Investigating Occupational Therapy Services For Post Stroke Patients In Saudi Arabia: A Qualitative Essay.

Investigate the Occupational Therapists Services for post stroke patients in Saudi Arabia a Qualitative Study.

Literature Review

Stroke is a leading cause of morbidity and mortality especially in the developing economies. According to Robert and Zamzami (2014), Stroke involves the rapid loss of normal brain function because of disruption in the normal blood flow to the brain. These problems can be as a result of reduced supply of blood to a specific area of the brain, or cranial bleeding. As a result, the patient can experience longer-term cognitive and motor function problems. Nonetheless, very little research work has been published regarding optimal treatment of stroke for best patient outcomes.  Blanton et al. (2008) suggest that drug-based treatments such as anticoagulants and statins may be helpful in mitigating on-going ischemia, while physiotherapy can be helpful in improving impaired motor functions.   

To understand the nature of stroke medication and therapy, the researcher conducted a preliminary search on Google Scholar using combination of keywords such as Healthcare, Stroke, Stroke rehabilitation’’ and “Occupational therapy”. A search including the Kingdom of Saudi Arabia as a keyword found no publications relevant to the topic and was subsequently excluded from the research. This was followed by an assessment of the text words revolving around the title of the study and the variables. Further search relying on the highlighted keywords and index terms was conducted across various databases including but not limited to PubMed, CINHAL, Google Scholar, and Google Books ranging from 2007 to 2018, with emphasis on the variables of this study. Therefore, only a limited amount of relevant resources were identified.

Hoffman et al (2015) describe occupational therapists as health professionals whose primarily function is to rehabilitate patients, especially those with severe physical injuries (Hoffman et al. 2014). The role of occupational therapists is increasingly valued, as rehab and therapy have been proven to make significant contributions in the treatment and recovery of patients using standardized outcome measures to ensure optimal recuperation of stroke survivors away from the hospital (Pergolotti et al., 2015). Occupational therapists visit patients at their homes for follow-up appointments to ensure that the patients become as independent as possible in their Activities of Daily Living (ADL). Chutkan (2013) writes that doctors, nurses and patients may need to consult occupational therapists in the treatment and management of complex conditions to help patients regain full independence of ADL faster. It is evident from the literature that it is important to recruit occupational therapists into healthcare facilities such as nursing homes and hospitals because occupational therapists can improve the health of patients to promote satisfying lives since they are trained to facilitate and enhance occupational activities in patients who are functionally compromised.

The Situation in Saudi Arabia

O’Halloran et al. (2015) express a contrary perspective that is critical of the studies supporting the essence of OT in clinical care. Their study identifies that for the interventions of the occupational therapists to be effective the patient should be involved at every stage of the therapy to increase the possibilities of fast recovery. It is therefore critical for the patient to understand their condition and therapy. Tang et al. (2016) emphasizes that therapists may experience difficulties in their interventions if patients lack sound knowledge about their condition. Therefore, patient education can be a vital aspect of OT. It has been shown that Saudi patients often fail to seek occupational therapy services, as well as this services might be unavailable (Meny and Hayat, 2017). However, in developed countries like the United Kingdom, occupational therapists visit the stroke patient within the first few days after admission to hospital (Clarke, 2013). Nonetheless, like in Saudi Arabia, many patients in the developed nations only seek treatment when their condition has deteriorated to a critical point which makes therapy a difficult ordeal for the occupational therapists (Clarke et al., 2016). From the literature it is observed that while patients in Saudi Arabia cannot access OT services with ease, patients form developed nations can get OT services from their nearest local health service provider (Stroke Association, 2017). These observations emphasise the importance of patient awareness and access to healthcare service as central elements in the achievement of better patient care in Saudi Arabia.

Treating stroke patients presents Saudi occupational therapists with a significant challenge of helping patients in recovering independence and doing routine daily activities. Chib et al. (2015) indicate that treatment for most stroke patients requires expensive medications and technologies; moreover, many patients lack medical insurance to pay for the expensive treatments. As a result, reliance on medical technology such as information technology might limit the services of occupational therapists to patients in cities and big towns while disadvantaging the communities in smaller towns and remote villages (Alotaibi and Federico, 2017). However, Bloom et al. (2015) agree with the views presented by Chib et al. (2015) that the use of information technology in OT medication can result in intense career-progression among occupational therapists while improving patient outcomes. It is thus vital for Saudi to improve the skills of its OT specialists for better patient outcomes.

