Our research question was “What are the environmental determinants for participation in stroke survivors who live in Africa?”

We searched CINHAL, PubMed, Medline, and EMBASE. We also conducted a manual search on Google scholar. We searched the databases from inception to August 2021 so as to include all relevant available literature. We used the following keywords and subject heads: “(participation or engagement or involvement or participate) AND (challenges or barriers or difficulties or limitations or obstacles) AND (stroke or cva or cerebrovascular accident or hemiplegia or hemiparesis or poststroke or post-stroke or stroke survival) AND (Africa or sub saharan africa or african countries or Algeria or Angola or Benin or Botswana or Burkina Faso or Burundi or Cameroon or Cabo Verde or Central African Republic or Chad or Comoros or Congo or the Democratic Republic of Congo or Cote dIvoire or Djibouti or Equatorial Guinea or Egypt or Eritrea or Ethiopia or Gabon or Gambia or Ghana or Guinea or Guinea-Bissau or Kenya or Lesotho or Liberia or Libya or Madagascar or Malawi or Mali or Mauritania or Mauritius or Morocco or Mozambique or Namibia or Niger or Nigeria or Rwanda or Senegal or Seychelles or Sierra Leone or Somalia or South Africa or Sudan or Swaziland or Tanzania or Togo or Tunisia or Uganda or Zambia or Zimbabwe).”

We exported the endnote citation and performed the screening process using the Covidence software. A total of 585 articles were retrieved from the databases after eliminating the duplicates. The titles and abstracts of 498 articles and, consequently, the full articles of 51 studies were reviewed by the two authors (YAA and ZDD), of which 13 articles met the criteria and were included in the scoping review. Conflicts were discussed between the two authors until a consensus was reached. The full articles of the 13 included studies were imported into NVivo 12 plus software for easy access to reading and synthesizing. We used the ICF framework (14) to thematize and present the review. The 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 (14).

Figure 1 shows the PRISMA diagram of the process used in the paper selection. Studies based on the following predetermined criteria were included: •

Articles only in English.

Product and technology is defined by WHO as “any product, instrument, equipment or technical system used by a disabled person, especially produced or generally available, preventing, compensating, monitoring, relieving or neutralizing” disability (14).

Five studies mentioned how products and technologies facilitate or hinder participation of people living with stroke. In the study by Cawood and Visagie (21), 77% of participants identified products and technology as a barrier. Difficulty in frequently using transport appeared as a barrier (21–24). In their study, Mudzi et al. (23) revealed that 100% of stroke survivors mentioned transport services as mild to moderate barriers to participation. Cawood and Visagie (21) also mentioned in their study that inaccessible transport creates a barrier for 80% of the community participation of stroke survivors (21).

In addition, it was stated that people with stroke need to pay extra to use public transport if they could find a driver who is willing to take them (22, 23). The independence of individuals with stroke in accessing private transportation is limited due to the lack of accessibility of public transport. Consequently, these individuals are often compelled to rely on others to assist them in getting in and out of the car, which can sometimes compromise their dignity (22). Lack of assets such as money also appeared as a barrier to participation in social activities (21). Cawood and Visagie (21) stated that stroke survivors were not able to afford for phone service. Not only this, but they were also unable to pay for assistive devices (21). In the same vein, access to and utilization of assistive devices were also found to be low in the studies (21, 22). Cawood and Visagie (21) stated that even though most people with stroke can access mobility devices, it is difficult for them to get other assistive products such as bath transfer, grab bars and ankle foot orthosis. For example, it was mentioned that people with stroke struggle to use a toilet that is not modified to accommodate their need (22).

Regarding natural environment and human-made changes to environment, nine articles met the inclusion criteria (15, 21, 22, 24–29). Almost all studies concluded that the natural and human-made environment is inaccessible and creates barriers to participation for people with stroke living in Africa. Amosun et al. (25) stated in their article that environmental barriers led to self-imposed restrictions as stroke survivors would prefer to stay at home than go out and experience the environmental difficulty.

