Health-related quality of life of stroke patients before and after intervention: Systematic review

World Health Organization defi ned stroke as “rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting quite 24 hours or resulting in death with no apparent cause other than that of vascular origin” [1]. In every 6 people will have a stroke in life; 15 million people suffer a stroke per year, from these 6 million people die [2]. In developed countries, stroke is a cause for death after cancer and heart condition [3]. In the current situation in Sub-Saharan Africa region stroke cases occur with high morbidity and mortality rate that leads to rapid epidemiological transition [2].


Introduction
World Health Organization defi ned stroke as "rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting quite 24 hours or resulting in death with no apparent cause other than that of vascular origin" [1]. In every 6 people will have a stroke in life; 15 million people suffer a stroke per year, from these 6 million people die [2]. In developed countries, stroke is a cause for death after cancer and heart condition [3]. In the current situation in Sub-Saharan Africa region stroke cases occur with high morbidity and mortality rate that leads to rapid epidemiological transition [2].
Stroke patients exhibit symptoms like mood changes (depression, apathy), paralysis of an extremity-face, spasticity, loss of memory, contracture pain, and personality changes [1]. Depending on the type and severity, a stroke can leave an individual residual impairment of physical, social, psychological, and cognitive functions [4]. And also features a substantial impact on the psychological well-being of their families [5]. This kind of impacts deteriorate patients perceptions of their position in life concerning their goals, standards, and expectations [6].
Health-Related Quality of Life (HRQOL) is quality of life suffering due to a disease, or health condition, or health care intervention on the individuals' subjective experience in social, psychological, functional, and cognitive processes [7,8]. The concept of HRQOL is essential within the assessment of the multiple impacts of a stroke on the patient's life and evaluation of their health states [5]. HRQOL measures encompass physical, emotional, social, and subjective feelings of patients and hence, utilized in identifying prioritizing areas, evaluation of the cost-benefi t and effectiveness of prophylactic, therapeutic, and rehabilitative interventions [9].
To assess HRQOL, generic and specifi c measurement tools are developed [10]. Generic HRQOL measurement tools utilized across a wide range of populations and health care interventions, whereas specifi c HRQOL measurement tools are designed to measure HRQOL only specifi c subpopulations [11]. Disease-specifi c HRQOL measurement tools are designed to assess HRQOL of patients with scales and questions that are specifi c (related) to a disease or health condition [12].
The assessment focuses on the alleviation of symptoms, prevention of deaths, and restoration of patient function. The care of a stroke patient requires measurements of the result, which are critical to assess and evaluate the treatment regimens. Therefore, the objective of this review was to review the HRQOL of patients with stroke.

Search strategy
A systematic literature search was conducted from Science Direct, Google Scholar, Hinari, Scopus, Web of Science, PubMed, Cochrane Library, and PROSPERO electronic databases for articles published from January 2000 -July 2020. A manual Google search was utilized to identify some studies and therefore the reference lists of retrieved articles. The entire searches were done July 5-10/2020 using keywords "health-related quality of life", "quality of life", "stroke", "intervention", "patients" and in combination.

Study selection
Articles were included within the review if they aimed to assess HRQOL of stroke patients. The inclusion criteria were: publication: peer-reviewed and gray literature, type of study: all, population: stroke patients, time: from 2000 to present, and language: English. Studies that were published only as dissertations, editorials, opinions, abstracts, and letters to editors were excluded.

Assessment of methodological quality
Before including the selected articles to the review methodological validity assessment was done and during the review by conducting critical appraisal using preferred reporting items for systematic reviews and meta-analysis (PRISMA) fl ow diagram and guidance set out by the center for reviews and dissemination [13]. Each of the 20 studies was evaluated for each criterion/question and rated it as "Yes" with score 1 if described partly, we scored it as 0.5, then 0 for "No." Then, the entire score was calculated by summing each score and score less than 75% graded as low quality, 75% to 90% graded to moderate quality, and greater than 90% was graded as high quality.
In this review, three reviewers participated. Two reviewers appraised the full text of each article independently. Any discrepancies between the two reviewers were resolved through discussion with a third reviewer as an arbiter.

Data abstraction
The author screened the studies based on the inclusion and exclusion criteria. The following details were extracted from each article using an abstraction form: authors, country, sample size, year, study design, HRQOL measurement tool, intervention types, before or after the intervention, HRQOL status, and complications.

Literature search results
The searching was conducted through stepwise procedures.
The initial advanced search in all databases yields 864 studies.
Finally, 20 studies in which full fi eld the inclusion criteria were reviewed. The fi gure below briefl y describes the fl ow of study selection employed within the study ( Figure 1).

Methodological quality of included studies
The reporting quality results showed that most studies were of high quality (n=18, 75%), whereas fi ve (20.9%) were of moderate quality and one (4.1%) were of low quality.