According to the literature, developed countries like the UK have an occupational therapist at every local health facility making access to OT services easier while the multidisciplinary approach to service delivery improves the efficiency and effectiveness of therapy (Clarke, 2013; Stroke Association, 2017). The current state of Saudi Arabia is one that is significantly behind when compared to the situation in developed nations as there is only one active stroke centre out of the seven centres in over 350 hospitals that are located across the Kingdom (Al Khathaami et al., 2011). Additionally, the available data on stroke in Saudi Arabia is insufficient due to limited published research. Such research is essential in informing decision-making to design appropriate management programs for effective implementation of preventive strategies and proper allocation of health resources. The lack of research can be blamed for the lack of adequate response from policymakers in the health industry. Tran et al. (2010) looked at the occurrence of strokes in Saudi Arabia in the period between 2000 and 2010.  The work was the first of its kind in the country and took a fairly simplistic look at the incidence of stroke in the Saudi population.  Tran et al. (2010) reported an incidence of 0.03% of the Saudi population as having being diagnosed and treated for stroke each year, with older age appearing to be a contributing factor. The findings in this literature review inspires the need for research to examine the current situation of OT services in Saudi Arabia for the purpose of addressing the lack of knowledge and making recommendations for future improvements.

Statement of the Problem

With the current trend of an ageing global population, it is estimated that there will be nearly 5.6 billion nonagenarians in the world; a figure that is 800% more than the current situation (Benamer and Grosset 2009). In Saudi Arabia, the frequency of stroke has demonstrated a steady increased with age till the 7th decade. Robert and Zamzami (2014) reported that stroke is more prevalent in the 61 years to 70 years age bracket and relatively lower among the 20 years-30 years and 31 years-40 years age groups.

For effective treatment, occupational therapists need to work in collaboration with other professionals like nurses, and doctors, and actively engage patients and their families (Clarke, 2013). The multidisciplinary team ought to consist of professional teams whose duty is to help with the patient’s physical needs, focusing on the cognitive, emotional and vocational skills (Nancarrow et al., 2013). It has however been established that multidisciplinary teams cooperating in groups are more effective in the role of enhancing the functional recovery as well as the quality of life when compared to the single speciality (Langhorne et al. 2011). Overall, the specialist programs are dynamic changing according to the setting and influence the duration of stroke rehabilitation although there are other internal factors like the level of stroke severity, related complications and responsiveness to medication and therapy (Tempest and Mcintyre 2006).

The most relevant resources were selected for review through truncation and search phrases. Also, the information on the resources was criticised using the Specialist Unit for Review Evidence (SURE) framework. The literature review found limited or no evidence that addressed the role of occupational therapists in the treatment and recovery of outpatient stroke patients in Saudi Arabia. However, one study by Ellis-Hill et al. (2009) sampled 20 patients and 13 caregivers to determine what constituted a positive or negative response to medication and therapy at home after hospitalisation for stroke patients. The research was undertaken to ascertain patients’ subjective response to follow-up treatment in post-stroke treatment.  The key elements in ‘successful’ follow up treatment, that is, where patients felt they had an improved likelihood of recovery, were threefold.  First, patients wanted to feel that medical staffs were personally involved and supportive.  Secondly, patients wanted to know what was happening and how their treatment was planned.  Thirdly, patients wanted to feel that continual progress was being made, with no periods when ‘nothing happened’.

Greenwood et al. (2009) assessed a sample of 31 participants to look at an Early Supported Discharge program.  In this program, patients are released into community care and receive a combination of medical care and care from local authority community services. The study found that collaboration between the caregivers and the patient is vital in achieving full recovery. Cobley (2012) set out the perceived problems with this Early Supported Discharge program as lack of training in local authority carers; lack of medical knowledge in carers; Pressure on carer services; insufficient medical information given to patients; lapses and problems in continuity of care when moving to long-term support. These studies will inform the decision on the research design and methodology of the current study.

Ellis-Hill et al. (2009), Greenwood et al. (2009) and Cobley et al. (20120) exemplify the overall consensus on the audio recording of semi-structured interviews as an established qualitative approach. However, all of these studies can be criticised because the samples used were not random.  The participants were purposively chosen, and this may undermine the results of the studies, particularly if the researcher has had prior contact with the subjects, as in Greenhalgh (2014).  Also, the choice of selection factors may be open to question: for example, Ellis-Hill et al. only used women in their sample; Cobley and his colleagues set out the grounds on which participants were selected, but lacked clarity. Moreover, Ellis Hill et al. (2017) and Greenwood et al. (2009) tend to diminish the authority of their work.

