motor performance was assessed through observation while face-to-face interviews were carried out to assess activity and participation. Posthospital discharge follow-up assessments were carried out at the places of abode of the stroke survivors which were either their homes or homes of their relatives. 2.5. Statistical analyses Descriptive statistics of percentages, mean and standard deviation were used to summarize demographic and clinical data, while data from the S-FM, FIM and
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Table 1 Comparison of demographic and clinical characteristics of stroke survivors who completed and those who did not complete the study using one-way ANOVA and Fisher’s exact test (N = 83) Variable
Gender Male Female Type of Stroke Ischemic Hemorrhagic Unknown Side of Hemiplegia/Hemiparesis Left Right Stroke Severity (Stroke Levity Scale) Severe Moderate Mild Age (years) Mean ± SD Range
Completers (55)
Non-completers (n = 28)
Test
P-value
5 (71.4) 2 (28.6)
1.81
0.42
16 (76.2) 2 (9.5) 3 (14.3)
4 (57.1) 2 (28.6) 1 (14.3)
5.88
0.16
33 (60) 22 (40)
8 (38.1) 13 (61.9)
2 (28.6) 5 (71.4)
4.46
0.10
26 (47.3) 20 (36.4) 9 (16.4) 58.0 ± 12.78
11 (52.4) 9 (42.9) 1 (4.8) 54.7 ± 13.7
4 (57.1) 3 (42.9) 0 (0) 63.1 ± 22.3
2.31
0.69
1.03
0.36
31–85
28–75
35–95
n (%)
Attrition (n = 21) n (%)
Died (n = 7) n (%)
33 (60) 22 (40)
16 (76.2) 5 (23.8)
39 (70.9) 14 (25.5) 2 (3.6)
LHS were presented as median scores. Independent t-test and Chi square test were used to compare difference between male and female stroke survivors in terms of age, stroke laterality and sub-type, and baseline stroke severity. Age was computed as a continuous variable while stroke severity was presented as a categorical variable (severity was categorized as mild, moderate, severe) in addition to the other categorical variables. Mann-Whitney U test was used to compare indices of functioning (motor performance, activity and participation) between male and female stroke survivors across 5 time points (1, 3, 6, 9 and 12 months). Level of statistical significance was set at p = 0.05.
3. Results Fifty-five stroke survivors comprising thirty-three males (60%) and twenty-two females (40%) completed the study. There were twenty-eight non-completers of which seven died and twenty-one could not be located for follow-up. Gender of completers and noncompleters were however not significantly different (Table 1). Table 1 also shows the demographic and clinical characteristics of participants in the study. Comparisons of demographic and clinical characteristics between male and female stroke survivors are presented in Table 2. From the univariate analysis, motor performance, activity and participation were not significantly differ-
Table 2 Differences in baseline characteristics between male and female stroke survivors (n = 55) Variable
Male
Age (years) Mean ± SD 60.7 ± 12.4 Stroke Sub-type n Ischemic 22 Hemorrhagic 9 Unknown 2 Side of stroke Right 20 Left 13 Severity of stroke Severe 14 Moderate 14 Mild 5
Female
% 66.7 27.2 6.1
P-value
58.1 ± 12.6 n % 17 77.3 5 22.7 – –
0.06 0.61
60.6 39.4
13 9
59.1 40.9
0.91
42.4 42.4 15.2
12 6 4
54.5 27.3 18.2
0.54
P-value: level of significance. Statistical analyses for difference in age was carried out with the Independent t-test while Chi-square test was used for the other variables.
ent between male and female stroke survivors over the first 12 months after stroke (Figs. 1–3). 3.1. Motor performance Motor performance of the stroke survivors improved across 12 months. Females however had lower median scores on the Short-form Fugyl-Meyer assessment than their male counterparts. The differences in the scores did not attain statistical significance at each time-point with levels of significance (P) equal to 0.28; 0.21; 0.30; 0.36 and 0.41 at the 1st, 3rd, 6th, 9th and 12th months respectively (Fig. 1).
