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INTRODUCTION AND BACKGROUND

The Global Burden of Disease Study indicated that among 135 diseases, cerebrovascular disease is the second leading cause of death and disability after ischemic heart disease(1). High levels of disability are common in post stroke clients with only 10% independent with their activities of daily living (ADLs), 40% with mild disability, and 40% with moderate to severe disability, while 10% become totally dependent (2). Stroke rehabilitation is an active process beginning in acute hospitalization care with the eventual goal of returning to the community. It focuses on assisting clients to gain their functional independence(3) and to return to an active and productive lifestyle(4). Although stroke is a global burden, its impact may be experienced differently in developed and underdeveloped countries. The shift from rural to urban lifestyles in developing countries often results in varying levels of social support, increasingly sedentary lifestyles, sporadic employment and poverty (5). The resulting socioeconomic impact increases the risk of diseases(1).

In Iran, a Middle Eastern, underdeveloped country, there is no detailed information available on the status, statistics, or services available for individuals following a stroke. The most recent statistics available from a World Health Organization (WHO) report indicated 31,768 deaths from stroke in 2002 (6). A retrospective, descriptive study showed an incidence rate of 50 cases per 100,000 population with a higher incidence among women, and a mortality rate of 32 percent. The most common risk factors were hypertension (54%), heart diseases (43%) and (24%)(7).

The aims of our study were:
1) To understand the experiences of a group of clients in Tehran, Iran who were currently receiving or had received outpatient rehabilitation services, and their perceptions of the availability and effectiveness of these services (i.e. physiotherapy (PT), speech language pathology (SLP), and occupational therapy (OT)).
2) To explore the perspectives of health professionals regarding the availability and effectiveness of rehabilitation services for clients after stroke.

METHODOLOGY
This descriptive study was approved by the Research Ethics Board of the University of Toronto and the Iran Medical Sciences University (IMSU) in Tehran. This study applied mixed methods to investigate the experiences of post stroke clients, rehabilitation professionals and physicians regarding the availability and perceived effectiveness of rehabilitation services.

In this method, both qualitative and quantitative data are collected, analyzed, and "examined" from different approaches (8). Quantitative data were gathered from the survey, and qualitative data were gathered from the focus group, open ended questions in the survey of the clients, and in-depth interviews with health care professionals.

Quantitative Data: Survey
Thirty clients were recruited using convenience sampling. The Iranian collaborator accessed and reviewed the charts of post stroke clients and generated a list of current and former clients who fitted the inclusion criteria. After contacting and informing potential subjects about the study, she obtained consent to release contact information from the interested clients and passed it on to the primary investigator (PI). The eligibility criteria for post stroke clients are included in Table 1.

Table 1: Inclusion Criteria

A study survey with 22 pre-coded rating questions and three open ended questions was administered to the clients to explore their experiences (Table 2).

Table 2: Table of Survey Questions

Survey data were analyzed using the Statistical Package for the Social Sciences (SPSS -11) 9. Frequency and descriptive analysis, including mean, median, range and standard deviations, were applied to describe all quantitative data. A t-test was used to examine the differences between rehabilitation services in outpatient and inpatient settings.

Qualitative Data: Focus Group/Interviews
Based on the inclusion criteria (Table 1), eight professionals (two SLPs, three OTs and three PTs) participated in a focus group, and three others (two neurologists and one SLP) participated in in-depth interviews. The focus group assisted with the qualitative exploration and discovery of insights, provided the context in which participants operated, generated in-depth data about matters of importance, and explored reports on how and why participants provided rehabilitation services 10.
The same interview guide consisting of seven questions was used for both the focus group and the interviews (Table 3).

Table 3: Focus Group/Interview Questions

The qualitative data in this study were analyzed using the descriptive method [19] with low-interference interpretation. Questions such as who, what, when, and where were answered using the qualitative descriptive approach which is more relevant to practitioners and policy makers 11. Using content analysis, themes were developed related to the study objectives and to the key questions asked in the focus group/interviews. The investigator labeled ideas or issues within the focus group data as codes and from these codes larger themes were developed. A number of strategies such as prolonged engagement, triangulation, peer debriefing, and member checks were used to enhance the credibility of the qualitative analysis. The analysis was based on both the in depth interviews with focus group participants as well as the open ended questions from the survey with post stroke clients.