Still, there were no potentials for bias about sampling and recruitment because all samplings were based on specific inclusion criteria. The setting of the interviews was conducted in appropriate places for  Carers of stroke survivors from rehabilitation units in South-West London, the interviews were recorded at patient home enabling them to speak openly and express their emotional freely (Greenwood et al. 2009). Cobley et al. (2012) focused on Nottinghamshire-based community stroke services, although they did not indicate the duration of interviews and there is a chance that patients were attending appointments, so they could only engage in brief conversations. Neither the place nor process for interviews was explained by Ellis-Hill et al. (2009). Moreover, the researchers did not explain the timing of the interviews, although Cobley et al. (2012) noted interviews between 30 and 90 minutes long on three different occasions.

Despite the expanding volume of evidence currently available, there is limited understanding of the situation for occupational therapists working with stroke patients services in Saudi Arabia. Furthermore, Asirvatham (2014) emphasised the definite lack of published researches on stroke in Saudi Arabia, effective health asset distribution, primary prevention strategy introduction and relevant management programmes’ establishment rest critically on these studies. Moreover, improving all medical employees’ knowledge in Saudi Arabia of stroke rehabilitation, management and rehabilitation should be a primary concern to be able to provide high standards of care (Bindawas and Vennu, 2016).

This study aims to investigate the level of occupational therapy (OT) services available to stroke survivors in Saudi Arabia as compared to the OT services available for stroke survivors in developed countries.

General objective

1. To investigate the type of services to Post-stroke patients by occupational therapists in Saudi Arabia as compared to the case in developed nations.

Specific objectives:

1. To determine the impact factor on the Post-stroke patient's services in Saudi Arabia
2. To examine the occupational therapists’ satisfaction and reactions to post-stroke patients services.

This study will adopt a phenomenological qualitative approach to collect information from a sample of therapy services for post-stroke patients (Gerrish and Lathlea, 2015; Rees, 2011). A phenomenological approach is an empirical description of events as they occur, without any reference to objective questions such as ‘what caused this?’ or ‘why did it happen?’ (Adams and Van Manen, 2017).   A one-to-one, semi-structured interview method will be used to gather information regarding the aim and objectives of the proposal as well as the research Questions. A one-to-one interview method is a priori extrapolation from events – applying rational thought to reach an understanding of an event (Saunders et al., 2015).  As explained by Matua and Van Der Wal (2015), hermeneutic phenomenology is concerned with ‘meaning’, and goes beyond the objective to the subjective, or as Holloway and Brown (2016) express it, how an event manifests itself in the mind of the participant.  The participant in an event is an ‘interpreter’ rather than simply an ‘observer’. The study will thus seek to discover the subjective feelings and opinions of occupational therapists about the therapeutic processes applied in treating patients’ injuries, and what these processes mean to therapist and patient. The respondents are expected to outline the type of service provided and the processes of post-service delivery.

The phenomenological research design has an assortment of strengths that promote its use. According to Maxwell (2013), the strong motivation that the researcher has in the study plays a major role in ensuring there is the successful completion. The phenomenological design also has some downsides that affect its effectiveness including its subjective nature, an issue that raises concerns about the reliability and validity of the data gathered. Further, there are common concerns such as researcher induced biases that may affect the outcomes of the study (Reiner 2012).

Creswell (2014) explained that there is a philosophical and psychological basis for the phenomenological research approach. Creswell and Creswell (2017) explained how generally, the research design permits an investigator to focus on a specific issue and obtain data and responses to it, thus providing a fundamental underpinning of the research. As Mayoh and Onwuegbuzie (2015) related, greater openness during the interview process for gaining participants’ perspectives is possible through phenomenological research, something that was sought for this study. The Saudi Arabian individuals’ experiences of stroke could be more effectively comprehended through phenomenological design because it seeks to understand human, making it superior to possible alternative methods.

This section outlines the procedure used in recruiting the occupational therapists who would participate in the study. The inclusion and exclusion criteria are core to the maintenance of the transparent review (Tranfield et al. 2003). This proposal is based on the eligibility criterion that was established beforehand, that is, occupational therapists with more than one year of practice experience. The directors of occupational therapy departments in National Guard Hospital (King Abdulaziz Medical City in Riyadh, with a bed capacity of 1501 which is sponsored by National Guard) will be approached to identify six eligible participants to take part in the study.

With the consent of the occupational therapy directors, a hard copy of these details will also be affixed to the display board in the relevant occupational therapy departments. As recommended by Polit and Beck (2012) the researcher will develop an interview outline to guide the interview and restrict the interviewees from extending the discussions beyond the scope of this proposal.

Inclusion criteria:

• Qualified occupational therapists
• Experience of stroke rehabilitation of no less than one year.

Exclusion criteria:

• Non-qualified occupational therapists
• Those with less than one year of OT experience.

