Thesis

Participants’ experience of the
Bishop Lavis Rehabilitation Centre stroke group
Wendy-Lynne de la Cornillère
Student number: 12776750

Project number: N05/02/030
Thesis submitted in partial fulfilment of the requirements of the degree

M. Phil (Rehabilitation) at Stellenbosch University
Supervisor: Surona Visagie

Co-supervisor: Siphokazi Gcaza
Centre for Rehabilitation Studies

March 2007
Declaration
I declare that the work submitted in this assignment is my own work, that it has not been submitted
in its entirety or in any part for any degree or examination at any other university, and that all
sources I have used or quoted have been indicated and acknowledged by complete references.
Full name: …………………………………………………
Date: ………………………………………………….
Signed: …………………………………………………..
ii
Abstract
PARTICIPANTS’ EXPERIENCE OF THE BISHOP LAVIS

REHABILITATION CENTRE STROKE GROUP
W. de la Cornillère
M. Phil (Rehabilitation) Mini-thesis
Centre for Rehabilitation Studies, Stellenbosch University
Current emphasis for rehabilitation in South Africa remains on individual intervention within the
move towards primary health care. Primary health care is the strategy that has been adopted by the
South African department of health to bring access and equity in health care services. Even so, the
burden of providing effective rehabilitative services with limited resources requires innovative
strategies, such as the use of therapeutic groups, to address certain aspects of rehabilitation. These
strategies must be proven effective. There is a paucity of literature detailing the uses of group
therapy in physical rehabilitation, and particularly the use of interdisciplinary group work in stroke
rehabilitation. Furthermore, evidence shows that stroke survivors feel ill equipped to return to their
communities despite rehabilitation. Stroke is a major cause of death and disability in South Africa,
and is a condition shown to benefit from rehabilitation. These factors led to the selection of the
Bishop Lavis Rehabilitation Centre stroke group as the setting for this study, which aims to describe
the range of experiences relating to attendance or non-attendance of those referred to this
programme.
This descriptive study, employing quantitative means (to describe the demographic details of the
participants) and qualitative means (to describe the experiences of participants), was conducted with
twenty participants. Data was collected by means of an administered questionnaire. Following that,
a focus group discussion involving six participants was used to gather in-depth information.
Quantitative data was analysed with the assistance of a statistician, utilising the computer program,
Statistica. The Chi-Squared, Kruskal-Wallis and ANOVA tests were used, with p>0.05 showing
statistical significance. Qualitative data was thematically analysed, whereby data was categorised
by means of an inductive approach.
The study population consisted of 20 participants, with an average age of 59 years, of whom 15
were female and five male. The stroke group provided meaning to participants on two levels. On a
psychosocial level, the phenomena of universality (identifying with others in a similar position),
development of socialising techniques, imparting information and cohesiveness emerged strongly.
ii
On the level of meaning related to stroke recovery, improvement in ability to execute activities of
daily living, mobility and strength were most frequently mentioned. Transportation issues were
most commonly mentioned as factors negatively influencing attendance. Staff attitude and
activities of the programme were most often cited as positive factors.
Given the positive response of study participants, and the programme’s ability to sustain
intervention with limited resources, it was concluded that this programme has a valid place within
stroke rehabilitation in Bishop Lavis.
Recommendations in terms of the group programme included investigating methods of providing

transportation, providing childcare facilities and expanding the content of educational sessions.
Further recommendations were to maintain the positive attitude of staff and the current activities of
the programme. Frequency of group outings should also be increased and compensatory strategies
for inclement weather must be explored.
iii
Abstrak
GROEPLEDE SE ERVARING VAN DIE

BISHOP LAVIS REHABILITASIE SENTRUM BEROERTE GROEP
W. de la Cornillère
M. Phil (Rehabilitasie) Mini-tesis
Sentrum vir Rehabilitasie Studies, Universiteit van Stellenbosch
Ten einde toegang tot en gelyke verspreiding van dienste te verseker fokus die Departement van
Gesondheid op die verskaffing van primere gesondheidssorg. Die klem val egter steeds op
individuele behandeling. Beperkte hulpbronne bemoeilik egter effektiewe diensverskaffing en
innoverende strategieë soos die gebruik van terapeutiese groepe om sekere aspekte van behandeling
te dek is nodig. Daar is weinig literatuur rondom die impak van groep terapie in fisiese
rehabilitasie, of beroerte rehabilitasie, en die gebruik van inter-dissiplinere spanwerk in groep
terapie. Dit tesame met bewyse dat persone met beroerte, ten spyte van rehabilitasie, onvoorbereid
voel om terug te keer na hulle gemeenskappe, het gelei tot die studie. Beroerte is een van die hoof
oorsake van mortalitiet en morbiditeit in Suid Afrika. Voorts is dit ook `n toestand wat baat vind by
rehabilitasie. Die studie fokus op die beroerte groep program van die Bishop Lavis Rehabilitasie
Sentrum. Die doel van die studie is om die spektrum van ervarings van groeplede ten opsigte van
groep bywoning te beskryf.
Die studie is beskrywend van aard en maak gebruik van kwantitatiewe (om die demografiese
samestelling van die studie populasie te beskryf) en kwalitatiewe (om groeplede se ervaring van die
groep te evalueer) metodes van data insameling. Data is ingesamel deur middel van ‘n vraelys en
na dit ‘n fokus groep bespreking, met ses deelnemers, om in diepte inligting in te samel.
Kwantitatiewe data is met behulp van ‘n statistikus en die rekenaar program, Statistika, geanaliseer.
Die Chi-Squared, Kruskal-Wallis en ANOVA toetse is gebruik. `n P-waarde van >0.05 is gesien as
statitisties beduidend. Kwalitatiewe data is volgens tema age-analiseer deur middel van `n
induktiewe proses.
Die studie populasie het uit 20 deelnemers bestaan. Hulle gemiddelde ouderdom was 59. Vyftien
van die deelnemers was vrouens en 5 mans. Deelnemers het beide op `n psigososiale and fisiese
vlak baat gevind by die groep. Op ‘n psigisosiale vlak het die verskynsel van universitaliteit
(identifisering met ander in dieselfde posisie), die ontwikkeling van sosialiseringstegnieke, oordrag
iv
van inligting en kohesie sterk na vore gekom. Op `n fisiese vlak het deelnemers gevind dat hulle
vermoë om aktiwiteite van die daaglikse lewe uit te voer, hulle mobiliteit en hulle spierkrag
verbeter het.
Probleme ten opsigte van vervoer was die mees algemeenste faktor wat bywoning negatief
beinvloed het. Die houding van personeel en die aktiwiteite van die program het na vore gekom as
faktore wat groep bywoning positief beinvloed het.
Die positiewe reaksie van deelnemers en die program se vermoë om volhoubare behandeling ten
spyte van beperkte hulpbronne te verskaf het gelei tot die gevolgtrekking dat hierdie program ‘n
defnitiewe plek in beroerte rehabilitasie in Bishop Lavis het.
Aanbevelings sluit in om ondersoek in te stel na moontlike metodes van vervoerverskaffing,

kindersorg fassiliteite en uitbreiding van die inhoud van die gesondheidsonderrig sessies. Verdere
aanbevelings is om die positiewe houding van die personeel, sowel as die aktiwiteite van die
program te behou. Daar moet ook aandag geskenk word aan meer gereelde groep uitstappies, en
alternatiewe strategieë om bywoning in ongunstige weerstoestande te verbeter.
v
Acknowledgements
God, for being my strength and hope.
Scott Barr, for his endless patience and unparalleled love and support.
Surona Visagie, for her excellent supervision, her understanding and her patient guidance in her
role as supervisor. For challenging my thinking and for being available - every step of the way.
Gené Guthrie, Peter, Liz and Jo de la Cornillère, Siegi Rabe, Ryan Rutherford and Aisha
Abdulatief, for their support and generosity with time in being unpaid “research assistants”.
The Bishop Lavis stroke group, for their inspiration and willingness to share openly.
Siphokazi Gcaza, co-supervisor.
Gubela Mji, head of department.
Dedication
This study is dedicated to Rachel Nakeli (1944 - 2006), generous and selfless member of the Bishop
Lavis community, who volunteered at the Bishop Lavis Rehabilitation Centre for many years and
facilitated the Bishop Lavis community stroke support group with love and skill.
vi
Key words
Bishop Lavis, community-based rehabilitation, rehabilitation, stroke, therapeutic group.
Definition of terms
Community-based rehabilitation
“…a strategy within community development for the rehabilitation, equalisation of
opportunities and social integration of all people with disabilities. CBR is implemented
through the combined efforts of disabled people themselves, their families and communities
and the appropriate health, education, vocational and social services.”1
Interdisciplinary team approach

Type of team approach characterised by the coming together of health professionals who
specialise in different areas of care, and who set common goals for client care and have
regular communication regarding progress in relation to these goals.2
Primary health care

“The first level contact with people, taking action to improve health in a community”,3 with
focus on maximal use of resources, community participation, affordable and accessible care,
integration of all levels of disability prevention and co-ordination between health and other
sectors.4
Rehabilitation
“Ways of helping people with disabilities to become fully participating members of society,
with access to all the benefits and opportunities of that society.”5
Stroke
“Rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with
symptoms lasting 24 hours or longer leading to death with no apparent cause other than of
vascular origin.”6
Therapeutic group
Setting in which several clients are treated together by one therapist as a group.7 The group
provides a context for therapeutic intervention, where the processes of the group contribute to
healing.
vii
Contents
Chapter 1 – Introduction and background 1

1.1 Thesis outline 1
1.2 Background 1
1.3 The community of Bishop Lavis 2
1.4 The Bishop Lavis Rehabilitation Centre 4
1.4.1 Introduction 4
1.4.2 Management of the stroke client 6
1.5 Research problem 9
1.6 Motivation for and significance of the study 11
1.7 Summary of Chapter 1 12
Chapter 2 – Literature review 13

2.1 Introduction 13
2.2 Rehabilitation - an overview 13
2.2.2 Rehabilitation policy trends in developing nations 15
2.2.3 Health care and rehabilitation in South Africa 17
2.3 Stroke 19
2.3.2 Approaches to stroke rehabilitation 21
2.4 Therapeutic groups 23
2.4.2 Curative factors of therapeutic groups 23
2.4.2.1 Instillation of hope 23
2.4.2.2 Universality 24
2.4.2.3 Imparting information 24
2.4.2.4 Altruism 24
2.4.2.5 Corrective recapitulation of the primary family group 25
2.4.2.6 Development of socialising techniques 25
2.4.2.7 Imitative behaviours 25
2.4.2.8 Interpersonal learning 26
2.4.2.9 Group cohesiveness 25
2.4.2.10 Catharsis 26
2.4.2.11 Existential factors 27
viii
2.4.2.12 Impact of curative factors 27
2.4.3 Types of therapeutic groups 27
2.4.3.1 Task groups 28
2.4.3.2 Social groups 28
2.4.3.3 Communication groups 29
2.4.3.4 Psychosocial groups 29
2.4.4 Characteristics of therapeutic groups 29
2.4.4. 1 Size 29
2.4.4.2 Member selection 30
2.4.4.3 Timing 31
2.4.5 Barriers to therapeutic groups 31
2.4.5.1 Practical barriers 31
2.4.5.2 Certain personality attributes 31
2.4.5.3 Particular therapeutic needs 32
2.4.6 Therapeutic groups in physical rehabilitation 33
2.4.7 Therapeutic groups in stroke rehabilitation 33
2.5 Measuring instruments 34
Chapter 3 – Methodology 36
3.1 Study aim 36
3.2 Study objectives 36
3.3 Study design 36
3.4 Study setting 37
3.5 Study population and sampling 37
3.5.1 Inclusion criteria 38
3.5.2 Exclusion criteria 39
3.5.3 Allocation to study groups 39
3.6 Instrument design 40
3.6.1 Section A 40
3.6.2 Section B 40
3.6.3 Section C 41
3.6.4 Section D 41
3.6.5 Section E 42
3.7 Piloting process 42
3.8 Data collection 43
ix
3.9 Data analysis 44
3.9.1 Quantitative data 44
3.9.2 Qualitative data 45
3.10 Phase II – Focus group 45
3.10.1 Sampling 45
3.10.2 Data collection 46
3.10.3 Data analysis 46
3.11 Trustworthiness of qualitative data 47
3.12 Reliability and validity of quantitative data 47
3.13 Ethical considerations 48
3.13.1 Protection of participants’ interests 48
3.13.2 Confidentiality 48
3.13.3 Informed consent 48
3.13.4 Approval 48
Chapter 4 – Results and discussion 50

4.1 Introduction 50
4.2 Demographic profile of the study population 51
4.2.1 General 51
4.2.1.1 Gender 51
4.2.1.2 Age distribution 52
4.2.1.3 Employment status and household income 53
4.2.1.4 Ethnicity and language 53
4.2.2 Stroke-related factors 54
4.2.2.1 Laterality 54
4.2.2.2 Barthel ADL Index score 54
4.2.2.3 SIS v3 scores 55
4.2.3 Factors relating to stroke group attendance 56
4.2.3.1 Mode of transport 56
4.2.3.2 Cost of transport 57
4.2.3.3 Physical preparation 58
4.2.3.4 Presence of caregiver 58
4.3 Meaning that group programme involvement has to participants 58
4.3.1 Meaning related to psychosocial outcomes 59
4.3.1.1 Introduction 59
x
4.3.1.2 Instillation of hope 59
4.3.1.3 Universality 61
4.3.1.4 Imparting information 62
4.3.1.5 Development of socialising techniques 64
4.3.1.6 Imitative behaviour 64
4.3.1.7 Cohesiveness 65
4.3.1.8 Self-esteem 66
4.3.2 Meaning in terms of improvement in stroke-related areas of recovery 67
4.3.2.1 Introduction 67
4.3.2.2 Activities of daily living 67
4.3.2.3 Strength 68
4.3.2.4 Mobility 69
4.3.2.5 Thoughts and memory 69
4.3.2.6 Communication 70
4.3.2.7 Mood and emotions 70
4.3.2.8 Hand function 70
4.4 Factors influencing attendance or non-attendance of the BLRC stroke group 70
4.4.1 Positive influence 71
4.4.1.1 Personnel 71
4.4.1.2 Activities 72
4.4.1.2.1 Exercise 72
4.4.1.2.2 Games 73
4.4.1.2.3 Health education talks 73
4.4.1.2.4 Relaxation 74
4.4.1.3 Structure 74
4.4.2 Negative influence 74
4.4.2.1 Transportation 74
4.4.2.2 Family responsibility 75
4.4.2.3 Weather 75
4.4.2.4 Emotional/personal 75
4.4.2.5 Personnel 76
4.5 Recommendations regarding improvement of the programme 76
4.6 Other results 79
4.6.1 Personal responsibility for rehabilitation 79
4.6.2 The role of the community in rehabilitaiton 79
xi
Chapter 5 – Conclusions and recommendations 82
5.1 Introduction 82
5.2 Conclusions 82
5.2.1 Meaning that the stroke group has to participants 82
5.2.2 Factors influencing group attendance 83
5.2.3 General conclusions 83
5.3 Recommendations 87
5.3.1 Access-related difficulty 87
5.3.1.1 Transport 87
5.3.1.2 Weather-related difficulties 89
5.3.2 Childcare facilities 89
5.3.3 Health education 89
5.3.4 Focus of input 89
5.3.5 Personnel 90
5.3.6 Group outings 90
5.3.7 Group structure and activities 90
5.3.8 Community stroke group 91
5.3.9 Facilitation of curative factors not identified by participants 91
5.3.10 The role of the BLRC in educating the community 91
5.4 Limitations of the study and recommendations for further study 91
5. 5 Summary of Chapter 5 94
References 95
xii
List of tables
Table 1.1 Example of stroke group planner 9

Table 2.1 Advantages and disadvantages of smaller versus larger groups 30
Table 2.2 Advantages and disadvantages of open and closed groups 30
List of figures
Figure 3.1 Study population 38

Figure 4.1 Gender distribution 51
Figure 4.2 Average age 52
Figure 4.3 Average ratio of people with income to adult inhabitant per group 53
Figure 4.4 Hemisphere affected 54
Figure 4.5 Barthel ADL Index 54
Figure 4.6 Average SIS v3 scores 55
Figure 4.7 Transport used to access BLRC 56
Figure 4.8 Cost incurred in accessing BLRC 57
Figure 4.9 Time taken to prepare for and access group 58
Appendices
I Interdisciplinary group progress sheet a

II Client satisfaction survey (Groep terugvoervorm) b
III Questionnaire c
IV Focus group – interview schedule k
V Information and informed consent form l
xiii
Abbreviations
ADL Activities of daily living

BI Barthel ADL Index
BLCHC Bishop Lavis Community Health Centre
BLRC Bishop Lavis Rehabilitation Centre
CBR Community-based rehabilitation
CHC Community health centre
HSL Household subsistence level
IDP Integrated Development Plan
OT Occupational therapist
PHC Primary health care
PT Physiotherapist
SIS v3 Stroke Impact Scale, version 3
WHO World Health Organisation
xiv
Chapter 1
INTRODUCTION AND BACKGROUND
1.1 Thesis outline