Procedure
Signed consent forms were obtained from all participants, and all study materials were translated into Farsi by a certified translator in Tehran. For the health care professionals, the focus group discussion and key informant interviews were conducted in Farsi at the rehabilitation centres. The interviews and focus groups were tape recorded and transcribed by the research assistant and another bilingual Iranian individual.

For post stroke clients, the PI administered the survey at each participant's home or another location decided upon by the clients. The primary investigator completed surveys, based on their oral responses, for clients who were unable to read.

Table 4: Demographic and Clinical Characteristics of Post Stroke Clients at Outpatient Rehabilitation Centre

RESULTS
In our study, quantitative data were gathered through pre-coded questions in the survey and the qualitative data were collected through the clients answering three open-ended questions, the discussion in the focus group, and in-depth interviews to obtain the health care professionals' perspectives. The following data and themes emerged through the use of triangulation between all qualitative and quantitative sources. In the following section, the quantitative data will be presented first, followed by the qualitative themes.

1) Quantitative results
a) Demographic and Clinical Characteristics (Table 2), Assistance with ADLs at Home (Table 3)
b) Rehabilitation Services in Outpatient Settings

Table 4 illustrates that private outpatient settings provided more PT services (18±19 weeks) than public outpatient settings (12±13 weeks). In contrast, more OT and SLP services were offered in public outpatient settings. Only four of 30 clients received private outpatient OT services; the rest attended public outpatient centres. Clients reported that they visited their neurologists on average four times a year (4±2.6), visits which required payment by the clients.

c) Perception about the Effectiveness of Rehabilitation Services at Outpatient Centres.

As seen in Table 5, more than 50% of clients indicated that PT and OT services were effective; only 3% stated that they were not effective at all. Sixty-six per cent were not referred to SLP after their stroke; however, from the number of patients who were referred (n=10), 60% indicated that SLP was effective. Only 27% of the clients indicated that physicians were effective in their rehabilitation. The majority (67%) stated that the rehabilitation services they received were not adequate to meet their needs, and just over half (53%) of the clients identified the availability of rehabilitation services as below average. Most of them rated the effectiveness of their rehabilitation services as average or above average. The majority of clients (73%) reported that they did not achieve their goals or expectations.

Table 5: Assistance with ADLs at Home

Table 6: Availability of Outpatient Rehabilitation Centres

Table7: Post stroke Clients' Perspectives on the Effectiveness of Rehabilitation Services at Outpatient Rehabilitation Centres

Table 8: Quotation Numbers


The qualitative analysis which follows supports the quantitative findings; health care professionals also indicated that the post stroke clients did not have adequate access to effective and available rehabilitation services.

2) Qualitative Results: Barriers to the Availability of Rehabilitation Services in Tehran
Five major factors influenced the accessibility of rehabilitation services in Tehran. These factors were:

1) family income;
2) availability of rehabilitation centres, including:
a) geographical inaccessibility of public rehabilitation centres and
b) lack of continuity in rehabilitation services;
3) insufficient health coverage;
4) family situation, including: a lack of client and family knowledge about the existence of rehabilitation services and each rehabilitation discipline's role, and
5) lack of an interdisciplinary approach, including: lack of knowledge among rehabilitation and medical members about having an interdisciplinary approach and an atmosphere of competition among medical and rehabilitation professionals. Quotations by focus group participants and clients are presented to illustrate the key themes. The participants' names were replaced with pseudonyms and clients were referred to by numbers.

Theme 1: Family Income
A family's financial status is perceived as a leading factor in accessing rehabilitation services. As attested to by both professionals and clients, an affluent family has greater access to these services.

Theme 2: Availability of Rehabilitation Centres

a) Geographical Distance

In Tehran, the public rehabilitation centres are often geographically distant from clients' residences, especially from poor families. According to Ahmed (PT), this is a situation that often influenced poor clients to choose private rehabilitation centres because they were cheaper when factors such as time off work and cab fare were considered. See quote #1(Table 8).

b) Breaks in the Continuity of Rehabilitation Services.
The public rehabilitation centres that are affiliated with one of the medical universities are dependent on a student work force and can only provide services according to the school calendar rather than the ongoing needs of their clients.

Theme 3: The need for more comprehensive health coverage
Even those who could afford insurance could not always access rehabilitation services as public hospitals accepted only one of the two major plans and were selective in the services covered. See quote #2 (Table 8).

Lower socioeconomic status and not having the requisite insurance are the major issues in accessing rehabilitation services. These problems further impeded a client's access to effective rehabilitation so the client and the health care professionals felt that all of the insurance plans needed to cover a complete range of services for the required time. See quote #3 (Table 8).