G.O. Vincent-Onabajo et al. / Are there gender differences in longitudinal patterns of functioning in Nigerian stroke survivors
Fig. 1. Longitudinal Patterns of Motor Performance of Male and Female stroke survivors across 12 months as assessed with the Short-form Fugyl Meyer Scale (higher scores denote better motor performance.
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Fig. 3. Longitudinal Patterns of Participation in Male and Female stroke survivors across 12 months as assessed with the London Handicap Scale (higher scores denote better participation).
3.3. Participation Median scores on the LHS for male and female stroke survivors are presented in Fig. 3. Although without statistical significance, participation differed between male and female with males having slightly higher median scores at the 1st, 3rd, 6th and 9th months (P = 0.78; 0.55; 0.96; 0.64; 0.39). However at the 12th month, females had higher participation scores at P = 0.39.
4. Discussion
Fig. 2. Longitudinal Patterns of Activity in Male and Female stroke survivors across 12 months as assessed with the Functional Independence Measure (higher scores denote better activity).
3.2. Activity Differences in the FIM median scores for male and females were not statistically significant although females scored lower than males across 12 months. Figure 2 shows the longitudinal patterns of male and female stroke survivors’ activity at the 1st, 3rd, 6th, 9th and 12th months; with respective P values of 0.45; 0.34; 0.55; 0.93 and 0.65.
In addition to anatomical, hormonal and role differences between men and women, gender difference could also be seen in the pattern and outcome of disease conditions. This study explored possible differences in motor performance, activity and participation between male and female stroke survivors in Nigeria within the first year after stroke. Although majority of the stroke survivors were males, their age, stroke sub-type, side and severity of stroke were not significantly different from the females. The age similarity between men and women observed differs from earlier reports. The report from a comprehensive review of literature on gender differences in stroke showed that women are usually older than men at onset of stroke (Reeves et al., 2010). However in line with our findings, Reeves et al. (2010) reported similar stroke severity in males and females, especially when stroke subtype and age were taken into
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account. Also similar to our findings, two previous studies reported a lack of gender disparity in the distribution of ischemic and hemorrhagic stroke sub-types, and the location of stroke (Di Carlo et al., 2003; Lai et al., 2005). Motor performance is one of the important components of post-stroke functioning that was assessed in this study. The construct represents the ability to assume, maintain, alter and control voluntary postures and movement patterns. Most commonly impaired in the mirror half of the body (hemiplegia or hemiparesis), motor performance after stroke is regarded as a major indicator of the pathophysiology of the disease (Feydey et al., 2002). Motor performance in male and female stroke survivors in this study did not significantly differ across 12 months after stroke although males had higher scores on assessment. Reports on gender differences in post-stroke motor impairments are rare. One available study however reported better motor function in males at one year after stroke (Wyller et al., 1997). Although stroke survivors and their families tend to place more importance on functional activity and participation than degree of paralysis (Kollen et al., 2006), assessment of motor performance provides a more objective insight into recovery after stroke. Traditionally, many stroke studies focus on activities of daily living although attention has been shifting to higher levels of functioning and quality of life in recent times. There are therefore a number of studies that have examined gender differences in functional activity after stroke. Similar to our findings, some earlier studies observed no gender difference in activities of daily living after stroke (Wade et al., 1984; Lai et al., 2005). However, a more consistent pattern in majority of the available studies is the lower level of functional activities in women (Reeves et al., 2008). In the study of stroke survivors in Kansas City, United States, women reported lower performance in instrumental activities of daily living (IADLs) than their male counterparts (Lai et al., 2005). The authors however suggested that the difference could have resulted from traditional gender roles which shield men from many IADLs and may result in favorable estimation of their capability rather than actual performance of those activities. Similarly in a study of stroke survivors in Germany, perception of stroke impairments was reported to differ between males and females irrespective of actual stroke severity and disability as assessed by Barthel index (Wiltz, 2007). Differences in coping and adaptation patterns between male and female stroke survivors may also be responsible for the gender differences observed in functional outcomes (Gray et al., 2007). In longitudinal