Chapter 1 serves as an introduction to the study. It provides the reader with the
background to the study and the study setting, as well as motivation for and significance of
the study.
Chapter 2 provides insight into the current literary context of the topic in the form of a
literature review. It defines rehabilitation, gives an overview of current trends in
rehabilitation, with a focus on stroke rehabilitation in South Africa, and introduces the
reader to therapeutic groups.
Chapter 3 summarises the methodology used in the study.
Chapter 4 presents the results of data collection, and discusses these results in terms of the
stated objectives.
Chapter 5 contains conclusions drawn from the study, outlines resulting recommendations,
and highlights the limitations of the study. It also makes recommendations regarding
future study.
1.2 Background
Within the context of South Africa as a developing nation, there is a significant burden to provide
effective health care with limited resources. Rehabilitative aspects of health care are often under
even more pressure, as they are not considered as high a priority as life-saving interventions are.4
Traditional forms of medium and long-term individual therapy programmes, whilst effective in
certain contexts, are insufficient in meeting the current needs of the South African public. From an
egalitarian perspective, there is insufficient manpower and resources to provide comprehensive,
long-term, individual rehabilitation programmes for all clients in need thereof.8 Simply put – there
are just not enough therapists, facilities or funds available.
It is clear that alternative means of providing rehabilitation must be investigated. This is supported
9
by the Western Province’s health plan 2010, which aims to provide ninety percent of health
services – including rehabilitation services – at community level by the year 2010. Within this
plan, there is a move away from the expensive, labour-intensive strategy of in-patient rehabilitation,
which removes the client from their natural setting, effectively isolates them, and trains them to
1
cope in an environment that is often far-removed from the reality these clients will face upon
discharge. The movement of resources for rehabilitation in South Africa is now in the direction of
primary health care (PHC), and the associated approach of community-based rehabilitation (CBR).
CBR helps to address the low level of available professional resources by involving the family, and
community as a whole, in the rehabilitation process. The inadequacy of resources to meet the needs
of the 82 % of South Africans dependant on the public health system cannot be ignored.8 It is
envisaged that the approaches of PHC and CBR (discussed in further detail in Chapter 2) will be
instrumental in bridging this gap.
The emphasis of rehabilitation currently remains on individual intervention, even at community

level. At this point, it must be questioned whether individual treatment approaches are still the
most effective means of rehabilitation. Individual treatment plans do have definite advantages, as
every individual has unique needs. It seems, however, that certain aspects of rehabilitation that do
not rely on one-on-one contact, may actually be enhanced within a group setting. Group
programmes could, for example, be an effective method of providing health education, teaching
lifestyle modification, promoting socio-emotional support, providing maintenance exercises and
allowing for emotional expression. A review of the literature (refer to Chapter 2) reveals that there
are, in fact, many such advantages. These include reducing anxiety, fulfilling the need to share and
feel supported, overcoming dependency and guilt, increasing self-esteem, accepting change,
learning new behaviours and setting realistic goals,10 amongst numerous others.
At the Bishop Lavis Rehabilitation Centre (BLRC), which forms a part of the Bishop Lavis
Community Health Centre (BLCHC), one of the means used to provide rehabilitation to clients who
have suffered a stroke is interdisciplinary group therapy. It is this stroke group programme that is
the subject of this research project. An understanding of the functioning of the stroke group
programme, and the context within which it operates, is essential to this study. Therefore, a
detailed outline of the community of Bishop Lavis, the BLRC and the stroke group programme is
included at this point.
1.3 The community of Bishop Lavis

Bishop Lavis was founded in the early nineteen hundreds by Bishop Sidney Warren Lavis, in an
attempt to raise the poor standard of living amongst ‘coloured’ people of the Cape Peninsula. It is
situated approximately twenty kilometres from central Cape Town, in the Western Cape Province
of South Africa. Bishop Lavis is a densely populated, urban area – home to 23 737 people. Of
these, 98 % are so-called ‘coloured’ and two percent are ‘black’ Africans. Afrikaans is the mother
tongue of ninety percent of the population, with nine percent of the remainder speaking English as a
2
home language, and one percent speaking Xhosa. Bishop Lavis has a youthful population, with a
mean age of 24 years.11
Only 66 % of the economically active population (aged 15 to 65 years) of this community are
employed. Approximately half of these (54 %) earn R0 - R1600 per month, thus less than the
household subsistence level of R2 000 per month.12 The dominant types of occupation in Bishop
Lavis are those classified as elementary occupations, e.g. machine operators and assemblers, craft
and related trades workers, and clerks. Of those unemployed, only seven percent report to be so by
choice. Of the remaining unemployed, 15 % are unable to find work and 12 % are ill or disabled.11
In general, education levels in Bishop Lavis are fairly low, with only one percent of the population
having tertiary education. A fair proportion (41 %) of the adult population has some secondary
school education and six percent have no formal schooling at all.11
Extended families tend to live together in this community. Bishop Lavis is classified as a public
housing area within the Cape Metropole, which means it is an area consisting mostly of council-
built housing.12 More than ninety percent of these households have access to flushing toilets,
running water, and lighting by means of electricity. Most (70 %) of the houses are brick, built on a
separate stand or yard.12 Public transport is provided by the Golden Arrow bus company, Metrorail
train services and minibus taxis. The vast majority of the community does not have access to
private transport, and many cannot afford to use public transport. Walking therefore remains a very
common mode of transport.12 The researcher has heard many complaints from clients of the centre
regarding the inaccessibility of transport systems, as well as the unsuitability of roads and kerbs for
people with disabilities. Furthermore, the researcher has observed that there are no elevators in
place at the local train station and there are high steps into buses and taxis. The local roads and
kerbs are in a state of disrepair, with potholes and poor drainage in many areas. There is also sand
and gravel surfacing in some areas of the community. Rainwater has been observed to flood the
roads and entranceways to some of the houses.
The community is plagued by gangsterism and drug abuse, with a high rate of violent crime (seven
murders per 10 000).11
Resources in the community include: a day hospital, maternity unit, library, police station, sports
centre, two old age homes, a day centre for the elderly, eleven primary schools, three high schools,
various pre-primary schools and crèches, Lifeline counselling services, a youth centre,
Communicare social work agency, various churches and mosques, Meals on Wheels, The Caring
3
Network home-based caring agency, as well as the BLRC. A shopping area is located centrally in
Bishop Lavis, which includes a grocery store, hardware store, clothing store, pharmacy, butchery,
fruit and vegetable market, post office as well as various smaller, specialist stores. The shopping
area has been observed to be accessible by the researcher. This observation is supported by the
regular sight of wheelchair and assistive device users utilising the area.
The BLCHC is a PHC facility catering for the basic health needs of this community. It operates on
weekdays for eight hours a day. The service includes dentistry, psychiatry, social work, a
children’s clinic and a 24-hour maternity unit, in addition to general practitioner services. There
are a number of private general practitioners in the area, but no private therapists. The BLRC,
which provides rehabilitation to the Bishop Lavis community, forms a part of the services of the
BLCHC.
1.4 The Bishop Lavis Rehabilitation Centre

1.4.1 Introduction
The BLRC provides occupational therapy, physiotherapy as well as speech and language therapy to
the community of Bishop Lavis and its surrounds. It was opened in January 1994 as an academic
PHC centre, and is a joint venture between the University of Stellenbosch, the Provincial
Administration of the Western Cape, and the Bishop Lavis local authority. The BLRC functions as
an ambulatory, out-patient unit, which operates for eight hours a day, five days a week. The project
was developed with two aims in mind: to provide a comprehensive therapy service to the Bishop
Lavis community, and to provide students of Stellenbosch University opportunities to gain
experience in primary health care. The BLRC forms a part of the BLCHC. Although the BLRC
occupies separate premises and is a joint project between the various parties, described above,
service delivery is directly linked to the BLCHC. The staff of the BLRC functions as part of the
BLCHC team, attending regular management and staff meetings, as well as making referrals to and
accepting referrals from this establishment.
The current aims of the BLRC, as stated in the 2004 annual report,13 are:
To provide therapeutic, rehabilitative and maintenance programmes for all ages of clients,
both individually and in group settings
To implement health promotion and preventative strategies
To empower the community
To enhance therapy services
4
An interdisciplinary teamwork approach is followed during rehabilitation. The core team consists
of the patient, his or her family, an occupational therapist, a physiotherapist as well as a speech and
language therapy student. The expanded team consists of the following members, who are based at
the BLCHC: doctor, nurse, dietician, pharmacist, radiographer, sonographer, orthopaedic sister,
psychiatric nurse, psychologist and social worker. It might also include the following community
organisations: home-based care, old age home staff, and staff of the local day centre for the elderly.
Whilst the core team operates at the BLRC, this team is expanded as necessary by inclusion of the
relevant professionals at the BLCHC by means of well-established lines of communication. For
logistical reasons, it is difficult to have all members of the team present at all meetings. The
professional members of the core team meet weekly to set integrated goals for new clients and
discuss progress in relation to aims relevant to each client. This is after having first clarified these
with the client and his/her family to ensure that a co-ordinated approach to treatment is adhered to.
Joint documentation is kept, with an integrated assessment form in use.
Students of the University of Stellenbosch Physiotherapy, Occupational Therapy, and Speech and
Language Therapy departments are placed at the BLRC during term times. These students form an
integral part of the team as they gain their practical experience in this setting. Students are placed
for six to ten weeks at a time, and can total twenty at any given time. The students have a positive
impact on service delivery, as they contribute to managing the caseload as well as to programme
development. On a negative front, however, the regular changing of students can be disruptive to
the formation of therapeutic relationships with clients.
Conditions that are treated at BLRC include neurological and surgical (e. g. stroke, head injury,
amputation, spinal cord injuries, burns); orthopaedic (e.g. vertebral and peripheral joint and muscle
conditions, hand injuries, fractures and sport and work related injuries.); respiratory (e.g. chronic
obstructive airway disease, pneumonia, paediatric chest conditions.); gynaecology and obstetrics
and paediatric conditions (e.g. cerebral palsy, spina bifida, developmental delay, learning
difficulties.) Clients are seen at the BLRC or at their home, as appropriate. Treatment programmes
are individualised and, thus, vary from a few days to several months. Services rendered include
management of clients on an individual basis – both at the BLRC and on home and work visits,
work ability screenings, various community outreaches and a range of group programmes. The
latter will be discussed in further detail as one of these groups forms the basis of this study.
5
There are currently eleven therapeutic group programmes running at the BLRC, which are
classified by the BLRC as curative, rehabilitative or maintenance – according to their aims and
duration. Curative groups operate as short-term, set courses, which are presented in a rolling
fashion. Each client will attend a set number of sessions covering a spectrum of education topics
related to, and exercises appropriate for their condition. After this time, clients should be in a
position to self-manage the health condition in question. Examples of curative groups are the
arthritis and back pain groups.
Rehabilitative groups operate over longer periods and, although goal orientated, do not follow as
rigid a programme as the curative groups. They provide education, appropriate exercise, and have
various other aims on a holistic level. There is a strong emphasis on socio-emotional support within
these groups. Clients attend for a period of their choice, not exceeding 18 months. The stroke
group is an example of the BLRC’s classification of a rehabilitative group. It tends toward the task
and social end of the group spectrum, having a focus on development of functional skill and social
interaction (refer to 2.4.3).
Maintenance groups are groups that were established by the BLRC, and are now operating
independently in the community with volunteer facilitation. Members of rehabilitative groups are
invited to attend maintenance groups after their discharge from the BLRC’s group programme for
the purposes of ongoing support and maintenance exercises. The move from a rehabilitative group
to a maintenance group is seen as part of the gradual withdrawal of rehabilitative input in order to
ensure community reintegration. There is no time limit for involvement in maintenance groups.
The group programme does not replace individual intervention at BLRC. All clients are assessed
individually, and an individual treatment plan is devised by the interdisciplinary team according to
personal needs. A team decision is taken to invite the client to the group programme if that client
meets the criteria for inclusion for a particular group.
In the following section, the management of the stroke client at BLRC will be discussed, and the
stroke group programme introduced.
1.4.2 Management of the stroke client

Stroke clients referred to the BLRC are usually medically stable. They are most often referred from
a CHC or a general practitioner, after having been evaluated, but not admitted to hospital post-
stroke. In some cases, clients are referred from Tygerberg Hospital (a tertiary health care facility in
the vicinity of BLRC) post-discharge. These clients tend to have been discharged as soon as they
6
are medically stable, and have seldom commenced rehabilitation. Where they have, this is usually
in the form of learning transfer techniques, positioning and basic home exercises. Referrals are also
received from the local home-based care agency, when these clients have not already been referred
by the health care facility where the diagnosis was made. Several referrals are made by family or
friends of the stroke survivor who have heard of the BLRC.
The initial assessment is carried out by the occupational therapist (OT) or physiotherapist (PT) in
the presence of the primary caregiver. Thereafter, subsequent team members build on assessment
information gathered until a treatment plan can be devised, based on a client-centred approach. The
Barthel ADL Index14 (BI) is used as tool to provide a baseline indication of a client’s level of
functioning. This index is used several times during the course of treatment to monitor progress
and identify therapeutic plateaus. This is not done on a regular basis, but rather according to the
progress of each individual.
The client will attend individual sessions with the relevant core team members who, on occasion,
combine sessions when it is to the benefit of the client. One or more home visits are carried out for
each stroke client, depending on need and available manpower. If and when the client meets the
group inclusion criteria, he or she is invited to attend the stroke group programme. The inclusion
criteria are that the client must:
Have sustained a stroke, or have another neurological condition which has resulted in
similar symptoms (e.g. traumatic brain injury)
Be medically stable or moderately stable*
Have one or more persistent disability*
Have the cognitive capacity to integrate new information*
Posses the physical endurance to sit for the duration of the group and participate actively*
Be able to manage own toileting needs, or have a carer present to assist
Have consented to inclusion
Be a client of the Bishop Lavis CHC (If not already a client when referred to the BLRC,
clients are referred to the BLCHC.)
Have been assessed by the BLRC team
Have undergone or commenced necessary individual therapy
Literature15 suggests that certain criteria (those marked with asterisks above) indicate a person’s
readiness for rehabilitation. Other of these criteria are unique to the context of the BLRC group
programme, which are subjectively judged by the therapists involved as necessary for a client to be
able to derive benefit from this fairly flexible group programme. Clients are free to discharge
7
themselves from this programme at any stage within the 18-month time frame. This approach to
group entry and exit has been chosen for its emphasis on control by the client, according to the
social model of disability (discussed in Chapter 2).
Group programme inclusion is voluntary, and supplementary to other intervention. Participation in

the stroke group can be concurrent with individual intervention where the client stands to derive
benefit from both. However, the group programme shortens the period of individual intervention at
the BLRC, and meets a range of needs that the therapists have observed are not being as effectively
addressed on an individual basis.
The stroke rehabilitation group consists of weekly sessions of one, to one and a half hours.
Attendance varies from eight to twenty two clients, with an average weekly attendance of 15 during
the study period. The group is divided into two sub-groups, which operate concurrently. One sub-
group is facilitated by an OT, and the other by a PT, or by students of these respective disciplines.
After thirty minutes, the sub-groups change over.
The aims of the group are:

Maintenance of physical abilities – range of motion, tone normalisation, balance and
endurance
Revision of home exercise programmes
Monitoring of physical status
Provision of a forum for socio-emotional support
Intellectual stimulation
Promotion of autonomy
Health education
Several of these aims are the primary focus of one group per month, which are achieved by the use
of a variety of leisure and social activities, educational methods, discussion groups, hemiplegic-
specific exercises in supine, sitting or standing; and physical games (for example, ball games and
skittles). Secondary aims are included in various sessions. These are monitoring functional status,
experience and expression of positive emotion, promoting communication, enlarging life area and
skill development.
8
After the initial one-hour programme, the sub-groups are sometimes merged for input from health
professionals or students from other disciplines, which takes the form of health education. This
includes a broad range of topics, such as depression and stroke, communication, and the indications
and side effects of medication associated with stroke. Health promotion talks do not occur every
week due to limited availability of team members. Six of these sessions were held during 2004. A
typical month planner for the group may resemble the example presented in Table 1.1.
Table 1.1 – Example of stroke group planner

Physiotherapy Occupational Therapy Other team member
Week 1 Exercise - with focus on Creative activity: Doctor
upper limb. Making thank you cards for carers Talk on prevention and
(printing and painting). management of hypertension
Week 2 Physical Games - skittles Health education: -
Stress management
Week 3 Exercise - with focus on Social: Speech and Language Therapy
lower limb. Tea and snacks with icebreakers and student:
facilitated discussion. Talk on how to interact with
people with aphasia.
Week 4 Exercise - with focus on Intellectual Stimulation: -
trunk. General knowledge quiz.
Thus, the programme aims to remain interesting by including a variety of activities, whilst
providing the security of a reliable format.
Records of the group are kept as follows:

A weekly attendance register provides statistics, which are reflected in the annual report.
Weekly sessions are planned and recorded on interdisciplinary group progress sheets
(Appendix I).
Evaluation of the group occurs by means of bi-annual client satisfaction surveys that are completed
by all clients attending the group (Appendix II). The results are analysed and included in the BLRC
annual report. Suggestions are incorporated as far as possible in year planning.
1.5 Research problem