Theme 4: Client and Family Knowledge about Rehabilitation Services
The rehabilitation professionals stated that the most important factor was the family and client's knowledge about the existence of rehabilitation and the value they placed on it as the means of regaining function. See quote #4 (Table 8).

Theme 5: Need for an Interdisciplinary Approach
An interdisciplinary approach has been identified as the most effective practice to manage rehabilitation after stroke (12). Our analysis indicated that Iranian health care professionals and physicians were aware of the need for a team approach, but it was not currently available; this was an issue that clients felt affected their recovery. Physicians were the first to work with clients and families after stroke. They could play a major role in creating an interdisciplinary practice, but they tended to keep their clients and did not refer them in a timely manner to rehabilitation services. See quote #5 (Table 8).

DISCUSSION
To our knowledge, this is the first study to investigate the accessibility and perceived effectiveness of rehabilitation services in Iran. Even though all post stroke clients included in this study felt that the rehabilitation services that were available were effective, many identified major barriers such as poverty to accessing such services. The clients felt that they had not achieved their goals due to poor access and still needed more rehabilitation interventions to decrease the burden on their families (e.g. for ADLs). The direct connection between poverty and access to effective rehabilitation services was reinforced by both clients and the rehabilitation team. Poor families were assisted mainly by their children who were taught some therapeutic techniques that could be carried out at home. It is important to note that the sample for this study was drawn from the more affluent areas of Tehran where the median income for post stroke clients was $ 434 per month, but the majority of the population lives in poor areas.

Other factors may also have impacted on economic status. Urbanization may have added to the impoverishment of a majority of Iranians 13. In this study, 63% of post stroke clients were not born in Tehran, an industrialized city; rather they had migrated from small towns or villages. Literacy is another important factor with a negative impact on the economic situation and potentially on stroke outcome (14); it can affect the awareness and knowledge of post stroke clients concerning the prevention of secondary stroke and the modification of risk factors such as diet, physical activities, and lifestyle. In this study, the literacy rate among post stroke clients was 23%, higher than in the general Iranian population (13%) (15).

After being discharged from acute inpatient hospitals, there were no community based
services to support the clients and/or their families. It was the family's responsibility to take the client home and provide the necessary care. A majority of post stroke clients in this study reported that a family member was their sole caregiver, providing an average of 6.5 hours of assistance with ADLs per day; in many cases, 24 hour care by the family member was required. The rehabilitation professionals also reinforced the importance of the family in dealing with various challenges resulting from a stroke. The families had to allocate money for rehabilitation sessions and specialists' fees, give time and energy to assist the post stroke client at home, learn skills and knowledge about different rehabilitation techniques to be applied at home, and take the client to his or her rehabilitation treatment sessions.

Iran's health care is a public system and free at the entry point, but people who can afford it attend private hospitals which offer rehabilitation services. A poorer client could also access these services if the private hospital was closer to their home, or public rehabilitation services were not available. Iran does not utilize any guidelines for stroke management resulting in rehabilitation professionals and physicians treating each client in isolation without the benefit of a team approach. As a result, health care professionals felt a lack of efficacy in their rehabilitation intervention.

Limitations and Future Direction
Data were collected from one group of health care professionals and from one group of clients. This study was conducted in only one of three medical universities in Tehran. Due to the small sampling method and sample size of this study, the generalization of the findings may be limited. In addition, this research was a hospital based study; as such, it does not account for community based services.
Further studies to examine the cost effectiveness and clinical efficacy of different service delivery models for post stroke clients could be an effective step in improving access to necessary rehabilitation services. Iran is not alone in attempting to increase access, but given poverty rates, it is indeed a daunting task. As a general understanding of rehabilitation accessibility needs evolves in Iran, it may act as a catalyst towards an agreed upon national guideline to drive better access.

Conclusion
Based on the hospitals where this study was conducted, there appears to be a lack of consistency in the stroke rehabilitation services offered in Iran with poverty an underlying factor in accessing effective rehabilitation. Although the effectiveness of the team approach in stroke management has been demonstrated and encouraged, it has not yet been adopted among Iranian rehabilitation professionals and physicians. As the Iranian population is aging, the incidence rate of stroke is likely to increase so the lack of a team approach will negatively impact recovery. Underdeveloped countries such as Iran could be brought to global health standards by considering the areas of improvement that resulted from this study.

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