studies that reported gender differences in post-stroke functional activity, there appeared to be no specific pattern in relation to time after stroke, rather, both short (Di Carlo et al., 2003; Kim et al., 2010) and long-term (Kim et al., 2010) trends showed a female disadvantage. Higher level of functioning such as involvement in life roles, also known as participation, did not significantly differ between male and female stroke survivors in this study. Studies that have assessed specific components of participation such as employment (Vestling et al., 2003; Lindstrom et al., 2009), leisure activities (Sveen et al., 2004), and community ambulation (Robinson, 2011) indicated that gender played no significant role in involvement in these life areas after stroke. Similarly in our previous study, rate of return to work after stroke was not significantly different between male and female stroke survivors (Peters et al., 2012). There is however a report on worse outcome in women than in men in terms of post-stroke participation restriction (Di Carlo et al., 2003). Differences in functional recovery after stroke between males and females are seldom attributed solely to gender (Gargano et al., 2007). Rather, many stroke studies that have reported lower levels of functioning in women compared to men provided inconclusive reasons for the observed differences (Reeves et al., 2008). One of the most common explanations for gender differences in stroke outcomes is the older age of women at the stroke onset. This was however not the case in this present study as the age of men and women did not significantly differ. In a one-year follow-up study in Korea, female stroke survivors were reported to be older than males and the fact that older women in that country were likely to be unmarried, and with no caregivers was given as a possible reason for their lower level of functioning (Kim et al., 2010). The converse however tends to be the case in Nigeria where in old age, women are dutifully cared for by family members, especially their children, as a show of appreciation for the care they received in early life. Also, it is culturally unacceptable for children to fail to care for their aged parents, especially the mother. Furthermore, care of older women, especially widows, is often regarded as a religious obligation in Nigeria. Poor physical function prior to stroke and depressive symptoms were the factors attributed to poor physical functioning in women in a United States study (Lai et al., 2005). Although our study did not obtain information on pre-stroke functioning, there are indications of increasing similarity in levels of functioning between genders in Nigeria especially in terms of role
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performance. In some instances, due to contemporary socio-economic realities, women take up roles that were previously male-dominated such as providing family income. Increasing rates of single parenthood leading to women taking up roles that were previously regarded as paternal could also be contributory to transition in gender roles in the Nigerian society. Although there were also variations among previous reports, the socio-cultural differences between an African country such as Nigeria, and Western and Asian countries where previous studies were conducted could have contributed substantially to the dissimilarities between our findings and those of the other studies. There are however no available data from other African countries with which to compare our findings. The fact that stroke survivors in this study were recruited from acute hospital settings might have resulted in selection bias which limits the generalizability of our findings. A community–based study might therefore provide a more representative sample although the 12-month follow-up design of our study enabled us compare functioning between male and female stroke survivors from the time they were on hospital admission till they returned to the community. Also, the rate of drop-out and the small size of the sample of stroke survivors that completed the study constitute limitations although there were no significant differences in the clinical and demographic attributes between those who completed the study and those who dropped out. 5. Conclusion Functioning in the group of Nigerian stroke survivors studied did not significantly differ by gender over the first 12 months after stroke. These findings are indicative of a lack of difference in post-stroke functioning in male and female Nigerian stroke survivors and thus imply the need for parity in provision of health care and support for all stroke survivors irrespective of gender. Furthermore, interventions and strategies needed to enhance motor performance, activity and participation in the first year of stroke should be provided without gender inequality or bias in order to ensure optimal outcomes in both male and female stroke survivors. Declaration of interest The authors report no conflict of interest
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