Group therapy is by no means a new concept. Traditionally used in the field of mental health, it is
now increasingly being utilised within South African health systems. Of concern is the significant
lack of literature in existence to substantiate it within the field of physical rehabilitation.
Furthermore, in the South African context, there is no evidence of a published model for group
9
work that can be implemented to facilitate physically disabled clients through the rehabilitation
process to the level of community reintegration. It seems that groups are being used to decrease
cost of intervention and maximise therapists’ coverage, amongst other reasons. However, without
sufficient research in this area, the validity of this intervention remains in question. Perhaps, more
significantly, a very valuable and effective method of intervention is being overlooked for lack of
knowledge. Given the apparent advantages of group work in other settings, it would seem sapient
to research this approach in physical rehabilitation as well.
The BLRC group programme is an example of a group programme for physical and psychosocial
rehabilitation (refer to 1.4) that was developed in order to maximise the use of resources. The
programme is perceived to have a positive impact on participants and is assisting the involved
therapists to cope with the heavy caseload. However, this group programme has never been
formally researched.
There are several issues around this programme that warrant investigation. For example, the
researcher has observed that some members attend inconsistently. What distinguishes clients
making use of this service from those declining it? Are the aims and objectives relevant for the
community and users of the programme? Are activities of the programme appropriate and
acceptable? What meaning does the programme hold for users? What effect do they perceive the
group to have on their post-stroke recovery – physical and psychosocial? And, what effect does it
actually have on an objective level, as measured by an objective outcome measure? Are these
effects similar?
With such a range and number of questions it was necessary to limit the scope of this study to
manageable proportions. The researcher focussed on the issue of the participants’ experience of the
group programme as a starting point to evaluating the effectiveness of the group, and its place in
stroke rehabilitation. It is, after all, the service-user that one has in mind in developing the service
of rehabilitation. This makes the concept of satisfaction with a programme central.
Understanding a client’s experience of a programme can provide a starting point for gauging that
client’s satisfaction with the programme, and goes a long way to answering questions of
effectiveness relating to that programme, as this underlies many issues around how and why a
service is utilised. The satisfied client is likely to further utilise a service, and s/he may refer others
to it. A study of client satisfaction will help to identify aspects of the programme that are perceived
to be helpful and enjoyable, and which not. It will also assist in measuring whether or not the aims
of the group are being achieved. In the case of the BLRC group programme, the issue of client
10
satisfaction is central to understanding why stroke survivors attend and the meaning that group
involvement holds for them.
The BLRC group programme was developed based on available literature of best practice,16
experience of the therapists involved, and feedback from the clients included in the programme.
But, the lack of research regarding the group programme leaves an ethical question as to the
appropriateness of its use. If the use of the group programme as part of the rehabilitation of stroke
survivors in Bishop Lavis is to continue, the responsible team must ask: Does the BLRC stroke
group programme have a valid role to play in physical and psychosocial rehabilitation of the stroke
client? This necessitates gaining an understanding of the experiences of stroke group participants
relating to their participation in the stroke group.
1.6 Motivation for and significance of the study

South Africa’s National Rehabilitation Policy17 emphasises the need to develop accessible and
affordable rehabilitative services that are feasible within current manpower and other resource
limitation. This policy highlights the need to strengthen community rehabilitation services and
maximise use of available resources. A potential method of maximising resources is to make use of
therapeutic groups for the purposes of rehabilitation.
There are many centres in South Africa that offer group programmes in physical rehabilitation.
One of them is the BLRC, discussed above, where the researcher is currently employed as the
occupational therapist.
However, many questions remain unanswered regarding therapeutic groups in rehabilitation. For
example: How do group programmes impact the user? What type of client stands to derive the
most benefit? What resources are required for the effective use of such a group? What factors draw
or repel users from group programmes, or influence compliance? What is the ideal format for such
a group? Who should be included or excluded from a therapeutic group programme? This study
attempts to answer a few of these questions by exploring the meaning that stroke group involvement
has to participants, and examining the factors that influence attendance of the group.
The staff of the BLRC perceive the groups to be having a positive effect on participants – both in
terms of their physical recovery, and on their general motivation and well being. The staff feels that
time is better utilised – and therapy enhanced – by the inclusion of clients meeting the inclusion
criteria for the group programme (refer to 1.4.2) into groups. This observation has, however, not
been formally researched until now.
11
The stroke group was selected for this study, as stroke is a prime example of a condition with
lasting impairment, and resulting disability, that requires rehabilitation. Stroke rehabilitation is
interdisciplinary by its nature, and is topical in South Africa, considering that stroke has been
labelled the most disabling chronic disease18 and the third leading cause of death in this country.19
It is of particular significance for Bishop Lavis, given that stroke is the most common cause of
physical disability in this community.20
There are various treatment approaches to stroke, as discussed in Chapter 2. This study, however,
aims to explore some of the issues around group therapy in stroke rehabilitation by describing the
range of experiences relating to attendance or non-attendance of stroke survivors referred to the
stroke group programme of the BLRC. This includes the meaning that stroke group participation
has to those who attend, factors that affect attendance as well as aspects of the programme that
members of the group find enjoyable or not enjoyable. Information gained through the study will,
therefore, provide feedback regarding the suitability of the programme developed for the clients in
question.
On a micro-scale, this study will contribute to maximising the rehabilitative potential of the stroke
group programme at the BLRC. On a larger scale, a critical analysis of the stroke group programme
will provide a baseline for the development and piloting of stroke and other rehabilitative group
programmes in other settings. This would be of use to other PHC establishments in South Africa,
particularly those serving areas with similar demographics. This potential use leaves significant
scope for further study, and could lead towards establishing a group programme that can be piloted
in more diverse contexts within South Africa, in order to begin the development of a model for
rehabilitative group work. Furthermore, the BLRC is a unique setting in the sense that it operates as
a partnership between the University of Stellenbosch, provincial government and the community of
Bishop Lavis. Lessons learnt from this study will thus be useful in contributing to an evaluation of
this partnership, and to issues raised in future discussions regarding the sustainability of the project.
1.7 Summary of Chapter 1

Within the context of South Africa as a developing nation, there is a significant burden to provide
effective health care with limited resources. The movement of resources for rehabilitation in South
Africa is in the direction of CBR, with the emphasis remaining on individual intervention. It seems
that group work, whilst overcoming cost implications of individual intervention, would be useful in
addressing certain aspects of rehabilitation, although little published evidence exists to substantiate
it within the field of physical rehabilitation.
12
Chapter 2
LITERATURE REVIEW
2.1 Introduction
This chapter provides the reader with a literary context relating to the study question. It gives an
overview of rehabilitation in order to set the scene for the topic of rehabilitation within the South
African milieu in general, and stroke rehabilitation in particular. The chapter is concluded with a
discussion on therapeutic groups and their role in physical rehabilitation.
2.2 Rehabilitation - an overview

2.2.1 Introduction
The Integrated National Disability Strategy5 of South Africa defines rehabilitation as “ways of
helping people with disabilities to become fully participating members of society, with access to all
the benefits and opportunities of that society”. It is a holistic and ongoing process, which ends only
once the individual has fully reintegrated into his society. Rehabilitation has also been described as
“planned withdrawal of support”.21 These definitions imply a graded process of support for
individuals with an impairment of any sort, to a point at which that individual has achieved
satisfaction with his or her ability to participate and fulfil his or her life roles.
The above definitions subscribe to the social model of disability, which sees disablement as a form
of social oppression, rather than as a disease state, as is the case with the medical model of
disability.22 The social model emphasises independence in terms of the degree of control that the
individual has over his or her life. It is on the basis of the social model that the holistic field of
interdisciplinary teamwork rests.
Team-work in rehabilitation is gaining increasing popularity. The rehabilitation team arises from
the compromise between specialisation of disciplines and the need for a comprehensive approach to
care when managing chronic illnesses.23 There are various teamwork approaches, the most popular
in rehabilitation being the multi-disciplinary and the interdisciplinary approaches. The
interdisciplinary team approach, as is followed at BLRC, brings together members that specialise in
different areas of rehabilitative care. It is characterised by regular communication and the
establishment of common goals.2 Theoretically, by integrating the different aspects of rehabilitative
care, the team can create better treatment outcomes for its clients. A literature review by Halstead,
13
which was cited by Lubkin and Larsen,2 concluded that team care resulted in better control of
chronic illnesses, and less deterioration in clients with chronic illnesses. As a disadvantage,
however, the same review found that team care also resulted in increased utilisation of health
services at higher cost.
Rehabilitation can be categorised into: a) interventions aiming to reduce physical disability; and b)
interventions aiming to reduce psychological and social problems.24 As discussed in 1.4, the stroke
group programme at BLRC aims to address both these aspects of rehabilitation. Neither of these
areas should be neglected when aiming to provide a holistic programme. Reduction of the physical
aspects of disability can include treatment of problems related to components of function – for
example, muscle strength, range of motion and sensory retraining. It could also mean the provision
of assistive devices or changes to the physical environment. The aspects of rehabilitation aiming to
reduce psychological and social problems are slightly more difficult to define, and are the areas that
have traditionally received less attention during the rehabilitation process.22 These are, for
example, the adjustment to altered life roles, loss of self esteem, and community reintegration. This
aspect of rehabilitation, by its nature, involves a variety of role players.25
A key aspect of rehabilitation is, in fact, the inclusion of stakeholders other than the client and the
professional in the process. These stakeholders include, amongst others, the individual’s family as
well as the community and the account payer. Literature supports the collaboration of all persons
involved in the individual’s care in order for rehabilitation to be effective.26 The community
should retain primary responsibility for the rehabilitation process,27 given that this is where the
individual will be living and that he or she must be able to function in the community in order to
have completed his/her rehabilitation.
Community can be defined as a collection of people sharing an environment, recognisable as a

group.7 In order to be part of a community, people must have certain characteristics in common
that allow for identification – by self and by others. Often, people with disabilities feel they have
lost their ability to contribute meaningfully in their community, and no longer feel as strongly that
they have identifying links with their community.25 Members of the community can help or hinder
the rehabilitation process by removing or imposing a variety of barriers, including physical (such as
accessibility issues) or psychosocial (such as bias and ignorance).25 The community can provide a
wealth of resources for individuals recovering from a health incident, which can help to buffer the
effects of impairment or disability.15 The types of resources offered by the community can be
classified as educational, instrumental or emotional. Educational resources include health
information talks or literature. Instrumental resources include services of a practical nature – for
14
example, Meals on Wheels or home-based care. Emotional resources are those to be found, for
example, in a group of peers able to offer support.15
One way for stakeholders to influence the rehabilitation process is by participating in policy
development, from local through to national level, which determines to a large extent the face of
rehabilitation in a country. In the following section, rehabilitation policies in developing nations,
and more specifically, in South Africa, will be examined.
2.2.2 Rehabilitation policy trends in developing nations

It is estimated that global rates of disability stand at ten percent, with approximately eighty percent
of people with disabilities living in developing countries.28 Unfortunately, rehabilitation services in
developing countries are very poorly developed.4 Perhaps this is because rehabilitation has,
historically, been seen as a low priority world-wide due to the following factors:4
“Cost-benefit ratio of providing services to those with disabilities”

“Under-estimation of disabled peoples’ potential to achieve”
“Negative societal attitudes towards disability”
“Discriminatory practices”
“Absence of urgency – rehabilitation tends to focus on the chronic, non-communicable
diseases or illnesses that do not pose a risk to others”
“Interest of biomedical practitioners focuses on improvement and cure, which is not
always feasible or realistic for rehabilitation”
“Public policy is not influenced by those with disabilities as they represent a relatively
small marginalised minority.”
However, with the increased attention rehabilitation has been receiving of late, it would seem that
the relevant parties are beginning to move beyond the above factors. Strategies are now in place to
address the problem of under-developed services for people with disabilities, the most important of
which is PHC. The Alma Ata Declaration29 of 1978 was the first international declaration
underlining the importance of PHC. It highlighted the role of the community in the development
and provision of health services, emphasised the importance of inter-sectoral collaboration, and
prioritised those most in need of basic health care. The United Nations Standard Rules for the
Equalisation of Opportunities for Persons with Disabilities followed in 1992, aiming to ensure that
all people with disabilities had the same rights and obligations in their society as others.7 The
World Programme of Action was later established in 1993, outlining actions to be taken towards the
realisation of this ideal.7 The United Nations and World Health Organisation (WHO) have been
15
placing increasing emphasis on PHC and community services over the past decade, with promotion,
prevention, rehabilitation, social integration and equalisation of opportunities for people with
disabilities as key features thereof.4
Primary Health Care refers to “the first level contact with people, taking action to improve health in
a community”3 and is particularly emphasised for developing nations. It focuses on:4
“Maximum use of local resources, including traditional healers and trained community
health workers”
“Participation of the individual and the community”
“Affordable and accessible care”
“Integration of prevention, promotion, - treatment and rehabilitation”
“Co-ordination between the health care sector and other aspects of society, such as
housing and education.”
A term strongly associated with PHC is CBR. Community-based rehabilitation was formalised in
1976 by the WHO as a model for provision of essential services and training for people with
disabilities as part of the ‘Health for All’ campaign.1 A United Nations joint position paper1 defines
CBR as follows: “CBR is a strategy within community development for the rehabilitation,
equalisation of opportunities and social integration of all people with disabilities. CBR is
implemented through the combined efforts of people with disabilities themselves, their families and
communities and the appropriate health, education, vocational and social services.” It is a client,
rather than professional, centred service.4 The ultimate aim of this approach is to integrate people
with disabilities into their society.30 PHC and CBR are inherently linked, as they share many of
their original principles.1 It is not difficult to see how these strategies could be used together to
optimise rehabilitation.
Both PHC and CBR seem ideal solutions to the problems associated with provision of rehabilitative
services in developing nations. There has, however, also been criticism. Both PHC and CBR have
been accused of falling short of the ideal by using a top-down approach to gain compliance, rather
than emphasising the importance of community participation, as is theoretically key.31
South Africa is striving towards the effective use of the systems of PHC and CBR. In the next
section, the researcher will discuss health care and rehabilitation in South Africa in more depth.
16
2.2.3 Health Care and Rehabilitation in South Africa
At present, a two-tiered system of health provision exists in South Africa – the private and the
public systems. Richer households tend to make use of private health care, whilst poorer
households depend on public services. In 2003/2004, private care was provided by 66 % of South
Africa’s physicians to only 18 % of the population, totalling sixty percent of the health expenditure
within the country.8 The remaining resources were allocated to public health. For the purposes of
this study, the public health system will be examined more closely.
Public health care in South Africa has been faced with many challenges and has undergone radical
change over the past years. In 2000, the World Health Report ranked the South African health care
system as 175th in overall performance and 182nd in efficiency amongst 191 countries.32 This is
not a positive reflection. The Western Cape Province now, however, has a long-term, strategic plan
in place, entitled Health Care 2010.9 A key aspect of this plan is to develop primary-level services,
community-based care and preventative care. The desired outcome of this is to improve the quality
of health care, as well as to bring health expenditure within sustainable limits. The plan aims to
have 89 % of acute health care contacts and 99.5 % of chronic contacts at community level by the
year 2010, provided closest to where the individual resides. The plan aims to ensure that no person
in the Cape Metropole has to travel more than five kilometres to access their nearest PHC facility.
The other two levels of health care provision are mentioned briefly, as they are not the focus of this
study, nor of the province’s health plan. Secondary health care is defined as “specialised
ambulatory medical services and commonplace hospital care (out-patient and in-patient services),
not including highly specialised, technical inpatient medical services”.3 Tertiary health care refers
to “medical and related services of high complexity and usually high cost.”3
South Africa’s national budget demonstrates commitment to the change in focus of the country's
health care. There has been a significant increase in allocation to health over the past years.33 In
2003/2004, 11 % of the Gross National Product was allocated to public health services, catering for
82 % of the population.34 The previous total of health expenditure was increased by a further 11 %,
bringing the total to R9, 825 billion for 2005/6. This figure is projected to increase further still.
This understood, South Africa has some way to go to meet the standards of health care in developed
nations.32 It must be acknowledged that South Africa is a developing nation, and therefore
comprises largely of disadvantaged settings. Models of health care must take cognisance of this
reality. In such settings, innovative intervention strategies are required to compensate for limited
resources.35
17
Rehabilitation forms part of PHC, which means that, in line with Health Care 2010, rehabilitation
services in the Western Cape should be developed. For this development to be effective, models
and methods of rehabilitation must be established – and these proven to be appropriate, necessary
and accessible.35 These requirements necessitate research in this field.
There are several established settings for rehabilitation, including varieties of both in-patient and
out-patient settings. The move towards PHC in South Africa, however, places increasing emphasis
on out-patient rehabilitation over in-patient rehabilitation. Out-patient rehabilitation is often in the
form of home-based or community-based services.36
Home-based rehabilitation is rehabilitation occurring in the patient’s home environment. This form
of rehabilitation has been shown to be feasible and acceptable to patients and their caregivers, and is
now generally accepted as routine care.37
Community-based care is defined as “care that a consumer can access nearest to his home, which
encourages participation by people, responds to the needs of people, encourages traditional
community life and creates responsibility.”36 Community rehabilitation services are usually linked
to CHC within South Africa. These provide out-patient rehabilitation to individuals and serve as
the link between hospital discharge and full community reintegration. A major advantage of this
setting is that it can assist individuals and their families through the process of rehabilitation,
without the high cost of hospital care.15 This is much the same as for home-based care, but
community health centres, theoretically, have added advantages for rehabilitation – such as access
to an interdisciplinary team, availability of equipment and the opportunity for peer support.15 Due
to manpower limitations, the concept of the interdisciplinary team is unfortunately under-developed
in many of these settings.
Rehabilitation services at PHC level, such as the service provided by the BLRC, cover the entire
spectrum of disability prevention from primary to tertiary. Primary prevention consists of
“measures to prevent diseases, injuries, or conditions that can result in impairments or
disabilities”.38 This includes services such as health education of relevance to the field of
rehabilitation. Primary level prevention is particularly important for the Western Cape, which has
high rates of modifiable lifestyle risk factors, as well as biological risk factors for stroke and other
vascular diseases. Twenty six percent of the province’s population is overweight, and a further
31% are obese. The Western Cape has the highest provincial rates of hypertension, heart attack,
high cholesterol levels, diabetes, asthma and arthritis.39
18
Secondary prevention consists of “early intervention in the treatment of diseases, injuries, or
conditions to prevent development of impairments”.38 Whilst this type of intervention is most often
initiated elsewhere, it is usually followed up within the PHC system.38 It includes services such as
mobilisation post fracture to prevent contracture formation, or lifestyle modification programmes
for hypertensive and diabetic patients.
Tertiary level prevention interventions are “measures to limit or reduce impairments or