Study characteristics
All selected studies varied in the study design. The sample size ranged from 24-700 (

HRQOL measurement tools
Fifty percent (n=10) of articles included in the review Short-Form (SF-36) was utilized to assess HRQOL stroke patients. Whereas, 20 %( n=4) of studies Barthel Index and three (15%) of studies Stroke Specifi c Quality of life (QOL) Scale were used to assess HRQOL of stroke patients ( Table 2).

Assessment of HRQOL before and after intervention
Eighty-fi ve percent (n=17) of reviewed articles assessed HRQOL of stroke patients after the interventions of the disease, whereas three (15%) of studies assessed HRQOL before the interventions done to the complications of the diseases. In the current review, in fi fty percent (n=10) of studies physical disability and in six (30%) of studies depression occurred the complications of stroke (Table 3).

Intervention types and HRQOL Status
From the reviewed articles, 40% (n=8), 25% (n=5), 20% (n=4), 20% (n=4), and 10% (n=2) of studies medication therapy, physical exercise, psychological intervention, assistive devices, and surgical procedure were utilized as an intervention to overcome the complications of a stroke. Fifty percent (n=10) of studies assessed HRQOL improvement in stroke patients, from this physical and psychosocial well-being of stroke patients were identifi ed as predictors of HRQOL (Table 4).

HRQOL of stroke patients before intervention
The impact of stroke on HRQOL is disastrous without getting intervention and stroke can complicate multiple domains of life. In the current review, the physical disability problem was assessed in fi fty percent of studies (n=10), and in six studies (30%) reviewed articles depression was occur the complications of a stroke. This was similar to Robinson RG (2006) and Gurenlian J (2002) studies revealed that the brain affected by stroke [14]. Also, HRQOL was signifi cantly reduced with the presence of depression and previous stroke were all signifi cantly associated with worse QOL (P = 0.0001) study done by Pinkney JA (2017) [15]. Brain edema, depression, and emotional problem were the common central nervous system complication of stroke.
Naess H, (2006) study revealed that a close association between low HRQOL and depression among older patients with stroke [16]. Similar studies by Carod-Artal J (2000), Khalid W (2016), and Chaves DBR (2013) described that stroke survivors mostly depressed and their HRQOL was profoundly infl uenced by increased physical functional dependency, neurologic pain, and depression [17][18][19]. Also, study conducted by Chen Q, et al. (2019) patients with strokes scored signifi cantly lower in all mental dimensions including vitality, social functioning, role limitations due to emotional problems, and mental health (P < .001) [20]. Brain injuries caused by a stroke can also determine writing and verbal language skills. That, in turn, can produce communication diffi culties, causing social isolation, which aggravates depression and thus interferes with HRQOL.
Physical disability is a consistent determinant of HRQOL in stroke survivors in almost all studies and survivors after stroke has very poor HRQOL in the long term after stroke  and Hohmann, et al. study [31].   17 Clarke P [37] Activities of daily living scale (ADL) 18 Thomas LH [38] Incontinence QOL Instrument (IQoL) 19 Kahn SR [22] VEINES QOL and Short form SF-36 20 Armstrong JR [23] Clinical Pulmonary Infection Score Citation: Hailu   Carod-Artal FJ [25] Medical intervention Physical and psychosocial well-being is greatly affected in stroke survivors 7 Rønning OM [19] Medication therapy Improvement in HRQoL from 1 to 6 months after stroke 8 Kauhanen M-L, et al. [29] Physical and medication therapy The most important determinants of low QOL seem to be depression and being married 9 Chandrasekhar D, et al. [27] Pharmaceutical care Pharmaceutical care improve HRQOL of patients  The toileting assistance intervention had benefi t individuals who are functionally or cognitively impaired and who rely on a career to assist them to maintain continence [41]. Individuals who use bladder-protection pads, behavioral interventions, and bladder training assist to manage incontinence improve HRQOL of the patients [42].

Limitations of this review
Numerous tools are available to measure HRQOL of stroke patients and every of the reviewed articles uses the distinct tool. This diversity of domains within the assessment of HRQOL makes compression troublesome and it's unclear to conclude that interventions have a sound improvement in HRQOL.

Conclusions
This review covered wide range of HRQOL measurement tools that has been conducted in patients with stroke. There is no existing measurement tools comprehensively covers all relevant domains or addresses fully the issues of obtaining and combining HRQOL assessment in stroke patients.
The incidence of complications like depression, disability, seizure, and different complications was the determinant of poor HRQOL. Generally, physical functions and psychosocial well-being are greatly affected when the incidence of a stroke.
Inpatient interventional program contains a sturdy and positive impact on HRQOL. Interventions like medication, physical, psychological interventions, and environmental helpful technology have shown effectiveness in HRQOL patients with stroke. The investigation of relevant factors with health-related quality and assessments of individual HRQOL provides necessary data for clinicians and decision-makers to choose upon acceptable treatments and allocation of resources.

Data availability
The datasets are available from the corresponding author upon reasonable request.