Magister Scientiae (Physiotherapy) - MSc(Physio) / Background and aim: Despite the high number of strokes globally, and among people of African origin in particular, there are few available data on stroke in most countries of sub-Saharan African (SSA), including Tanzania. In addition, the profile and challenges affecting stroke patients in these countries has not been adequately explored. The aim of this study was to determine the profile and explore the challenges experienced by stroke patients admitted at Haydom Lutheran Hospital in Tanzania. The objectives of the study were to determine the documented risk factors among the patients admitted to Haydom Lutheran Hospital, to identify the stroke on-set admission interval and length of hospital stay, to identify the process of physiotherapy for the stroke patients, and to explore the challenges experienced by stroke patients discharged from Haydom Lutheran Hospital, Tanzania. Methods: Qualitative and quantitative research designs were used to collect the data. The quantitative design used a retrospective descriptive study, in which medical records of stroke patients were reviewed. The qualitative approach included in-depth interviews to collect information regarding the challenges experienced by stroke patients residing in Haydom, Tanzania. Existing medical records were perused to obtain information related to demographic profile, medical characteristics and rehabilitation data among stroke patients admitted at Haydom Lutheran Hospital. Relevant data was captured on a data information sheet. The SPSS (14.0 version) and Microsoft Excel (2007) were used to analyse quantitative data. Descriptive Statistics were used to determine ranges, percentages, frequencies, means and standard deviations calculate. The qualitative interviews were transcribed verbatim and also translated from Kiswahili to English. Stated concepts were coded, grouped into categories, and reduced into sub-themes and main themes. Prior to conducting this study, final permission was obtained from the Senate Research Grant and Study Leave Committee at the University of the Western Cape as well as the relevant authorities of the Tanzania Ministry of Health, Tanzanian National Institute of Medical Research, and the Administration of Haydom Lutheran Hospital. Written informed consent were obtained from the participants prior to interviews. Results: A total number of 145 stroke patients were admitted to Haydom Hospital between 1st January 2004 and 31st December 2010. However, only 128 of the potential sample participants met the inclusion criteria for the sample. The mean age of the participants was 57.7years, (SD=18.673). Of these, 104 (81.2%) had haemorrhagic stroke and 24(18.7%) had ischemic strokes. HIV infection (78.1%), previous stroke (74.2%), smoking (58.5%) and hypertension (55.4%) were the most common risk factors for stroke. Among the participants, the documented impairments included emotional impairments 42(32.8%), speech impairment 47(36.7%), cognitive impairment 39(30.4%), muscle impairment 36(28.1%), and occurrence of coma 33(25.8%) respectively. The mean time from onset of stroke to admission was 1.2 days with (SD=0.42 days). The mean length of hospital stay was 12.16 days (SD=4.1 days), the majority (61.7%), started physiotherapy within 3 days after admission, mean duration of physiotherapy was 14.1 days (SD=5.79), and the mean number sessions of physiotherapy 3.7days (SD=18.8 days). The challenges that emerged during the qualitative interviews with participants were limitation in walking activities, inability to return to work and to participate in leisure activities as before the onset of stroke, and environmental factors such as physical barriers and attitude of family. Conclusion: The findings of the research reveal that stroke in Tanzanian patients occurs at a relatively young age, and that frequency of intra-cerebral haemorrhage is higher than that reported in developed countries. The clinical presentations and risk factors are similar to those in other studies. The qualitative findings revealed that the stroke patients had problems with limitation of activity, participation restrictions, and environmental challenges. They also expressed uncertainties as a result of a lack of knowledge about stroke and its effects, and discharge challenges relating to rehabilitation. These challenges should be addressed in the process of management of patients with stroke in the research setting.

This thesis examines 5-year clinical and health-economic outcomes of ischaemic stroke, and their relationship to short-term post-stroke disability, as captured by the 3-month modified Rankin Scale (mRS) - the favoured primary outcome measure in acute stroke trials. I use data from the Oxford Vascular Study (recruited 2002-2014), a population-based prospective cohort for which I followed patients in-person and via medical records until 15-May-2017. I demonstrate that 3-month mRS strongly predicts 5-year post-stroke disability and mortality, including in clinically-relevant groups (treatable major strokes, atrial fibrillation-related strokes, and lacunar strokes), reaffirming its use as a trial outcome measure. About one in four patients experience functional recovery between 3-12 months post-stroke, and mortality follow-up beyond 1-year by stroke trials can show translation of early disability gains into lower mortality. Contrary to previously reported apparent sex-differences, I find no evidence of worse outcomes in women after accounting for differences in age and pre-stroke mRS. I find that late recovery between 3-12 months occurs more often in lacunar strokes, supporting the focus of restorative therapies in this group, but highlighting that uncontrolled studies cannot assume that improvements after 3-months are treatment-related. In addition, I demonstrate that like death/disability, outcomes of institutionalization, post-stroke dementia, health/social-care costs, and quality-adjusted life expectancy (QALE) also show meaningful differences with each step up the mRS ladder. Consequently, ordinal analysis of the 3-month mRS (capturing transitions across the scale's range) better predicts long-term outcomes than dichotomous approaches, which also foster high exclusion rates of relevant patient segments from trials owing to their pre-morbid disability. However, the mRS should be weighted in ordinal analyses, as different state transitions carry different implications for long-term outcomes. Using 3-month mRS-stratified data for clinical endpoints, care costs, and QALE, I derive mRS weights that could be used for meaningful ordinal analyses, clinical prognostication, and cost-effectiveness analyses of stroke therapies.