disabilities”.38 These also include the treatment of disabilities, and therefore rehabilitation.
Whilst rehabilitation within PHC has a role to play at each of these levels, the results of health
promotion and disability prevention are often intangible, and in the context of South Africa’s
limited economic resources, competition is strong for adequate funding for such programmes.27
What type of intervention can realistically be offered within the context of limited resources of a
developing nation? It would seem as if traditional individual therapy, whilst it has its definite
advantages and uses, cannot be considered to be adequate as the only form of intervention offered
in the context of rehabilitation at the primary level.
This study examines therapeutic groups, and specifically rehabilitative groups, as a supplementary
approach to out-patient rehabilitation at PHC level, addressing primary, secondary as well as
tertiary disability prevention needs. Therapeutic groups are utilised in the management of a variety
of physical conditions. This study will focus on stroke group therapy, as stroke is a complex
condition that requires input on multiple levels.
2.3 Stroke
2.3.1 Introduction
As mentioned in Chapter 1, stroke is a prime example of a condition requiring rehabilitation, given
that it has been classified as the most disabling chronic disease world-wide.18 Literature reveals
that it is the third most common cause of death in South Africa.19 In 2004, 5.6 % of deaths within
the district in question in this study (Western District of the Cape Metropole), were due to stroke,
making it the third highest cause of death in the district after ill-defined/unknown causes and
ischaemic heart disease.40 In South Africa, the highest incidence of stroke is amongst the so-called
‘coloured’ and Asian population groups41 and, unlike the world incidence, occurs fatally to a similar
extent in men and women, with a 30 % higher incidence in men.19 Up to 72 % of those sustaining
stroke in sub-Saharan Africa have low-socio-economic backgrounds.42 With advances in health
care, the incidence of fatal stroke is decreasing, leaving an increasing number of individuals
returning to the community in need of rehabilitation.43
19
According to South Africa’s National Guideline on Stroke and Transient Ischaemic Attack
Management,41 non-modifiable risk factors for stroke are age (incidence doubling for each decade
over 50), gender and race. Modifiable risk factors include hypertension, diabetes mellitus,
smoking, alcohol use, atheroma, hypercholesterolaemia, heart disease and atrial fibrillation.
Currently, there are an estimated six million hypertensive people, seven million smokers and three
to four million people diagnosed with diabetes mellitus who are at increased risk of sustaining a
stroke in South Africa.41 In Bishop Lavis, stroke patients have an average of 2.4 of these risk
factors at the time they sustain their first stroke.20 A review of literature revealed that there is
generally under-diagnosis and poor control of these modifiable risk factors in sub-Saharan Africa.42
Primary prevention of stroke can be achieved by addressing the modifiable risk factors mentioned
above, and by having early detection mechanisms in place. Secondary prevention strategies are
employed after a vascular event has occurred, and involve identifying and treating the causes and
risk factors leading to that event, as well as treatments aimed at limiting the extent of the
impairment. This aims to prevent a second stroke, which most often results in severe impairment.
Tertiary prevention consists largely of rehabilitation41 and limiting the extent of disability.
Those who suffer a stroke are likely to experience a wide and varied pattern of impairment – from
physical and functional, to emotional and cognitive. Obvious deficits include hemiplegia,
incontinence, as well as perceptual, sensory, and language disturbances, cognitive loss and
swallowing difficulties.41 Depression, decline in leisure and religious activities, and problems with
social integration have also been shown as concerns for stroke survivors.44 One study showed some
degree of depression to be present in half the respondents in a 14-year stroke survival study.44
Psychosomatic symptoms are also common, including exhaustion, stress, mental confusion, anxiety,
irritability, and dizziness when required to work fast. These psychosomatic symptoms have been
found to be more common in older than younger patients.45 The combination of the residual
symptoms of stroke make the prospects of employment bleak for many stroke survivors.25
Given the high incidence of stroke, the significance of the resulting impairment and disability, and
the impact that rehabilitation can have on stroke outcomes, it is a relevant condition to investigate
with regard to effectiveness of rehabilitation at PHC level.
20
2.3.2 Approaches to stroke rehabilitation
The Neurological Association of South Africa Stroke Working Group19 established guidelines for
stroke therapy in 2000, which state, “Rehabilitation and community care need to be evaluated in
light of currently available resources, future vision and outcome measures. A goal-orientated, time-
limited programme that enables the impaired person to reach an optimal level of mental, physical
and social functioning should be the objective of therapists.” This seems to summarise the ongoing
challenge for stroke rehabilitation.
There are currently several schools of thought in existence on stroke rehabilitation. Some of the
great names associated with stroke rehabilitation approaches include Bobath, Brunnstrom, Clayton,
Coulter, Fay, Kabat, Knott, Rood, and Voss.46 Two separate reviews46,47 revealed that none of these
approaches has been proven more effective than the others. It is, however, evident that stroke
patients benefit from rehabilitation in general, even if the improvement is sometimes statistically
small.46 Whitelaw et al.48 found significant evidence that rehabilitation improves functional
outcome in strokes, and therapy-based rehabilitation has been shown to reduce the risk of stroke
survivors’ deterioration in ability to undertake activities of daily living (ADL).24 The conclusions
of Ernst’s46 review advocate for the use of the most cost-effective rehabilitation method available in
the absence of evidence of best practice. It is also recommended that rehabilitation be commenced
as soon as possible post stroke, and continue over a longer period to prevent deterioration. At the
BLRC, rehabilitation is commenced as early as possible after referral (within two weeks) and is
sustained for as long as 18 months by means of the group programme.
A review25 of five randomized control studies showed that stroke survivors rehabilitated on
specialised stroke rehabilitation units had significantly better outcome than those rehabilitated on
general wards. This was particularly true for ambulation and self-care. Certain studies included in
this review also found significantly decreased length of hospitalisation and increased discharge
rates to own home in-patients treated in specialised stroke units. Most of the clients referred to the
BLRC have not had the opportunity for treatment in a specialised unit, with some never having
been admitted to hospital at the time of their stroke at all.
Both in-patient and out-patient rehabilitation can be beneficial to the stroke survivor, depending on
the stage of recovery and the particular circumstances of the individual. Literature25 recommends
that all stroke patients should at first be hospitalised. After the acute phase of rehabilitation has
passed (two weeks), out-patient rehabilitation becomes more appropriate if the patient can be
mobilised in the community with reasonable effort. Due to the situation of limited resources in
South Africa, this process is somewhat accelerated for stroke survivors. Home-based rehabilitation
21
is most appropriate when the client has significant logistical difficulties in accessing the
rehabilitation centre.25 Again, limited resources in this country often limit the coverage of such
services. The good news is that certain studies37,49 have shown that early discharge with home-
based rehabilitation is at least as effective as in-patient rehabilitation, and in one study,49 it was
found to be more effective in the areas of motor and functional recovery. Given the move towards
out-patient rehabilitative services, this finding is positive for South Africa.
Several guidelines on stroke management exist internationally.18 The Melbourne Declaration of the
Asia Pacific Consensus Forum on Stroke Management50 states that all stroke patients should have
access to rehabilitation by means of locally available and culturally appropriate resources. In the
context of the South African health care system, this would seem a tall order. This struggle is
recognised in the declaration. It acknowledges the inability of most developing countries to provide
ideal stroke services due to the limited resources, but states that efforts should be made to reduce
incidence of stroke, largely by means of risk factor modification. The declaration suggests that
resources should be focused on, amongst other, developing rehabilitation services. It also
emphasises the need for cost effectiveness of all aspects of stroke management, including
rehabilitation and community integration.
Despite the positive effects of rehabilitation, there is often a poor outcome following stroke. This is
possibly because the long term psychosocial needs of stroke survivors are often overlooked.37 One
study26 showed that stroke survivors, although provided with in-patient rehabilitation following the
stroke, often feel ill equipped to return to community living. This may be as a result of the lack of
social support. It has been found51 that strong social support improves outcomes in stroke patients,
particularly those with severe strokes.
The above indicates a need for an alternative type of rehabilitative input to supplement what is
currently in practice. Perhaps the incorporation of structured, interdisciplinary group work to the
rehabilitation programme can assist with more effective utilisation of resources and provide a basis
for social support outside the family. Group therapy has been shown to be a time, and therefore
cost effective method of intervention when treating the elderly. One study showed savings of
between fifteen and forty percent of therapists’ time by utilising group therapy.52 Furthermore,
groups have been shown to have many positive, curative factors resting on the basis of social
interaction and support. These factors are discussed in the following section.
22
2.4 Therapeutic groups
2.4.1 Introduction
It is within groups, both informal and formal, that we develop our sense of identity, establish roles
and learn who we are.53 Groups can be said to be the building blocks of society – each group
sharing an identity and common objectives, and forming part of the greater whole. Thus, none of us
is a stranger to groups. If groups are this fundamental to our existence, what is it that sets
therapeutic groups aside from other groups and requires them to be researched and developed?
2.4.2 Curative factors of therapeutic groups

The founder of group psychotherapy for health is accepted to be Joseph Henry Pratt, an internist,
who started a treatment group for tuberculosis patients in 1905.53 Since then, group work has
traditionally been used in the field of mental health, but research is increasingly showing its
effectiveness in other fields.54
Yalom (1985)54 is largely responsible for laying the foundation for current therapeutic groups. He
established 11 curative factors of group therapy, which he defines as “guided human experiences”.
These factors are described in the sub-points below. The impact that a stroke has on the individual
in each of these areas is also highlighted. However, since there is a notable lack of literature of the
role that group therapy can play in stroke rehabilitation, no conclusions can be drawn. The
researcher intends to compare the results of the study to these factors in order to ascertain whether
the participants of the BLRC stroke group programme experienced similar phenomena on a
psychosocial level as a result of their group participation.
2.4.2.1 Instillation of hope

Instillation of hope is the first phenomenon that patients experience in a group, because members of
a group with common experiences act as inspiration for each other.53 Instillation of hope is a major
contributor to effective healing,55 as it enables the individual to conceptualise a way forward in the
face of major loss. It is this factor that maintains an individual’s involvement with therapy in order
for other interventions to occur.54
The acute loss of function associated with stroke is very traumatic. For stroke survivors facing this
loss, the idea of future meaningfulness in life is exceptionally important.56 Motivation and hope
have, in fact, been described as “critical to post-stroke recovery”.57
23
2.4.2.2 Universality
Universality is the phenomenon whereby members of a group find they are not alone with their
problems.53 The group setting provides members with the opportunity to disclose their experiences,
feelings and perceptions in a safe environment.53 They find acceptance and support within a
group,54 which leads them to continue to risk disclosure, leading ultimately to trust.58
It has been found useful for medical patients to realise, within groups, that they are not alone with
their medical issues,59 as being part of a group can be a good way of inspiring adjustment to
changes in health status.53 A stroke results in dramatic, unforeseen changes in one’s life, including
lasting impairment and disability which are fairly unique to stroke survival.56 One author53 reports
that stroke patients would often share their experiences of the stroke within groups for the elderly,
thereby experiencing the phenomenon of universality.
2.4.2.3 Imparting information

Information imparted in groups can relate to diagnosis, or be advice from other group members or
the therapist. Learning in a group context can occur either formally, by means of lectures, or
informally as members share their experiences with each other.53 Whilst individual intervention
can be effective for formal education, it does not provide a forum for informal learning.
Literature supports that education is crucial to successful outcome in stroke survivors.57 As

mentioned previously, stroke is most often related to chronic diseases of lifestyle.41 Lifestyle
adaptation is, therefore, required to reduce the risk of further strokes and subsequent disability. In
addition to this, stroke patients are at risk of developing spasticity and contractures,57 and require
education regarding the prevention thereof. Stroke survivors also have the need to be educated in
compensatory strategies for the execution of certain ADL.60
2.4.2.4 Altruism
Altruism is “the practice of placing others before oneself”.7 A group setting provides various
opportunities for one to be of service to others – from provision of advice, to practical assistance.
Within groups, self-esteem is boosted by these altruistic acts of members giving of themselves, and
therefore being important to others.53 Altruism is a significant contributor to morale, which is a
strong indicator for rehabilitation. Morale can be defined as one having a “feeling of having
attained something in his life, of being useful now, and thinking of himself as an adequate
person.”56
24
The loss of function and role-fulfilment associated with stroke can lead to a loss of self-esteem and
morale,60 which must be addressed as part of the rehabilitation process. The need for the
experience of altruism is particularly strong for those who consider themselves a burden to others,
with nothing of value to offer.54 As stroke survivors have been reported to feel this way,25 altruism
can be considered an important factor for them.
2.4.2.5 Corrective recapitulation of the primary family group

Yalom54 states that group processes can simulate the original group each of us was exposed to,
namely, the family. Group members explore their reactions to each other so as to repeat or heal
past experiences of family interactions.
2.4.2.6 Development of socialising techniques

This factor is inherent to all groups as members learn and practice social skills, and provide
feedback for each other.53 Within the safety of a group setting, members are required and
encouraged to communicate, which aids in the development of socialising skills.
Stroke is associated with communication difficulty – whether this be as a result of expressive or

receptive dysphasia, facial muscle tone abnormalities or loss of confidence. In fact, communication
difficulty may occur in as many as forty percent of stroke survivors.57 The loss of speech
associated with stroke has a profoundly negative effect on one’s sense of self.25 Non-verbal aspects
of communication may also be affected by hemiparesis associated with stroke,60 and loss of self
esteem associated with stroke may negatively affects one’s ability and desire to communicate.25
The goal of rehabilitation in this regard is to facilitate the recovery of communication by various
methods, including assisting patients to develop compensatory strategies, as well as counselling and
educating people in the patient’s environment to facilitate communication and to decrease
isolation.57
2.4.2.7 Imitative behaviours

Group members model each other and the leader, which is desirable for learning adaptive
behaviour.54 Positive behaviour within groups is encouraged by the leader, and this positive
reinforcement may illicit similar behaviour in others.
25
2.4.2.8 Interpersonal learning
Groups help members to self-reflect on their behaviour, relationships and emotions.53 Elderly
people, in particular, tend to become socially isolated, and these individuals benefit greatly from the
social aspects of group participation.53 This is because groups provide what is often the only forum
for essential feedback about interpersonal skills for socially isolated individuals. This should, then,
also be a consideration for stroke survivors who tend to be elderly, and are known to experience
social isolation in many cases.51
2.4.2.9 Group cohesiveness

Cohesion refers to “the degree of connectedness and closeness members feel toward each other and
the value they place on the group”.53 Several authors identify cohesiveness in a group by the “we-
feeling” – that is, the use of the pronoun ‘we’ in group dialogue.53 A cohesive group is
characterised by trust, warmth, loyalty and sense of belonging. This creates an environment where
self-disclosure is encouraged and risk-taking, in the form of new behaviour, is enabled.53 A study
by Dickoff and Larsin, cited by Finlay,53 reported over fifty percent of group psychotherapy
participants found mutual support to be the most useful aspect of the group. She also reports that
members are more inclined to express themselves in an atmosphere of acceptance.
2.4.2.10 Catharsis
Within groups, members learn how to express their feelings freely.53 Catharsis is used within the
field of psychology to relieve tension and anxiety by bringing repressed feelings and fears to
consciousness.7 This can be by means of activities used in the group context, or by interacting with
others who are experiencing and expressing emotion.54
It is very common for stroke survivors to experience periods of emotionalism,57 whether this be as a
residual symptom of the stroke, or associated with the extreme sense of loss following stroke.
Depression is a common consequence of stroke,61 occurring in an estimated 25 % to 75 % of stroke
survivors.57 Anxiety is another factor seen in those surviving strokes, often co-existing with
depression.57 The loss of roles associated with stroke has also been found to cause significant
emotional distress.56
26
2.4.2.11 Existential factors
Members of a group begin to recognise philosophical aspects of the group.53 Stroke suffers are
often confronted with their own mortality by virtue of the fact that they have sustained a major
health incident.62 They struggle with issues such as life and death, fate and future, meaning and
meaninglessness. They are further confronted by this when members of the group pass away, often
due to a subsequent stroke. The group context can be a valuable forum in which members can
express their thoughts and fears relating to mortality and other aspects of philosophy.53
2.4.2.12 Impact of curative factors

