What are the Environmental Determinants to Participate Among Stroke Survivors in Africa? a Scoping Review

Stroke is the main cause of serious long-term disability worldwide, and it is the second commonest cause of death and a leading cause of adult disability. Two-thirds of stroke cases occur in low- and middle-income countries, which all African countries fall. In Africa, the incidence and survival rate of stroke is increasing. Various personal and environmental factors limit the participation of stroke survivors. As a result, in this review, we aimed to review the environmental factors that are inuencing the participation of stroke survivors in Africa.


Introduction
Stroke is the main cause of serious long-term disability worldwide (Pan, Sun, Okereke, Rexrode, & Hu, 2011). It is the second commonest cause of death and a leading cause of adult disability (Bonita et al., 2004;Organization, 2008; The World Bank Annual Report 2003). Two-thirds of strokes occur in low-income and middle-income countries (Bonita et al., 2004). Also, over 87% disability-adjusted life years (DALYs) from Figure 1 shows the PRISMA diagram of the process used in paper selection. Papers were reviewed using predetermined criteria:

Articles only in English
All style literature including grey literature to maximise and broaden the scope of literature found

Articles conducted in Africa
Articles assess the environmental determinants on stroke survivors All age group population who survived stoke, not TIA Results A total of 13 papers met the eligibility criteria and were included in the present scoping review. Table 1 (Additional le) summarizes the papers. Majority of the paper were conducted in South Africa. We used the ICF framework ("International classi cation of functioning, disability, and health : ICF," 2001) to thematize and present the review. ICF framework, under the environmental factors, comprises Products and Technology, Natural Environment and Human-Made Changes to Environment, Support and Relationships, Attitudes, and Services, Systems and Policies ("International classi cation of functioning, disability, and health : ICF," 2001) Additionally, it was stated people with stroke need to pay extra to use public transport if they could nd a driver who is willing to take them (Arowoiya, 2014;Mudzi et al., 2013). Lack of assets such as money also appeared among stroke survivors as a barrier to participate in social activities (Cawood and Visagie (2015). Cawood and Visagie (2015) stated that stroke survivors were not able to afford phone service. Not only this, but they were also unable to pay for assistive devices (Cawood & Visagie, 2015). In the same vein, Access to and utilization of assistive devices was also found low in the studies (Arowoiya, 2014; Cawood & Visagie, 2015). Cawood and Visagie (2015) stated other than mobility devices people living with stroke struggle to get assistive devices such as bath transfer, grab bars and Ankle foot orthosis. Moreover, they also struggle to use a toilet that is not modi ed to accommodate their need (Arowoiya, 2014). A Rhoda (2012) mentioned how stroke survivors can bene t from and are dependent on their walking devices.
Also, due to inaccessibility of the public transport, people with stroke need to have someone who can assist to carry and put them on wheelchair as well as in and out of the car in a way that indiginify the people (Arowoiya, 2014 (2017) concluded home to clinic distance was a major factor not to adhere to therapy. On the other hand, some people changed their home address to live near hospitals where they get therapy (Urimubenshi, 2015) This led them to lose their previous social contact (Urimubenshi, 2015).
We also found in the articles that the home and the surrounding environment were inaccessible and a barrier to participation ( However, we also understood from the articles that as time passes the support and relationship diminishes (Anthea Rhoda et al., 2015). In the study done in Rwanda, to assess activity limitations and participation restrictions, Urimubenshi (2015) revealed that the social interaction of stroke survivors decreased from time to time. One reason stated was people with stroke changed to more accessible and near to hospital residency (Urimubenshi, 2015). Others also could not maintain their relationship with friends due to nancial restrain (Arowoiya, 2014). Elloker (2016)  Cawood and Visagie (2015) found in their study that majority of immediate families have positive attitudes towards stroke survivors. Additionally, the attitude of health professionals was a facilitator for participation (Cawood & Visagie, 2015). However, the societal attitude was found negative and created a barrier for participation (Arowoiya, 2014;Cawood & Visagie, 2015). Mudzi et al. (2013) also revealed in their study that majority of friends' attitudes were a barrier for stroke survivors to participate in their community.
We also understood from the articles that people see the stroke survivor as pity and support from the sense of duty ( Cawood and Visagie (2015) revealed that nearly half of their study's participants indicated that they did not receive assistance from associations or organizations. Cawood and Visagie (2015) and Mudzi et al. (2013) presented that housing services were a barrier. Stroke survivors experienced di culties to get government subsidised houses (Cawood & Visagie, 2015). Housing policies were also a barrier (Mudzi et al., 2013). Additionally, the paperwork to process disability grants took too long which led the stroke survivors to nancial strain (Cawood & Visagie, 2015). In another study, Soeker and Olaoye (2017) indicated stroke survivors struggle from nancial constraints that led them to opt-out from therapy. This indicates that there was no or minimum support to help them continue their therapy.

Discussion
Evidence has shown that personal factors such as level of function, motor activity, cognitive ability and  , 2006). In this review, we particularly examined the environmental determinates of participation among stroke survivors. We identi ed 584 papers and reviewed 13 papers to understand the environmental determinants for participation among stroke survivors living in Africa. We used the ICF framework ("International classi cation of functioning, disability, and health : ICF," 2001) to thematize and present our ndings. Every style of paper including grey literature were included in the review, and we did not set a time limit to our search so we could include as many studies as we can. We presented our ndings grouped under Products and Technology, Natural Environment and Human-Made Changes to Environment, Support and Relationships, Attitudes and Services, Systems and Policies.
Regarding product and technology, access to transport, service charge for transport and access to assistive devices appeared to be a barrier for participation for stroke survivors ( Moreover, public transport cars are not accessible, and they have to nd assistance to carry them and put them in the car, which indigni ed stroke survivors (Arowoiya, 2014). It was also evident from the studies that there is limited access to assistive devices that limit mobility in the community which eventually limits participation. The low provision and utilization of products and technologies, as it was evident from the literature, greatly hinders the participation of stroke survivors in life activities. This creates frustration to go out and participate in the community. Hence, people usually prefer to stay at home and avoid social participation. This indicates increasing accessible transport in the community could help to facilitate the participation of stroke survivors.
The natural and human-made environment was also found inaccessible and barriers to participation. It is obvious that a fully accessible environment facilitates mobility, and participation (Elloker et al., 2019). Additionally, public buildings were also found inaccessible that people with mobility issues could not access (Cawood & Visagie, 2015).
Most of the evidence, but also contradicting, were found regarding support and relationships. The limitations of this review were; we only included articles published in the English language. As a result, articles published in other languages were not included. Additionally, a methodological appraisal was also beyond the scope of this study. Hence, the absence of this can be considered as a limitation of the study.

Conclusion
Stroke is the main cause of serious long-term disability worldwide. Not only this, but evidence also showed it is increasing in Africa. Stroke limits participation. In this scoping review, we assessed how the environment, in Africa, is positively or negatively affecting participation among stroke patients. Studies were mainly conducted in South Africa and assessed the adult population. We followed the ICF framework for the environmental determinants to present our ndings. Products and Technology, Natural Environment and Human-Made Changes to Environment, and Services, Systems and Policies found to be a barrier for stroke survivors to participate. Conversely, stroke survivors are getting good support from their immediate family and health professionals. The result of this review suggests that there is a gap in making the environment accessible, provision of assistive devices. This hugely decreases the participation of stroke survivors. Policy makers and other government and non-government organizations can use this review to understand and ll the gap. Additionally, health care providers and social workers can utilize the support and relationship stroke survivors may have to improve their participation.