Human-made changes to the environment prevent stroke survivors from participation, including participating in therapy. Cawood and Visagie (21) found in their study that 65% of public buildings were inaccessible. Inaccessibility of the environment hindered people living with stroke from participating in rehabilitation therapy (27, 28). This further complicated their condition and deteriorated their recovery and ability to participate. Soeker and Olaoye (27) concluded that the distance from home to clinic was a major factor not to adhere to therapy. The inaccessibility forced some people to change their home address to live near to hospitals where they get therapy (15). This led them to lose their previous social contact from their old neighborhood (15). Not only the public buildings and the neighborhood, the home environment of stroke survivors was also inaccessible. Maleka et al (29) revealed that the homes were small and cluttered.

Natural environments also imposed restrictions on participation. Walking or pushing a wheelchair on sandy and uneven pavements creates a huge inaccessibility and results in hindered social participation (21). Sandy and uneven pavements in the neighborhood make mobility, with or without a wheelchair, very difficult (15, 21). Arowoiya (22) also asserted that among their study participants, about 21% face severe difficulty in dealing with the physical environmental barriers in their society. Also, Rhoda et al. (28) reported that stones on the way, stairs, and uneven grounds create a barrier to using wheelchair and hinder social participation of stroke survivors.

A total of 11 articles out of 13 discussed support and relationships in stroke survivors. We found a contradicting result. Six articles (21, 23, 27, 30–32) discussed people living with stroke are getting positive social support that is facilitating participation. Conversely, five articles (15, 22, 24, 25, 28) stated that social support and relationships were low and eventually negatively affected stroke survivors.

Mudzi et al. (23) assessed the support and relationship in terms of the immediate family, personal care providers, friends, acquaintances, peers, colleagues, neighbors, and community members. They found that immediate family and personal care providers were supportive and facilitators of participation (23). However, stroke patients perceived that the lack of support from their friends is a barrier to social participation (23). Cawood and Visagie (21) found that the majority (88%) of the immediate families of stroke survivors were supportive. Stroke survivors need and get social support and assistance for activities of daily living (ADL) and instrumental activities of daily living (IADL) from family members (32). By the same token, they also get positive support in the workplace to resume their previous work (27). Ekechukwu et al. (30), while assessing the clinical and psychosocial predictors of community reintegration of stroke survivors, revealed that stroke survivors who received good social support were better at reintegrating into the community. Vincent-Onabajo et al. (31) also asserted that a high level of social support is associated with better social participation and economic self-sufficiency.

However, we also understood from the articles mentioned that as time passes, the support and relationship diminishes (28). In the study done in Rwanda, to assess the activity limitations and participation restrictions, Urimubenshi (15) revealed that the social interaction of stroke survivors decreased from time to time. One reason stated was that people with stroke frequently change their residence near to hospital as it would be easier for them to get continuous healthcare services (15), which leads to the lack of support from their previous social capital. Others also could not maintain their relationship with friends due to financial restrain (22). Elloker (24) assessed the social support and participation restrictions in patients living with stroke in South Africa. They revealed that nearly 90% of stroke survivors have low social support (24). Lack of adequate social support diminishes participation (25, 28). However, stroke survivors value the support they receive (24).

Four articles discussed how the attitude toward stroke survivors positively or negatively determines participation (21–23, 25).

Cawood and Visagie (21) found in their study that the majority of immediate families have positive attitudes toward stroke survivors. In addition, the attitude of health professionals was a facilitator for participation (21). However, the societal attitude was found to be negative and created a barrier to participation (21, 22). Mudzi et al. (23) also revealed in their study that the majority of the attitudes of friends were a barrier for stroke survivors to participate in their community.

We also understood from the articles that people see stroke survivors as pitiful and support them from a sense of duty (21, 22). The negative attitude does not always come from another person, but stroke survivors also have a perceived negative attitude that hinders their participation (25). Amosun et al. (25) concluded that stroke survivors experienced both self and enacted stigma.

We could not find enough information about services, systems, and policies and how they are affecting the participation of stroke survivors. Three articles (21, 23, 27) discussed services, systems, and policies regarding participation. These factors appeared to be barriers to participation for stroke survivors. For example, Cawood and Visagie (21) revealed that nearly half of their study participants indicated that they did not receive assistance from associations or organizations. Cawood and Visagie (21) and Mudzi et al. (23) presented that both the housing policies (23) and the bureaucracy to get government-subsidized houses create barriers. In addition, the paperwork to process disability benefits took too long, which led to financial strain (21). In another study, Soeker and Olaoye (27) indicated that stroke survivors struggle with financial constraints that lead them to opt out from therapy. This indicates that there was minimum or no support to help them continue their therapy.