Kriegsman and Cellota10 summarised the effectiveness of group work in its role of enabling
individuals to gain information, reduce anxiety, acquire specialised training, fulfil their need to
share and feel supported, overcome dependency and guilt, increase self-esteem, accept change,
learn new behaviours and set new, more realistic goals. Many of these agree with the factors
described by Yalom.54
The impact of therapeutic groups holds a challenge for evaluation. Not all factors are always
acknowledged by participants as having contributed to their recovery. Yalom54 states that when
patients evaluate the effects of the above curative factors on their well being, they tend to focus on
the obvious and superficial factors – and are often not even aware of the deeper healing factors that
are in place. One long term study, cited by Yalom,54 stated that subjects are more likely to
comment on the negative aspects of the group experience when interviewed four years after
completion of treatment than they are immediately after completion of treatment. He also reminds
the reader that the importance of the experiences of group work cannot be generalised, as each
person places their own value on their experiences.
2.4.3 Types of therapeutic groups

There is a wide range of therapeutic group types to suit the particular needs of the target group.
Finlay53 identified four types of groups that are used therapeutically in occupational therapy. She
arranged these on a continuum. On the one end, she placed the individual, end product focussed
group. On the other, she placed the group, and group process, focussed group. The main elements
on this continuum are task, social, communication and psychotherapy. These types of groups are
not mutually exclusive, but rather represent a shifting balance of focus, depending on therapeutic
need. The focus of each of these groups is discussed below.
27
2.4.3.1 Task groups
The purpose of a task group is to develop task and functional skill. In these groups, members talk
about a task, make decisions and problem-solve together. The ‘doing’ element is essential, and
there is most often an end product involved. Leisure activities are an important element of task
groups,53 with typical activities including craft activities or gardening.
Task-focused interventions are often characteristic of stroke rehabilitation, given that training in
self-care and leisure activities are two of the three most frequently chosen occupational therapy
interventions for stroke patients, along with provision of assistive devices.63 Stroke survivors have
significant need to develop functional skills lost, and to learn new skills in order to compensate for
areas of loss.60 These skills include the underlying components of function needed to perform the
task. (An example might be improving bilateral hand function in order to tie shoelaces.) Exercise
can also be considered as a leisure activity for a task for a group.53 Structured, progressive
exercises have been shown to have gains beyond those attributable to spontaneous recovery in
stroke survivors. These gains included improved endurance, balance, mobility motor control,
strength, upper-extremity use, and aerobic capacity.64
Literature reveals that participation in leisure activity is closely related to health status and quality
of life for stroke survivors, and can provide motivation for resuming an active lifestyle.57 Given
that leisure activities are often the focus of task groups, it seems likely that task groups would be
useful in stroke rehabilitation.
Task groups may also be useful for fulfilling Yalom’s54 curative group factor of imparting
information. Rickheim et al.,65 in their study regarding group education for diabetes sufferers,
provided evidence of its effectiveness.
2.4.3.2 Social groups

The purpose of social groups is to provide opportunities for participants to experience social
interaction and develop leisure interests. This is achieved by structuring group sessions in such a
way as to allow members to experience social interaction they might otherwise lack the opportunity
for.53 Social groups are characterised by informal chatting and sharing of feelings. Leisure
activities often serve as a medium for this interaction in groups,53 with typical activities including
playing Bingo and having newspaper discussions.
This type of group might be best used to evoke the curative factors of interpersonal learning,
imitative behaviour and development of socialising techniques, discussed under 2.3.2.
28
2.4.3.3 Communication groups
Communication groups provide a context for people with similar problems, conditions or concerns
to give and receive support,54 and provide an opportunity for mutual sharing.53 This type of group
can include, for example, gender-specific support groups, art groups and social skills training.
Social support, which is based on interaction with others, is an important need for stroke survivors,
shown to be inadequately met by existing researched rehabilitative programmes.51 Inadequate
social support is as much of a health risk as many common lifestyle factors (such as smoking,
obesity and lack of physical activity).66 As inadequate social support increases the risk of
subsequent stroke in stroke survivors, it should be addressed.
Communication groups would seem suited to promote the curative factors of group cohesiveness
and interpersonal learning, as discussed in 2.3.2.
2.4.3.4 Psychosocial groups

Psychosocial groups provide the opportunity for participants to express and explore their feelings,
and assist them in developing insight into their problems.53 This style of group provides a setting
for catharsis, mentioned in 2.3.2. It also encourages group cohesiveness and gives the opportunity
for members to explore existential issues. It may contribute to the instillation of hope, as members
share their experiences and encourage each other. This is promoted by universality, as members
share common experiences relating to stroke recovery.53
2.4.4 Characteristics of therapeutic groups

2.4.4.1 Size
There is no ideal size for a therapeutic group,52 given that groups vary so widely in function. Group
size will depend largely on the availability of leaders, space and resources, as well as the aims of
the group.67 It is suggested, however, that closed, therapeutic groups function best with seven or
eight members, with an acceptable membership range of five to ten.54 Groups, with participant
numbers between two and twenty, were found to be effective in diabetes education by Rickheim, et
al.65
29
The advantages and disadvantages of large and small groups, according to Finlay,53 are outlined in
table 2.1, as follows:
Table 2.1 - Advantages and disadvantages of smaller versus larger groups53

Advantages Disadvantages
The smaller the Easier for members to contribute Groups can become too ‘stuck’,
group Greater intimacy and depth norms and roles too established
Safer, less threatening and more Pressure on members who wish to be
predictable more passive
Less resources and energies to draw
The larger the group More energy, resources and creativity to Less freedom for expression
draw on More member under-involvement
Diversity of people and experiences Higher numbers can be anxiety
May be efficient use of time provoking and intimidating
Greater danger of cliques forming
2.4.4.2 Member selection

A guideline for selection of group members leans towards homogeneity, as members have more
opportunities for solving common problems, and higher likelihood of cohesiveness.53 It is also
important to consider whether membership should be open or closed. The advantages and
disadvantages of open and closed groups, according to Finlay,53 are stated in table 2.2 as follows:
TABLE 2.2 - Advantages and disadvantages of open and closed groups53

Advantages Disadvantages
Open group More practical for certain settings Unpredictable membership makes it hard to
Greater variety of resources available plan and to target treatment specifically for
with new members providing individuals in advance
stimulation Relationships more superficial with less group
Group can operate with fluctuating cohesion and trust, less intimacy, disclosure
attendance Sub-groups/cliques can form making it
Opportunity to work on issues of change difficult for new member to be accepted
and adaptability
Closed group Group can be specifically planned and Tendency for group to get ‘stuck’ with
targeted members operating in set roles
Deeper relationships occur with greater May not be feasible in certain settings
cohesion and trust Group dependent on members commitment -
Depth of content and level of disclosure may have to fold if several drop out
increased Less opportunity to deal with change and
More consistent and predictable adapting to others
30
2.4.4.3 Timing
Several time factors are relevant in presenting a group.53
Day and time of group
The natural rhythms of the members, other activities they are involved in and the
availability of resources for group presenters should be borne in mind when deciding on a
day and time for group presentation.
Session length
Attention span and physical endurance must be considered when determining session
length. Yalom54 suggests one to two hours for therapeutic groups. Finlay53 suggests thirty
minutes to all day for activity groups, dependant on the task at hand. The most important
factor related to session length appears to be consistency, and that a limit is set so that
members can pace themselves and have security in knowing expectations.
Frequency
Frequency of groups is influenced by the type of group as well as members needs.
Finlay53 reports on Whittaker’s (1985) recommendation that intensity, importance and
continuity should be balanced. Intensity of experience will be increased with increased
group frequency. Importance should not be over-emphasised as this fosters dependence.
Continuity refers to the ease with which members move from one session to the next.
More frequent sessions usually mean improved continuity.
2.4.5 Barriers to therapeutic groups

Despite the advantages of group work, there is literature to support that it is not suitable for
everyone. The following are contra-indications for group inclusion:67
2.4.5.1 Practical barriers

Practical barriers may include inadequate transport, lack of caregiver, and time constraints
associated with decreased ability to prepare one’s self for attending the group.67
2.4.5.2 Certain personality attributes

Personality attributes unsuitable for a group include those causing the individual to contribute
negatively to the development of other members of the group, or where the individual continues to
model negative behaviour which influences the group. This contra-indication may also include
individuals whose personalities lend them towards isolation by choice. Personal preference must be
respected.67
31
2.4.5.3 Particular therapeutic needs
Certain therapeutic needs must be addressed on an individual basis, for example, toileting or sitting
endurance, before the individual would be able to cope with a group programme. Some individuals
may never therapeutically achieve the level which allows them active or passive group
involvement.67
The Queensland government68 identifies other factors that may prevent individuals from
participating in a group situation as part of their guidelines for best practice. These are: times of
the programmes, time to attend rehabilitation programmes, access and the availability of transport,
financial constraints, and the number of health professionals available. They further identify factors
which may impact on the individual’s ability to fully benefit from their participation. These are
listed as: cultural issues, co-morbidities which influence recovery/rehabilitation, work issues,
language and literacy/communication barriers, physical/behavioural issues, psychosocial issues,
discomfort disclosing problems in a group environment, major barriers to change, and lack of
personal motivation.
2.4.6 Therapeutic groups in physical rehabilitation

There is significant literature supporting the use of therapeutic groups to achieve psychosocial aims
of rehabilitation, as mentioned above. There is, however, very little evidence available for the
suitability of therapeutic groups in physical rehabilitation.
The focus of Yalom's54 model on therapeutic principles such as installation of hope, universality
and mutual support resulted in this model gaining attention within the field of medical
rehabilitation.69 A meta-analysis found that interventions in these categories resulted in reduced
morbidity, mortality and psychological distress in patients embarking on cardiovascular
rehabilitation programmes.69 Research also suggests that psychological intervention offered in
groups may also influence compliance to treatment programmes.69
A study by Kääpä et al.70 showed that there was no significant difference between multi-
disciplinary group intervention and individual physiotherapy intervention on the intensity of pain,
disability, subjective working ability, sick leave taken, health care consumption, and symptoms of
depression amongst subjects with lower back pain. Although this does not advocate for group work
over individual rehabilitation, it does show that, in this instance, individual therapy and group
therapy are comparable, with regards to outcomes, in terms of physical rehabilitation. It is
interesting to note that, in the above mentioned study,70 there was a greater improvement in general
32
well-being in those subjects participating in the group programme than for those participating in the
individual programme.
Group work can be a tool of empowerment, if people with disabilities are involved in the process,
rather than the end product being ‘administered’.54 Empowerment is a term strongly associated
with rehabilitation, if we consider the end-point thereof to be a total withdrawal of support.
Rehabilitation essentially seeks to assist individuals to empower themselves in all aspects of their
daily life.25 If group work contributes to this, it would play a role in the process of rehabilitation.
Whilst the positive effects of group work are obvious, there is a lack of literature detailing models
of interdisciplinary group work in rehabilitation. Until this point, the literature has provided
information pertaining to the context of rehabilitation, and more particularly, the use of therapeutic
groups in rehabilitation. Focus will now be turned towards stroke rehabilitation, and the potential
for therapeutic groups in this arena.
2.4.7 Therapeutic groups in stroke rehabilitation

There is a paucity of literature regarding the use of therapeutic groups in stroke rehabilitation.
However, one study was found documented, which focused on the exercise component of group
rehabilitation for stroke survivors. This study, by Eng, et al.,71 found that an eight-week,
community-based exercise group programme for stroke survivors was effective in improving
strength, endurance and balance of the participants, as well as their satisfaction with their physical
and social performance. This study also found that adherence to the programme was improved
through group cohesion.
The study used a repeated measures design to evaluate the physical outcome of 25 subjects with
two baseline assessments, one post-intervention assessment, and one retention assessment by means
of the Berg Balance Test, 12-Minute Walk Test distance, gait speed, and stair climbing speed.
The programme did not specifically include any psychosocial aspects of rehabilitation, but the study
did attempt to measure the effects of the programme on psychosocial recovery by means of the
Reintegration to Normal Living Index and Canadian Occupational Performance Measure.
This group therapy programme of Eng, et al.71 is significantly different from the one outlined in the
current study. The former was an eight-week programme, whereas the latter allows for
involvement of participants for up to 18 months. The programme outlined by Eng et al.71 was run
solely by physiotherapists, whereas the programme in this study follows an interdisciplinary
approach. Furthermore, Eng et al.71 evaluated by quantitative means, whereas this study employs
33
qualitative and quantitative means of evaluation. There are also differences between the
participants of the two studies. In the former study they had an average age of 63 years, compared
to an average age of 59 years in the current study.
2.5 Measuring instruments

The purpose of this study was to measure the meaning that group participation had to clients, which
is subjective by nature. However, two objective measurement tools are mentioned in this study, and
will be discussed here to ensure clarity of their purpose in the study.
Due to the complex nature of the lasting effects of stroke, basic classifications of functioning, such
as the Barthel ADL Index (the objective measurement tool that is currently in use at the BLRC),
have been found to underestimate the consequences of this condition.72 The BI was therefore not
used as a measuring instrument in this study, except that the BI scores, as documented during the
initial assessments of patients at the BLRC, was used to give an indication of severity of stroke, and
to determine whether that had any impact on group attendance. Lai et al.73 found that stroke
patients, deemed recovered according to BI scores, had residual limitations of hand function,
overall physical functioning, community participation and independence in activities of daily living
(ADL). They found the Stroke Impact Scale (SIS), to be more effective in highlighting residual
problems. Another study found this particularly true of the important area of social participation.74
The SIS is also the only stroke outcome measure that assesses hand function.74
The SIS is a nominal scale of eight domains, which subjectively measures strength, hand function,
ADL, independent ADL, mobility, communication, emotion, memory and thinking.74 In the current
research project, the SISv3 is not used as a measurement tool to determine recovery, but as part of
the questionnaire, to encourage discussion form the participants around their perceptions regarding
their functioning in these different areas. Even so, scores are included with the demographic data to
provide the reader with a view of the extent of disability that participants in the study experience.
34
Rehabilitation includes interventions aiming to reduce physical disability as well as interventions
aiming to reduce psychological and social problems. It involves several role players, often within a
team setting. These include the patient, health professionals, family, community and the account
payer.
Although there are several established settings and approaches to rehabilitation, out-patient CBR is
gaining increasing status in South Africa, with its limited resources and relatively high prevalence
of disability. There is a need to develop rehabilitation interventions at this PHC level, including
primary, secondary and tertiary disability prevention strategies.
Stroke was explored as a condition requiring extensive rehabilitation. The literature revealed it to
be a commonly occurring and highly debilitating condition both worldwide and in South Africa.
There are several traditional approaches to stroke rehabilitation – none of which has been revealed
to be more effective than the others. Stroke rehabilitation, as documented, has tended to be on an
individual basis and has in general been shown to have a positive effect on stroke survivors. But,
research has shown that stroke survivors often feel ill equipped to return to community living,
mostly as a result of poor social support.
Therapeutic groups were investigated in the literature as a potential means of supplementing

individual stroke rehabilitation. Yalom’s54 curative factors of the instillation of hope, universality,
cohesiveness, existential factors, recapitulation of the family group, catharsis, imitative behaviour,
interpersonal learning, altruism and imparting information were discussed, as well as the relevance
of these factors to stroke rehabilitation.
Although the essential role of rehabilitation is acknowledged, and support of its development
encouraged in literature, there is a lack of literature proposing models of stroke rehabilitation, and
in particular, the use of interdisciplinary group work as part of the process.
Only one study was found exploring the effectiveness of therapeutic groups in stroke rehabilitation.
There is therefore a definite need for further research in this area.
35
Chapter 3
METHODOLOGY
3.1 Study aim

The aim of this study was to describe the range of experiences relating to group attendance or non-
attendance of stroke survivors referred to the stroke group programme of the BLRC. This was with
a view to identifying ways of improving this programme.
3.2 Study objectives

The objectives are:
(a) To describe the demographic profile of the study population.
(b) To explore the meaning that group programme involvement has to participants.
(c) To investigate factors influencing attendance or non-attendance of the BLRC stroke
group.
(d) To make recommendations regarding improvement of the programme.
3.3 Study design

This study was descriptive – utilising qualitative and quantitative methods of data collection. A
mixed method was selected for this study for the sake of complementarity. Quantitative data can be
used to enhance qualitative data by broadening the reader’s understanding of the population and,
thereby, allows for comparison or transferability.75 This type of design "enhances the research
purposes of corroborating, elaborating, developing, and initiating understandings of social
phenomena."76 This design was applicable to this study, because the researcher aimed to gain an
understanding of a phenomenon (the experiences of stroke group participants), and at the same time
gain a better understanding of the demographics of the participants being studied. This would assist
with the interpretation of the results obtained in the study, and increase the extent to which results
could be used for elaboration and comparison in further study. The first phase of the study utilised
an administered questionnaire, comprising a range of structured, semi-structured and unstructured
questions, which yielded both quantitative and qualitative data. The second phase of the study had
a qualitative focus, making use of a focus group discussion to gather in-depth information about the
participants’ experience of the stroke group.
36
3.4 Study setting
As discussed in Chapter 1, Bishop Lavis is home to a low socio-economic, predominantly
‘coloured’, Afrikaans-speaking community. The community has fairly low educational levels and
high rates of unemployment. Within this community, the BLRC operates to offer a range of out-
patient physiotherapy, occupational therapy, as well as speech and language therapy services to
clients with physical and psychosocial impairments and disabilities. It is the stroke group, meeting
weekly at this centre, which is the focus of this study. Participants of the stroke group are
medically stable clients that have suffered a stroke, or another neurological condition - with similar
symptoms to those of a stroke. They must have the cognitive ability to integrate new information,
as well as the physical ability to sit for an hour at a time – irrespective of the length of time post-
stroke. Stroke group attendance is voluntary. The broad aims of the stroke group are to maintain
physical abilities, provide socio-emotional support and promote client autonomy.
3.5 Study population and sampling