During the study, data will be mainly obtained from the one-to-one interviews using open-ended questions in a two-way conversation between the researcher and the participants. This method promotes the creation of rapport as well as access to the interview details (Brinkmann 2014). Through the use of one-to-one interviews, the researcher can use both verbal and nonverbal communication cues that enhance effectiveness of the communication and access to sensitive details (Brinkmann 2014). Further, through use of this method, the researcher will gain clear insight into the topic by answering the research questions as this method typically provides large amounts of rich data. However, the method typically requires more time compared to other data collections techniques (Brinkmann 2014). 

The interviews will be conducted in English since it is an international language and health professionals are required to communicate using the English language while at their places of work. Interviews will thus be recorded in audio files and will be transcribed verbatim. The researcher may also record some of the key points of the interview in note form to direct the interview. Each interview is expected to last between 30-45 minutes with the researcher recording observations where necessary.

Data from the in-depth interviews will be analysed using thematic analysis. The rationale behind the selection of this method is the fact that the method allows the researcher to gain insight as well as knowledge from collecting data on a specific subject (Peck et al., 2015). The use of this method allows the researcher to develop superior comprehension of the participants and situations they are researching (Vaismoradi et al. 2013). Considering the focus of this research is on gaining insight into the services provided by the occupational therapists and the level of quality in Saudi Arabia, the method presents the best strategy for analysing and understanding the intended issues. As such, the researcher will apply the method in identifying the emerging themes from the interview data.

After transcribing the audio files, the researcher will identify the arising themes inductively using coding. Further, the researcher will compare to check if the data obtained is consistent with the research questions in this proposal and that it provides sufficient information. Finally, the identified themes from the implicit and explicit data will be presented in tables for interpretation and discussion.  

The pilot study will interview three respondents to assess the effectiveness of the interview in collecting appropriate data (phenomenological qualitative approach will be used). Open-ended questions will be preselected for the interview (Gerrish and Lacey 2010; Cormack 2014). The pilot study will also be used to evaluate any issues that may affect the success of the main study, ensuring that measures are incorporated to address any emergent issues (Arain et al. 2010).

The reflexivity concept will be upheld by the researcher in ensuring that objectivity is maintained throughout the data collection (Haynes 2012). Therefore, the researcher will desist from deviating away from the scope of the proposal. The concept of reflexivity will be used as a complement to the instruments of data collection and analysis to increase accountability that is increasingly a feature in therapeutic/learning organisations and social research

Reliability is the ease of regenerating results that have been gained from a study, referring to the degree the results obtained from a study can be considered to be a true and accurate representation of the population that was considered in the study (Drost, 2011). In the case of the study, the reliability aspect will be promoted via ensuring that all the interviews are recorded via the use of tape-recorders to avoid the likelihood of missing on any details and also ensuring that clarifications are sought from the participants on all issues that need clarification. Once the recording is done and transcription follows, the researcher will ensure the participants access these transcripts to resolve any issues of misreporting or misrepresentation of facts from the interviews.

On the other hand, validity focuses on the assessment of the degree to which the measures obtained reflect the issue under considerations (Drost, 2011). The validity of the research is guaranteed by the fact that the respondents if the study will be qualified occupational therapists who meet the requirements for participation as indicated above.

It is imperative that the researcher recognizes the impact of the study on the participants during the implementation stage of the study (Mealer and Jones 2014).  Thus, ethical approval will be sought from the authority at the National Guard Hospital and the University of Cardiff to conduct the research at the hospital. At the same time, participants in the research will be allowed sufficient time to read and understand the information concerning the project before being allowed to sign as voluntary participants to the study.

A consent form will be created and sent to each participant, enumerating all the issues that make it necessary to undertake the study and the need for their participation. According to Egan (2006), the consent form ensures that the participants comprehend their rights before accepting to take part in the study. These forms will outline the fact that the decision to take part in the interviews is based on the willingness of the participant and that the research is merely for academic purposed (Egan 2006).

The researcher will also ensure that each of the participants is given a participant information sheet that seeks to ensure that the participant is fully aware of the intention, the strategies, risks as well as benefits of the research in addition to how they obtained data is going to be used (Ritchie et al. 2013). The researcher will also highlight to these participants that they have a right to withdraw at any point in the study without any undue pressure (Truman 2011). The interviews will be conducted in a secluded place to guarantee privacy and resect of respondents opinion (Mealer and Jones 2014). Further, all the personal information provided by the participants will be kept confidential and anonymous by interchanging names with numerical coding (Mealer and Jones 2014). Finally, audio data will be stored as encrypted computer files and hard copies of interview notes will be stored in safe drawers within the Capella University library. The procedure on the management of the data will be guided by the data protection Act (1998).

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