The population for this study consisted of individuals referred to the BLRC stroke group
programme between January 2003 and December 2004. Data was collected between January 2006
and August 2006. Figure 3.1, on the following page, provides a schematic representation of the
population and shows how the final sample of twenty participants was determined.
37
57 Referred to BLRC 8 = No lasting deficits
Jan 03 - Dec 04
Not eligible for 6 = Unable to learn
stroke group
8 = Unable to endure
35 of those referred to Not eligible for

stroke group study 3 = Died
5 = Untraceable
1 = Moved from CT
6= Old CVA
9 in Group A
20 of those eligible for 7 in Group B

the study
4 in Group C
Figure 3.1 – Study population
Of the 57 clients referred to BLRC with stroke during January 2003 and December 2004, 35 were
referred to the stroke group and thus were eligible for the study. Of these, 15 did not meet the
inclusion criteria for the study. The remaining twenty participants were all included in the study
and subdivided into the three different groups according to their attendance (refer to 3.5.3 on the
following page).
3.5.1 Inclusion criteria

Persons who met the inclusion criteria for the stroke group programme.
Persons aged eighteen years or older, in order to have simplified issues of consent.
Persons referred to the BLRC stroke group from January 2003 up to, and including, December
2004, as this time frame would end 6 months before data collection was scheduled to begin –
thus having allowed participants ample time to experience the stroke group programme. This
time frame also excluded those who had been part of the stroke group prior to January 2003,
which was approximately when the stroke group changed to its existing format.
38
Persons who sustained a first stroke less than 6 months prior to referral to the BLRC for
rehabilitation, as during this rehabilitative phase of recovery, one would have expected to note
a good rate of recovery.60
Persons who were residing in the Cape Metropole at the time of data collection, in order to keep
costs manageable.
Persons who were alive at the time of the study.
3.5.2 Exclusion criteria

Persons aged less than 18 years, due to issues of consent.
Persons referred to BLRC stroke group prior to January 2003 or after December 2004.
Persons who sustained a first stroke more than six months prior to referral to the BLRC, placing
them in the later stages of rehabilitation by the time they join the group programme.
Persons who were referred to the stroke group who suffered a neurological condition with
symptoms similar to those of a stroke, but did not suffer a stroke.
Persons who resided outside of the Cape Metropole at the time of data collection.
Persons who were deceased at the time of the study.
3.5.3 Allocation to study groups

The population was sub-divided into three smaller groups according to their rate and frequency of
group attendance. This was done in order to allow any factors or experiences that may potentially
influence attendance or non-attendance of the group to be revealed. By analysing demographic data
from these sub-groups independently, it would also be possible to observe any potential differences
between higher and lower attending groups.
The BLRC stroke group attendance register was used to calculate the rate and length of group
attendance for all participants. Attendance rate was calculated by dividing the number of sessions
attended since the client was referred to the group by the total number of sessions that were
available for attendance over the period of time the participant came, which was converted to a
percentage form. Duration was also taken into account, as certain participants had attended less
than 4 sessions before self-discharging from the programme. Although their attendances had been
consecutive, and therefore their rate of attendance was high enough for them to be admitted into the
high attendance group, the short period of attendance made it impossible for them to have
experienced the entire spectrum of the group programme. Therefore, both attendance rate and
length of group attendance were taken into account when allocating participants to specific groups.
The duration of attendance was calculated by subtracting the date the participant first attended from
39
the date they last attended, expressed in months. Participants were divided into Groups A to C
according to the frequency and duration of their group attendance:
Group A – Poor attendance
These were participants that were invited to the group but had attended for less than 3 months or
not at all, or who had an attendance rate of 29 % or less.
Group B – Average attendance
Group B comprised participants with an attendance of 30 - 59 % over a period of three to five
months.
Group C – Good attendance
Group C comprised participants who had attended the group for a period of 6 months or longer,
with an attendance rate in excess of 60 %.
3.6 Instrument design

No literature was found detailing a questionnaire designed to assess the experiences of group
participants on a physical and psychosocial level in a setting of this nature. A questionnaire was
thus developed as the main instrument of data collection (Appendix III). As discussed under 2.5,
the SIS v3 was used as part of the questionnaire to encourage discussion around stroke recovery.
The questionnaire was developed in Afrikaans, as this is the dominant language of the Bishop Lavis
community. The community uses a specific dialect of Afrikaans, common to the so-called “Cape
Coloured” people. Language use in the questionnaire was, therefore, made to be more appropriate
to the general frame of reference of the population than true to grammatical detail. The
questionnaire was reviewed by an experienced researcher and a statistician prior to its
implementation. The format of the questionnaire was as follows:
3.6.1 Section A
This section was answered by all participants and yielded quantitative data for the realisation of
objective (a). It comprised structured questions with predetermined response categories, aiming to
gather demographic information from participants. This included background information, such as
availability of transportation and caregivers, time taken to prepare for group attendance and access
the BLRC, as well as costs involved and household income.
3.6.2 Section B
Section B was only administered to participants in Group A (the poor attendance group), aiming to
gather information relating to objectives (c), and (d). This section comprised semi-structured and
open questions with no predetermined response categories, providing both qualitative and
quantitative data. It asked questions around why participants had not been attending the group –
40
first in an open question, and then in questions relating to categories covered in Section A and
questions relating to the content of the group. Participants’ were asked what they had and had not
enjoyed about group sessions, if they had attended one or more. Finally, they were asked for
suggestions to improve the group programme.
3.6.3 Section C
Section C was also devised to provide information towards the realisation of objectives (b), (c) and
(d), but was used only with participants in groups B and C (the average and good attendance
groups). The questions were different from those in section B so that the differences in attendance
of the groups could be taken into account. These questions were also semi-structured and open,
with no predetermined response categories, yielding qualitative and quantitative data. They were
asked if any of the demographic factors in Section A had influenced their attendance, why they had
attended as well as they had, and what they enjoyed or did not enjoy about the group. They were
then asked if they had noted any improvement in their health or lifestyle as a result of their group
involvement, and to elaborate on this topic. They were also asked to make suggestions regarding
the improvement of the programme.
3.6.4 Section D
Section D was completed by all participants. It consisted of the Stroke Impact Scale (version 3)
(SIS v3), which is a nominal scale providing a subjective rating of participants’ physical
functioning, mobility, memory and thinking, emotion, communication, hand function, personal care
and other ADL (including roles and life tasks),73 as discussed in 2.5. This provided quantitative
data. The average scores were included in the demographic profile of the participants - Objective
(a). The rationale for its inclusion in this study is that the subject population is not accustomed to
providing qualitative data relating to health care because of the medical model within which they
have traditionally been treated. It was hoped that the questions in the SIS v3 might assist
participants in broadening their thinking around the topic of stroke recovery, and thus provide
further information towards realising Objective (b). By drawing their attention to areas of recovery
shown to be significant in other studies, the participants could be encouraged to explore areas of
stroke recovery that they might otherwise have overlooked. This particular scale was selected as it
has been found to be effective in highlighting residual problems for stroke survivors.73 The SIS v3
was translated into Afrikaans by the researcher. This translation was verified by colleagues with
experience in the field of stroke rehabilitation, who are first-language Afrikaans-speakers. The
comprehensibility of questions was checked during the initial stages of the piloting process.
41
3.6.5 Section E
This section comprised unstructured questions relating to each of the nine sub-categories of the SIS
v3 in order to gather qualitative information relating to these topics, and was completed by all
participants. Here, participants had the opportunity to respond in more detail relating to their
responses to the closed questions in Section D. Data yielded in this section contributed to realising
objectives (b) to (d). They were asked, in each category in turn, whether they thought the stroke
group had had an impact on their recovery in that category. If they did, they were asked to describe
how. (For example, “Do you feel that your ability to move in your home and community was
affected by your group attendance? How was it affected?”) They were then asked whether they felt
the category of recovery had had an effect on their attendance or not. (For example, “Did your
ability to move in your home and community influence your group attendance? How did it affect
it?”) A final question in Section E asked what difference participants felt that stroke group
attendance had made to their lives.
3.7 Piloting process

The questionnaire was piloted in two phases. Firstly, an open discussion was held with four clients
of the BLRC who had sustained strokes and did not form part of the study population. Their input
regarding the appropriateness of terminology and comprehensibility of the questions was requested.
These clients provided verbal feedback on each question of each section, which was used to refine
the questionnaire. Refinement involved substitution of several synonyms in order to make the
language use in the translation of the SIS v3 appropriate to the study population.
The questionnaire was then piloted by its administration to six people currently attending the BLRC
stroke group programme, who had been excluded from the study population as they had been
referred to the group after December 2004. Pilot participants were asked to give feedback regarding
the appropriateness and clarity of the questions in an unstructured way. They were asked to
indicate any unclear questions during the administration. From this, it was established that the
translation of the SIS v3 into a local dialect of Afrikaans was clear and understandable, with the
exception of a few questions (1a-d and 6g), which were amended. These were all related to
translation issues, where the local dialect differs from grammatical tradition (‘stroke’ was
substituted for ‘beroerte’, and ‘lot trappe’ substituted for ‘stel trappe’). Also, it was determined that
questions in the SIS v3 fell within the frame of reference of this population group, with the
exception of questions 4f and 4g relating to telephone use, and question 5a relating to the use of a
knife and fork for eating. Some participants might not have access to a telephone, and some of the
participants might be following Islam and use their hands, rather than utensils, for eating. It was
42
decided to keep these questions for use where applicable, with note that these questions would not
yield complete data from the sample.
3.8 Data collection

Preliminary demographic data was gathered about each participant from their rehabilitation file at
the BLRC between January and March 2006. This included their date of birth, date of first
cerebrovascular accident (CVA), initial BI score, the hemisphere affected, gender and physical
address.
The stroke group attendance register was used to determine the dates that participants were first
referred to the group and when last they had attended the group. Data collected in this manner was
used to establish participants’ eligibility for inclusion in the study, and to provide demographic
information for use in realising objective (a).
The questionnaire was administered individually to each of the participants by the researcher
between June and August 2006. Data collection occurred later than initially anticipated due to
service delivery factors associated with the BLRC. As the later date for data collection did not
affect any of the inclusion or exclusion criteria of participants of the study, the originally selected
participants were maintained as the study sample. Administration was selected over self-
completion to overcome possible problems related to low literacy levels (refer to 1.4) of the study
population and possible impairments associated with stroke that may have influenced reading and
writing (for example, perceptual deficits and hand function limitation). The questionnaire was
administered in Afrikaans to all but one of the participants, who had Xhosa as a first language. This
participant was in command of both English and Afrikaans, and did not require translation services
as he chose to complete the questionnaire in English. Some of the participants used English and
Afrikaans interchangeably during their responses.
The researcher was known to all participants in a professional capacity prior to the study as the
occupational therapist currently employed at the BLRC. She was also one of the group programme
presenters. This could be seen as a disadvantage in many senses – such as potential bias that
participants may have wished to please the researcher by giving favourable reports of their
experiences.77 Researcher bias also becomes more difficult to avoid. In this instance, however, the
advantages appeared to outweigh the disadvantages. The researcher had already established a trust
relationship with each participant, in which honest interaction had been encouraged. The researcher
was familiar with participants’ levels of impairment. She was, therefore, able to tailor open
questions and feedback to each participant’s level of ability. The researcher also had a thorough
43
knowledge of the cultural and social setting of the study, which allowed her to use relevant
questions to probe, interpret, and ask for expansion on topics and descriptions which may not have
been as obvious to an uninvolved examiner. The questionnaire administration further provided a
useful opportunity for the researcher to monitor the progress being made by clients no longer
associated with the BLRC, and to extend an invitation for appropriate assistance, in line with
practice-based research. To reduce researcher bias, participants were expressly given permission to
give their honest opinion without fear of judgement or repercussion, and they were not corrected if
they said things that the interviewer believed to be wrong.77
Questionnaire administration lasted an average of 30 – 45 minutes per participant and, where

possible, was done in the presence of a primary caregiver in order to verify information and to gain
additional information regarding the impact of the stroke group programme. This was particularly
vital in the case of participants with obvious communication or cognitive deficits. Thirteen of the
questionnaires were administered at the participants’ homes, and seven at the BLRC. Those
administered at the BLRC were done so on a day that the participant in question was to attend the
BLRC, and thus resulted in no additional cost to the participant. Interviews were by appointment,
which were made in advance telephonically.
The primary method of data recording for open questions was tape recording. Full transcripts of the
recordings were made for analysis. Note taking, capturing the main concept of responses, was
employed as a secondary method. This was a fail-safe to be utilised in the case of technical failure.
In the instance of this study, however, all open questions were successfully recorded and could be
transcribed. Non-verbal elements such as hesitation, pauses and crying were included in the
transcripts. The transcripts were not corrected for grammar, nor word choices amended, for sake of
preserving the full meaning and feeling of the responses. Transcripts were not translated before
analysis.
3.9 Data analysis

3.9.1 Quantitative data
Quantitative data gathered from the participants' BLRC files and Sections A and D of the
questionnaire were entered into a Microsoft Excel spreadsheet, where they were analysed with the
assistance of a statistician utilising the computer program, Statistica. Tests used to determine
whether there were significant differences between subgroups with regards to any of the
quantitatively measured phenomenon were the Chi-squared test, ANOVA and Kruskal-Wallis tests
(when the data was not normally distributed). A p-value of > 0.05 was seen as statistically
significant in all tests. (Refer to Chapter 4 for specific tests used to obtain specific results.)
44
3.9.2 Qualitative data
Qualitative data gathered in Sections B, C and E of the questionnaire were analysed by means of
thematic analysis.77 An inductive approach was followed, meaning that themes were allowed to
emerge from the data, rather than pre-determined categories being used.77 The researcher has
command of both the Afrikaans and English languages and was, therefore, able to analyse the data
in its original language. Data was transcribed from the tapes by the researcher, which involved
listening to the tapes whilst typing and reading the transcripts numerous times, to check for
accuracy. Accuracy was further verified by research assistants listening to the tapes whilst reading
the transcripts. The researcher then read the transcripts several times before beginning analysis.
Raw data was arranged into basic categories with the assistance of a word processor. These
categories were identified as the categorisation occurred, with themes emerging being allowed to
shape and define the categories.77 The categories formed at this stage of analysis provided a
framework in which to group the phenomena, and were later refined and integrated.
3.10 Phase II – Focus group

By this stage of the study, it was decided that further methods of data collection should be
employed in order to enhance the results – particularly around the meaning that group participation
had to participants. As is characteristic of descriptive research, further in depth data collection was
conducted in the form of a focus group discussion. This second phase of data collection and
analysis is outlined below.
3.10.1 Sampling
In order to ensure a variety of experiences,78 participants for the focus group were selected through
the entire range of study participants, from those who attended poorly to those who attended well.
Two participants from each of groups A - C were selected for participation in the focus group. Two
participants were randomly drawn from each of Groups A – C. This was done so that the researcher
could not contribute bias to the study by selecting participants who had particular views of the
group, and so that each of the subgroups could be represented in the focus group. They were
contacted and asked to participate in the focus group discussion. All six participants consented to
participation; however, one participant in Group A was unable to attend on the day due to illness.
The focus group ultimately consisted of six people, as it included the primary caregiver of one of
the participants. The caregiver had been present with her husband during each of his group
attendances, as his cognitive impairment as a result of the stroke affected his memory. She was
included in the focus group due to her experience of the group in question, as well as her ability to
provide details of her husband’s experiences that he may have forgotten.
45
3.10.2 Data collection
The focus group was held at the BLRC on 20 September 2006. As suggested by literature,78 it was
held a room generally used by the stroke group, and at the time that the group was usually held.
Warm drinks and snacks were served to create a relaxed atmosphere, and participants were
reimbursed for any travel expenses.
An interview schedule (Appendix IV) was used to guide the focus group discussion. Questions
were structured around the results emerging from the first phase of data collection. Several broad
topics were identified for exploration during the discussion. These were: meaning, stroke recovery,
group activities, issues of interaction, factors influencing attendance, and recommendations.
Questions were developed around these themes, and possible prompting categories were noted. The
interview schedule was very loosely structured in order to take full advantage of the peer interaction
opportunity and not to stifle discussion that may have arisen.78 The focus group discussion content
was recorded and fully transcribed.
3.10.3 Data analysis

A content analysis was done on the transcript of the focus group. Data was coded into categories
along the lines of themes identified during the preliminary data analysis process. This was done
with the assistance of a computerised word processing programme, in which numerical codes were
assigned to emerging categories. The numbered sections of text were then grouped together into
themes, and further refined into sub-themes. Patterns were then sought that corroborated or
deviated from the identified themes. Attention was also given to the dynamics of the focus group,
specifically the nature of the interaction between the participants. This was done by including
nonverbal elements of the focus group in the transcript, and including a description of the tone with
which certain comments were made, as well as the response of other participants, in the discussion
which follows in Chapter 4.
At this stage of the analysis the researcher noted several similarities between themes that had
emerged and certain of the factors cited by Yalom as being characteristic of curative factors of
groups. For the purposes of discussing the themes, those that emerged were compared to these
factors described by Yalom. Not all of the themes that emerged were similar to those identified by
Yalom, but all were included in the results as they were noteworthy findings of this study, and
contribute to the description of the experiences of participants in this study.
46
3.11 Trustworthiness of qualitative data
Qualitative data should be tested for trustworthiness. That is to say: What is the truth value of the
study? To what extent can the findings of this study be applied to other studies? Would the findings
of the study be replicated should the study be repeated? Is the study free of excessive influences of
bias? In order to deem a study trustworthy, credibility, dependability, confirmability and
transferability must be established. Methods of establishing credibility are prolonged and varied
field experience of the researcher, the keeping of a field journal, triangulation, member checking
and peer examination. Methods of establishing dependability are a dependability audit, the dense
description of research methods, step-wise replication and code-recode procedures.79
Confirmability is ensured by use of a confirmability audit, reflexivity and triangulation.
Transferability can be ensured by dense description and by comparing the sample to the greater
population.79
The researcher employed certain of these techniques - specifically: the detailed demographic
description of the population and study setting to aid the reader in judging applicability to other
populations, thus to ensure transferability, varied methods of data collection (questionnaire and
focus group), peer examination, by means of a colleague checking the thematic analysis of data
from transcripts, and meticulous record keeping forming an audit trail which could be followed by
other researchers. In spite of this, more could have been done to ensure the trustworthiness of the
study. This may have included member checking and reapplication of the code procedures. Due to
manpower, time and resource restriction, this was not possible. This is a limitation of the study.
3. 12 Reliability and validity of quantitative data

The self-developed part of the questionnaire was not tested for reliability or validity, which is
another limitation of the study. The SISv3 was tested for both validity and reliability and was
found both valid and reliable.74 Reliability of the SIS v3 was determined by evaluating internal
consistency with the Cronbach [alpha] for each domain scale. Criterion-validity was assessed by
examining Spearman Rank correlation coefficients, and discriminant validity assessed by
comparing mean scores for each domain to the previously proven valid) Rankin scale.
47
3.13 Ethical considerations
3.13.1 Protection of participants’ interests
As the study was qualitative in nature, participants were not assigned to particular groups by the
researcher. Each participant determined his intervention status by his own choice to attend or not
attend the stroke group. As the researcher did not impose or withhold intervention, there was no
question of this study jeopardising a participant’s recovery.
3.13.2 Confidentiality
Participants were assigned a number as they were included in the study population. The number
was used as reference from that point forward in all documentation, including questionnaires and
data tables. Participants were informed of this prior to their consent to participate. Participants
were informed that findings of the research may be published, but that confidentiality would be
maintained. They were assured that information gleaned from this study would be used for the sole
purposes of this research project, and would not be disclosed to third parties for other purposes. All
tapes and transcripts were stored safely, where they could not be accessed by unauthorised persons.
Computerised data, tapes and transcripts did not contain the names of participants – only their
assigned participant codes.
3.13.3 Informed consent

Informed consent was considered to have been gained once a participant or their representative had
understood and signed a copy of the document termed, ‘Information and informed consent
document’ (Appendix V). Prospective participants were informed of the study aims and objectives,
as well as the requirements of participation during the study. Participants were asked to read the
consent form. If the participant was unable to read, the form was read to him/her, or translated from
English to Afrikaans by the researcher as necessary. A translator would have been employed for
translation to other languages should this have been necessary, but all participants were in command
of either English or Afrikaans. The participant or his representative, the researcher and a witness
signed the document to verify that the information had been correctly and completely conveyed.
Participants were given the opportunity to ask questions relating to the study and their involvement.
The researcher further clarified their understanding by asking them to recap the main points
conveyed to them and summarise the expectation of their involvement in the study.
3.13.4 Approval
Approval for the study was gained from the Committee for Human Research, at the University of
Stellenbosch, prior to commencement of data collection (Project number: N05/02/030).
48
This is a descriptive study, employing qualitative and quantitative means. It was conducted with the
study population of those invited to attend the stroke group programme at the BLRC between
January 2003 and December 2004. All participants in the study population were used as the
population size was small, with only twenty participants meeting the inclusion criteria.
The study was carried out in two phases. The first phase made use of a questionnaire, developed by
the researcher, in the dominant language of the area. This was individually administered to each of
the participants, after it had been piloted and refined. Where possible, questionnaires were
administered in the presence of a primary caregiver. The questionnaire comprised a range of
structured, semi-structured and unstructured questions aiming to gather information to realise each
of the five stated study objectives. Responses to closed questions were entered into a Microsoft
Excel spreadsheet and analysed with the assistance of a statistician. Open questions were fully
transcribed and thematically analysed.
At this point, the need for further qualitative data was identified, leading to the second phase of the
study. This consisted of a focus group to gather more in-depth information relating to the
objectives. Five members of the study population, selected by stratified random sampling, and one
primary caregiver participated in this group. The recorded content of the focus group was fully
transcribed and a content analysis preformed.
Data is presented in the following chapter as a narrative, using ‘voice’ to demonstrate themes.
Where necessary, these direct quotes were translated into English, but were also presented in
Afrikaans for the full benefit of readers in command of this language.
49
Chapter 4
RESULTS AND DISCUSSION
4.1 Introduction
Chapter 4 outlines the results obtained during this study, which are presented according to the study
objectives. Firstly, the demographic details of study participants, as determined by the quantitative
results, are presented. This is done in terms of general factors (gender, age and employment status),
stroke related factors (laterality of stroke, Barthel Index score and SISv3 score) and according to
factors which may have influenced their ability to attend the group (cost of transportation, presence
of caregiver and time involved for physical preparation).
Secondly, the meaning that stroke group involvement had to participants is described in terms of the
psychosocial effect it had, and then according to the impact that participants felt the group had had
on their recovery from stroke. Psychosocial effects included the installation of hope, universality,
imparting information, development of socialising techniques, imitative behaviour, cohesiveness,
and self esteem. Recovery in stroke-related areas included improvement in ability to execute
activities of daily living, strength, mobility, thoughts and memory, communication, mood and
emotion, and hand function. Finally, the factors that participants reported to have affected their
attendance are discussed, and their suggestions for improving the programme outlined.
Results are both quantitative and qualitative in nature, and are presented in an integrated fashion to
answer the stated objectives. A discussion around each objective is also included. Part of the
discussion includes narrative examples of statements relating to each topic. Quotations are in their
original language and, where appropriate, are translated into English as well. The chapter
concludes with other findings of interest from the study that were not previously identified as
objectives.
50
4.2 Demographic profile of the study population
4.2.1 General
4.2.1.1 Gender
Of the twenty study participants, 15 were female. There was no statistical difference between
gender distribution per group (Chi-Square test; p = 0.43). A complete breakdown of the gender of
the participants according to study subgroups is shown in figure 4.1.
Gender
10
8
Number
0
A B C
Groups
Male Female
Figure 4.1 – Gender distribution
The higher number of females in the study population does not relate to the expected higher
incidence of stroke amongst males, as highlighted in the literature review.19 It relates to a degree
with the profile of stroke patients in this community sketched in 2003, which found 54 % of stroke
patients to be female, compared to 46 % male.20 The larger proportion of women could mean that
males in this area who sustained strokes either had a higher rate of mortality, or did not meet the
inclusion criteria of the stroke group as result of being either too severely or too mildly impaired.
51
4.2.1.2 Age distribution
Lack of significance in terms of age across the groups was proven by means of an ANOVA test
(p = 0.73), and confirmed with a Kruskal-Wallis test (p = 0.71), as the residual values were not
normally distributed. Figure 4.2 demonstrates that Group B had the widest range of ages of the
study groups (ranges are depicted by the Y-bar line, with the bars depicting average age of each
group).
Age
90
80
Age (years)
70
60
50
40
A B C
Group
Figure 4.2 - Average age
The average age of participants was 59 years, which was similar across all groups. This was an
interestingly low average age, given that risk of stroke doubles for each decade over fifty.41
However, findings were consistent with a study carried out in 2003, which found that fifty percent
of the population of stroke survivors studied in the community of Bishop Lavis were younger than
60 years.20 Findings also correspond to the relatively young age of the onset of stroke in sub-
Saharan Africa.42
The population of Bishop Lavis is fairly youthful, as mentioned in Chapter 1. This is the trend for
sub-Saharan countries given the increasing rate of HIV/AIDS.42 This factor may also have an effect
on the younger average age of stroke onset. Alternative possible explanations for the younger than
expected average age of the population is the higher morality rate of older persons sustaining
stroke,42 along with the co-morbid conditions rendering older persons unsuitable for group inclusion
(for example dementia).67 The high rates of diseases of lifestyle recorded for the Western Cape
(refer to 2.2.3) may also have resulted in more people sustaining strokes at a younger age.
52
4.2.1.3 Employment status and household income
None of the participants was formally employed, although one took care of a grandchild and
another of an adult disabled daughter without remuneration. All but one was in receipt of a social
grant in the form of an old age pension or disability grant. It was not possible to determine
household income in absolute terms, therefore, this cannot be compared to the Household
subsistence level (HSL) discussed in Chapter 1. However, the number of adults with income per
number of adult household inhabitants was calculated as a guide. This ratio is reflected in Figure
4.3. This figure includes the participant as well as any other household members receiving a social
grant. Groups were similar in this regard (Kruskal-Wallace test; p = 0.38).
Average ratio of people with income to adult inhabitant per household
1.00
0.80
0.60
Ratio
0.40
0.20
0.00
A B C
Group
Figure 4.3 – Average ratio of people with income to adult inhabitant per group
4.2.1.4 Ethnicity and language

All but one of the study participants was ‘coloured’, which is reflective of the ethnicity of the vast
majority (98 %) of the Bishop Lavis population (refer to 1.3). These participants all had Afrikaans
as their first language, which is also reflective of the general population, of which 90 % are
Afrikaans speaking (refer to 1.3). The remaining participant was a Xhosa-speaking, ‘black’ African
– this being the second most common ethnic group of the community.
53
4.2.2 Stroke-related factors
4.2.2.1 Laterality
In total, nine study participants had sustained a left-sided CVA, and eleven a right-sided CVA
(refer to Figure 4.4). This represents a fairly even distribution of laterality, which is expected in
stroke survivors.20
Hemisphere affected
10
8
Number
0
A B C
Group
Left Right
Figure 4.4 - Hemisphere affected
4.2.2.2 Barthel ADL Index score

The average BI score of participants at initial assessment upon admission to the BLRC was 13.5 out
of a possible 20 (See Figure 4.5).
Barthel score
20
15
Score
10
0
A B C
Group
Figure 4.5 - Barthel ADL Index
This rating of ADL functioning provides an indication of the severity of functional impairment
participants experienced at the outset of their rehabilitation. Note that this BI score was not
intended to measure progress in this study, but only to give an indication of the severity of
54
functional limitation of each group in order to test a possible theory that the severity of stroke may
distinguish one group from another in terms of their attendance. However, there was no statistical
difference between the average BI score for each group (Kruskal-Wallace test; p = 0.45), although
the low attendance group, Group A, had slightly higher scores than the higher attendance groups.
The lack of significance disproves the possible theory that those with higher levels of functioning
find less benefit from the group, and therefore have lower attendance rates. From this data, it
appears that severity of stroke does not significantly affect attendance of the stroke rehabilitation
group.
4.2.2.3 SIS v3 scores

Although the main purpose for the use of the SISv3 in this study was to enhance qualitative data as
described under 3.6.4, an added advantage was that it also gave participants’ subjective ratings of
their recovery from stroke at the time of the study. Figure 4.6, below, depicts these average scores,
according to the eight different categories of the SIS v3.
Average SIS v3 scores for all participants per category
5.0
4.3 4.1 4.1
4.5 3.7 3.6
3.8 3.5
4.0
3.5
3.0 2.8
2.5
2.0
1.5
1.0
0.5
0.0
Physical recovery
ADL execution
Role fulfillment
Hand function
Feelings and mood
Communication
Mobility
Thoughts and memory
Figure 4.6 – SISv3 scores
Categories were scored between a low of 1, and a high of 5. Each category consisted of several
questions that are scored separately (See appendix III, section D). Averages were obtained by
adding the total scores for each participant in each category, and dividing these by the number of
participants who had completed the category of questions.
55
Note that average scores have been used rather than total scores, as some questions were not
applicable to certain of the subjects, so had to be excluded from the analysis. Also, there are no
baseline scores available. Thus, the rate or amount of recovery cannot be determined. However,
these scores provide information regarding residual impairments and areas of biggest residual loss
at the time of the study.
Feeling and mood (question D3 in the questionnaire) showed the lowest level of subjective residual
impairment, whilst hand function (D7) showed the highest level of subjective residual impairment.
It is clear from the literature that hand function often recovers poorly after stroke.80 It is of interest
to note that other areas showing poorer subjective recovery rates are also related to the physical i.e.
physical recovery (D1) and mobility (D6). One explanation for this finding might be that all these
areas are equally affected by a stroke in the left or right hemisphere, while communication (D4) and
thoughts and memory (D2) all high scorers as well as feelings and mood, the highest scorer are not
equally affected by a stroke to either hemisphere.60
4.2.3 Factors relating to stroke group attendance

4.2.3.1 Mode of transport
The most commonly used method of transport to access the BLRC was walking, which was
expected as it is the most commonly used means of transport in the community (refer to 1.3). This
was followed by attendant-propelled wheelchair use (refer to Figure 4.7).
Transport
9
6
Number
0
Walk Wheelchair, aide Private, other Private, self
Category
A B C
Figure 4.7 - Transport used to access BLRC
56
Comparatively few people made use of private transport. This may well be as a result of the cost
involved in utilising private transport in this low socio-economic area, as cost is obviously absent in
the case of walking, and only sometimes involves remuneration for those pushing wheelchairs.
4.2.3.2 Cost of transport

Figure 4.8 shows that 16 participants (80 %) incurred no cost in accessing the centre, with only two
paying more than ten Rand for transport.
Cost
18
15
12
Number
0
Zero < R5.00 R5.01 - R10.00 > R10.00
Group
A B C
Figure 4.8 - Cost incurred in accessing BLRC
There was no significant difference between the subgroups with regards to transportation cost.
Thus, the cost of transportation was not related to group attendance. Walking is possibly the most
common use of transport given the financial limitations of the population in question, rather than
because of choice. Although participants were able to access the BLRC by walking or wheelchair,
it was not possible to measure the difficulty encountered with this arrangement. With improved
finances, some participants may have chosen to use alternative methods of transportation.
57
4.2.3.3 Physical preparation
Most participants were usually able to prepare themselves and access the BLRC within one hour
(refer to Figure 4.9) with or without assistance (as was available and needed), which seems a
reasonable time frame.
Time
15
Prepare Access
12
Access
9
Number
Prepare
6
Prepare
3
Access Access
Prepare
0
<10 min 11-30 min 31-60 min >1 hr
A B C
Figure 4.9 - Time taken to prepare for and access group
4.2.3.4 Presence of caregiver

Half the participants attended the group alone, and half with a companion. Five of the participants
were always alone at home during the day. Three of these were in Group B and two in Group A. A
further two participants were often alone during the day, one in each of groups A and B. The other
participants all had an immediate family member present during the day, with one exception in
Group B having a paid carer. None of Group C (high attendance group) was without a full time
carer, which may have made it easier for them to attend the group.
4.3 Meaning that group programme involvement had to participants

In the context of this study, ‘meaning’ was understood to signify the value or significance that
participants attached to group involvement. The construct was thus measured in terms of the
participants’ reasons for involvement and what they felt they gained from their involvement. They
were additionally asked to describe how they felt involvement in the group programme had
impacted their lives.
This topic was addressed only with those who had attended the group for enough time to have
experienced the full range of group activities, and therefore could not comment on these. No data
was yielded in this section from Group A, who all reported insufficient attendance to have an
58
impression of meaning that group attendance would have provided. This group was, therefore,
omitted from this section of data analysis. The responses from groups B and C were analysed
together as no significant demographic differences had been found between them. Additionally,
these groups were very small (refer to Figure 3.1), so themes could not be established within the
separate groups.
4.3.1 Meaning related to psychosocial outcomes

4.3.1.1 Introduction
From the inductive approach used, the following themes initially emerged: Cohesiveness;
Universality; Support; Installation of hope; Self esteem; Imparting information; Imitative
behaviour; Development of socialising techniques. Each of these will be described with verbatim
quotes to demonstrate the theme.
It was not one of the study objectives to determine if Yalom’s54 curative factors can be related to
group therapy for stroke patients, and questionnaires were therefore not structured to this effect.
Upon reflection, however, it became clear that the themes identified by the researcher bore
similarities to those earlier identified by Yalom,54 which were discovered by the researcher in the
literature after data collection had ended. The themes were, therefore, grouped were appropriate,
according to Yalom's curative factors.
Not all of Yalom’s54 curative factors were evident from the data collected. Yalom,54 himself,
described this phenomenon (mentioned 2.4.2.12) whereby people are not always aware of the
effects of all these factors. As the questionnaire was not structured to illicit responses around any
of Yalom’s54 factors in particular, those that occur on a subconscious level did not necessarily
emerge. These issues were not specifically probed in the focus group, as Yalom’s factors had not
yet been identified by the researcher as having possible links.
Where a response could relate to more than one of the curative factors of groups, the researcher has
selected the most appropriate category per response, and has made reference to other relevant
categories.
4.3.1.2 Instillation of hope

It was clear from the following quote how important a role the group played in this regard.
“O, dit het ‘n baie, baie, baie verskil gemaak! Want die mense by die sentrum was baie
goed vir my. (Die arbeidsterapeut) het my geïnspireer. En (die fisioterapeut) ook. En ek
het daarvan afgeneem om te doen wat hulle sê. Ek het bygewoon die stroke klubs en
59
Dinsdae het ek kom leer om ‘painting’ en goed te doen en dit het my alles opgehelp tot ek
vandag is wat ek is vandag.”
“Oh, it made a very, very big difference! Because the people at the centre were very
good for me. (The occupational therapist) inspired me. And (the physiotherapist) as well.
And I decided from there to do what they said. I attended the stroke groups and on
Tuesdays I came and did painting and things, and it all helped me to become what I am
today.”
The above example shows how important the curative factor of instillation of hope is, as it leads to
sustained attendance and encourages compliance and, therefore, increases the likelihood of
successful rehabilitation. The following quote further illustrates this point:
“...ek vorder beter omdat ek gereeld oefen want ek oefen soos (die terapeute) vir ons
geleer het elke week.”
“…I am improving more because I exercise regularly, because I exercise like (the
therapists) taught us every week.”
Others expressed the concept of hope less directly:

“Daai vrou daar anderkant (volunteer at community stroke group) het ‘n terapie altans
gedoen twee weke terug en sy kan nie glo nie die arm raak nie seer nie. Is miskien
outomaties lam... ‘lammerig’. Maar hy sal maar bykom. Ek doen elke dag my
oefeninge.”
“That woman there on the other side (volunteer at community stroke group) did some
therapy two weeks ago and she can’t believe that my arm doesn’t get sore. It might be
lame. But it will come right. I do my exercises everyday.”
Findings from focus group discussion provided a good example of group members acting as
inspiration for each other, which, as discussed in Chapter 2, is part of the power of a group to instil
hope in the individual. This is illustrated in the following quote of one participant speaking to
another:
“ ‘n mens moet op! Jy moet ‘try’ en jy moet uit daai stoel uit. Jy moet sê, ‘hier wil ek nie
lê nie!’.”
“A person must get up! You must try and you must get out of that chair. You must say, ‘I
don’t want to lie here!’.”
60
This factor was further demonstrated in the focus group as participants shared their stories of
success with each other. The focus group beautifully illustrated the meaning gained from
seemingly small successes, which gave hope for greater things. It was very encouraging to note
that the focus of attention of the group participants was on their achievements and successes, rather
than on their limitations and short-comings.
“Nou ‘n kort tydjie toe ek na my dogter toe gaan in Mitchells Plain. Maar hulle sê,
‘Mammie kan nie gaan nie want die kar vra te duur – die trein vra ‘cheaper’.” Toe sê ek,
‘stoot my Netreg Stasie toe met die ‘wheelchair’.’ Hulle het my gestoot, en daai steppies
gaan mos so op? Ek het dit geklim! Ja, op en af. Toe ek nou daar kom, toe vra my dogter
vir my, ‘Hoe kom Mammie hier?’ Ek sê, ‘Ek het met die trein gekom’, en sy was verbaas!
Toe sê ek haar ek het alles geleer by die terapie, ja.”
“Now a little while later I went to my daughter’s in Mitchells Plain. But they said,
“Mummy can’t go, because the car is too expensive – the train is cheaper”. So I said,
“Push me to Netreg Station in the wheelchair. They pushed me, and those stairs, that go
up like that? I climbed them...Up and down. When I got there my daughter asked,
“Mummy, how did you get here?”. I told her I came by train, and she was surprised! So
I told her I learnt everything at (the rehabilitation centre).”
The results indicate that the stroke survivors included in this study experienced the instillation of
hope associated with group involvement, which serves to motivate them and to encourage their
participation in rehabilitation.
4.3.1.3 Universality
Participants identified their diagnoses as a uniting factor. They felt that other group members were
able to understand their situation, and, therefore, experienced a sense of security within the group.
As was expected from the literature,53 the feeling of safety, stemming from universality, provided
opportunity for disclosure. Statements made to this extent during the questionnaire administration,
included the following:
“Ek hou van tussen die mense wees. Almal ly aan die selfde ding, so ons verstaan mekaar.
Ander mense sal nie verstaan nie.”
“I like being amongst the people. Everyone suffers from the same thing, so we
understandone another. Other people wouldn’t understand.”
“Dis lekker om te deel met ander mense wat in die selfde situasie is as ek.”
“It’s nice to share with others in the same situation as myself.”
“Ek voel ‘safe’ saam met hulle.”
“I feel safe with them.”
61
“Ons kan lekker gesels. Ek voel ‘at ease’.”
“We can chat nicely. I feel at ease”
This phenomenon was again highlighted in the focus group:

“...Want ons het mekaar geleer ken … ons het mekaar verstaan wat daar ge te doen
gewees het, het ons gedoen... as die persoon se… kyk ons het mos miskien die ou lam
armpie. Dan hang hy mos. Dan sê die persoon, ‘nee wat soek daai armpie onder die tafel?
Sit hom bo-op die tafel!’. Die groep het baie, baie gehelp.”
“…Because we got to know one another… we understood one another. What there was to
do, we did… if the person’s… See, now perhaps I have a lame arm. Then it hangs. Then
another person would say, ‘No, what’s that arm doing under the table? Put it on top of
the table!’. The group helped very, very much.”
It is evident from the above that involvement in the group programme contributes to participants’
experience of universality, which results in security and leads to disclosure. This can contribute to
group participants’ ability to cope with the often dramatic life changes they face as a result of their
stroke.
4.3.1.4 Imparting information

Both formal and informal learning occurred in the context of the group, and had meaning to study
participants. The word ‘leer’ (learn) appeared frequently in the response transcripts of the medium
and high attendees, as well as during the focus group. The concept of the group as a forum for
imparting information arose eight times during questionnaire administration. On a formal level, this
learning was in the form of health related talks by therapists.
“Die geselsies. Ons was baie lief vir die geselsies. Daai het vir my baie geleer. Want ek
kan altyd vir die anders gaan vertel, ‘ons het vandag oor dit gesels’, en dit was goed.”
“The talks. We really loved the talks. Those taught me a lot. Because I could go and tell
the others, ‘we spoke about that today’, and it was good.”
More important, perhaps, was the informal learning that occurred as group members shared their
experiences, aided by the sense of universality discussed above.
“Die gesels - dit het goed gegaan, dan kan jy gesels en jy kan luister na daai een se siekte
of sy probleempie, en so kan jy nou leer van daai.”
“The discussion went well, you could talk and you could listen to that one’s illness or
problem, and you could learn from it.”
62
This phenomenon was again highlighted in the focus group, by the same quote used to illustrate
universality above.
“want ons het mekaar geleer ken … ons het mekaar verstaan wat daar ge te doen gewees
het, het ons gedoen... as die persoon se… kyk ons het mos miskien die ou lam armpie.
Dan hang hy mos. Dan sê die persoon, ‘nee wat soek daai armpie onder die tafel? Sit
hom bo-op die tafel!’ Die groep het baie baie gehelp.”
“Because we got to know one another… we understood one another. What there was to
do, we did… if the person’s… See, now perhaps we have a lame arm. Then it just hangs.
Then someone would say, ‘No, what’s that arm doing under the table? Put it on the
table!’ The group helped a lot.”
And by the following statement as well:

“Dit help mekaar... nou, ek sal sê ons is in dieselfde posisie. Ek het ‘n stroke gehad en jy
het ook ‘n stroke ‘gehet’. Ja, ons kan mekaar raad gee. Ek het die geleer by die
(rehabilitasie sentrum) en ons het so gemaak - probeer jy dit ook nou so. Ons kan mekaar
bemoedig.”
“It helps one another... Now, I'd say we're in the same position. I had a stroke, and you've
also had a stroke. Yes, we can give each other advice. I learnt this at the (rehabilitation
centre) and we did this – now you try it too. We can encourage each other.”
Given that education is crucial to successful outcome in stroke,57 and the fact that there is increasing
emphasis on prevention in the management of stroke,4 it was very positive to note that the group
programme appears to be achieving its aims in this regard. One of the aims (refer to 1.4) of the
stroke group programme is health education. It was, therefore, positive to note that participants
perceived improvement in their knowledge to be attributable to their group involvement.
“Ek dink ek ken meer as wat ek destyds geken het. Ek het meer geleer as wat ek destyds
geleer het. Daar’s baie dinge waarvan ek nie geweet het wat ek nou weet.”
“I think I know more now than I knew then. I've learnt more now than I learnt then.
There were a lot of things I didn't know about then that I know now.”
“En was dit ook nie vir hulle nie sal ek nie geweet het wat ek nou weet nie.”
“And if it wasn't for them I wouldn't know what I know now.”
From the above, it was evident that the stroke group was a useful context for formal as well as
informal learning, and, in the important area of education, contributed to positive outcome for
stroke survivors.
63
4.3.1.5 Development of socialising techniques
The high incidence of communication difficulties associated with stroke, as discussed in the
literature review, was also found in the study population. According to the SIS v3 responses, 58 %
of the participants experienced at least ‘some difficulty’ with communication. The perceived role
of the stroke group in improvement of communication was mentioned several times by the
participants. The participants’ responses showed that group members had the opportunity to
practice their communication skills – both verbal and non verbal – within the group and that it
provided them with the opportunity to participate, and thus to socialise. Some examples of
responses follow:
“Ek raak dan so ‘excited’ as (die fisioterapeut) of (die arbeidsterapeut) vir my sê, ‘jy gaan
nou praat vandag’. Ek het baie goed daar bygekom. Die kommunikasie – dit is lekker
saam met groepies te wees en ‘join’ en almal daai.”
“I get so excited if (the physiotherapist) or (the occupational therapist) says to me, ‘you’re
going to talk today’. I came right there. The communication – it’s nice to be with small
groups and to join in and all of that.”
“(Die kommunikasie) verbeter vanaf ek hier is, want ek kan nie altyd gepraat het nie. En
ek lees ook baie beter.”
“(The communication) is improving since I've been here, because I couldn't always speak.
And I also read much better.”
From the above, it was evident that the opportunity to practice and develop communication and
socialising skills was important to the study participants, and that the group provided a useful forum
for this.
4.3.1.6 Imitative behaviour

There was an example of the curative factor of imitative behaviour being expressed. In this
example, the participant referred to the imitation of therapists’ attitude.
“Ja, die terapie groep het (die arbeidsterapeut) en (die fisioterapeut) – almal, daai
‘patience’. Daai geduld. En hulle leer vir ons ook dit. Hier leer jy geduld. Jy leer geduld
by hulle.”
“Yes, the therapy group, the (occupational therapist) and ( the physiotherapist) –
everyone, that patience. And they teach it to us as well. You learn patience here. You
learn patience from them.”
64
4.3.1.7 Cohesiveness
Cohesiveness was mentioned as an important aspect of group therapy to them. The meaning that
participants found in belonging to a group was expressed in both direct statements to this end, and
also in “we-statements”, where the participants made statements of belonging by the use of the
pronoun ‘we’. Several of the sentiments expressed demonstrated the trust, warmth, loyalty and the
sense of belonging that are so characteristic of a cohesive group. For example:
“Ek geniet die ‘saamheid’ van die groep. Ek mis dit as ek eendag nie hier is nie. Ek is al
gewoond.”
“I enjoy the togetherness of the group. I miss it if I’m not here one of those days. I’m
used to it by now.”
“Want ek is baie opgewonde as ek moet kom. Ek ontmoet mos die span en ons gesels en
ons lag.”
“I’m very excited if I must come. I meet the team and we talk and we laugh.”
“As ons kom is ons altyd ‘n klomp groepe en ons mis gou een uit. En sê ons, ‘haai ‘jine’,
daai ‘aunty’ was nie hier nie’, of so.”
“When we come we’re always a bunch of people, and we quickly notice that one is
missing. And we say, ‘gosh, that Aunty wasn’t here’, or something.”
“Soos ons mense praat saam met mekaar, groet mekaar, so ek voel vriende saam met die
mense.”
“As the people talk to each other, greet each other, so I feel that I’m friends with the
people.”
Cohesiveness also featured as a theme during the focus group conversation.
The literature revealed the strong need for support for stroke survivors, who are often isolated. The
stroke group plays a role in preventing isolation:
“Ek geniet die mede pasiënte en die oefeninge. By die huis is ek geïsoleer.”
“I enjoy the fellow patients and the exercises. I’m isolated at home.”
Furthermore, the cohesion experienced within the group lent itself to opportunities for support. In
the focus group, one participant made this comment when expanding on another participant’s
response that talking to each other in the group setting was helpful:
“Want dit bring jou af van die stroke en al dinge wat jy in jou gedagte gehad het... Dit
help, ja dit help baie.”
“Because it takes you away from the stroke and all the things that you had on your mind...
It helps, yes, it helps a lot.”
65
Another participant added:
“En jy dink nie jys verlam nie as jy gesels met mense nie.”
“And you don't think you're paralysed when you speak to the people.”
There was general agreement from the group with this statement.
These statements are clearly indicative of a group that experienced a sense of connectedness, with a
feeling of warmth towards one another and a sense of belonging, as is characteristic of a cohesive
group. Yalom54 includes the value that members place on a group in the definition of cohesion,
mentioned in Chapter 2. All aspects of the definition of cohesion were present in the BLRC stroke
group, according to the responses of study participants.
4.3.1.8 Self-esteem
Although this is not identified as a curative factor by Yalom,54 self-esteem was a theme that
emerged strongly in both questionnaire administration and focus group discussion. It has been
included in this section, as the psychosocial effects of group involvement should not necessarily be
limited to those identified by Yalom.54
From the questionnaire, there was evidence of boosted morale.

“Ek voel so lekker!”
“I f eel so good!”
“Wat jy nie kan gedoen het nie het jy nou gedoen met ‘n plesier en jy voel... voel
gelukkig.”
“What you couldn’t do before, you now do with pleasure and you feel... feel happy.”
There were also several mentions of people feeling adequate, self-sufficient and able to make a
contribution. For example:
“Ek wil my eie dinge doen want ek bly alleen by die huis met die kinders. Ek doen nog
steeds my eie werk in die huis. Ek gaan na [die winkel].”
“I want to do my own thing because I live alone at home with the children. I still do my
own housework. I go to [the shops].”
“Ek borsel self my hare en my tande. Alles doen ek self. Ek trek my aan.”
“I brush my hair and teeth myself. I do everything myself. I dress myself.”
A more positive self-esteem and boosted morale can be linked to Altruism. Literature reveals
altruism to be a contributor to improved self-esteem.53 It also states that overcoming the feeling of
being a burden to others and considering one’s self a person of value with something to offer is
66
attributable, at least in part, to altruism.54 It was also clear from the discussion around ‘imparting
information’ that the members of this group offered advice to one another. This, according to
Yalom,54 also contributes to the experience of altruism. Although no conclusion can be drawn that
participants experienced altruism in the group, it was evident that they experienced some of the
effects of altruism.
4.3.2 Meaning in terms of improvement in stroke-related areas of

recovery
4.3.2.1 Introduction
From the data collected from questionnaire completion by Groups B and C, as well as from the
focus group, it became evident that much meaning was derived from improvement in areas relating
to recovery from stroke, which participants attributed to their group involvement. Participants
placed value on the fact that they were now able to do things that they were previously unable to do.
The areas of improvement have been grouped according to the sections of the SIS v3, which
highlight the main areas of stroke recovery.73 The themes identified included activities of daily
living, strength, mobility, thoughts and memory, communication, mood and emotions and hand
function. A discussion of some of these themes follows.
There are different prognoses for the various areas of recovery post stroke. For example, hand
function is known to have a poor outcome in many instances.80 Compensation can, for example, be
made for mobility and ADL deficits, which cannot be made for thoughts and mood. Also, certain
of the areas of loss of function are more universal to stroke survivors than others. For example,
most would suffer a degree of loss of strength, whilst fewer are likely to experience communication
difficulties. The remaining level of difficulty experienced in each category can, therefore, not be
calculated in absolute terms, but it does serve to broaden the understanding of the post-stroke
experience of the population in question. It may also help to explain the meaning that participants
associate with the different areas of post-stroke recovery.
4.3.2.2 Activities of daily living

The highest reported improvement was in the area of improved ability to perform ADL.
Participants expressed their advances in these areas with enthusiasm and pride, demonstrating the
meaning that these activities, and subsequent role-fulfilment, had to them. It was interesting to note
that, although improvement in ADL functioning was not a direct aim of the stroke group, it
remained a method of measurement of successful outcome for most of the participants, and
participants attributed meaning to it. All of the activities referred to were either of a self-care or
domestic nature.
67
Some of the comments around the topic of ADL were as follows:
“Ek kan vroeg opstaan, ek kan my was en aantrek en almal die kan ek doen... ek kan my
werkies doen by die huis.”
“I can get up early, I can wash and dress myself and all of that... I can do my jobs around
the house.”
“Ek kon nie opgewas het nie, ek kon nie geveë het nie, ek kon nie my bed opgemaak het
nie. Al daai dinge. Ek borsel self my hare en my tande. Alles doen ek self. Ek trek my
aan.”
“I couldn’t wash up, I couldn’t sweep, I couldn’t make my bed. All those things. I brush
my hair and my teeth. I do everything myself. I dress myself.”
ADL was also emphasised as an important area of improvement, attributed to group involvement,
during the focus group discussion. Although the activities that were mentioned could be closely
associated with role-fulfilment, there was no specific mention of this by participants.
The average score on the SIS v3 for the category of ADL was 3.7, indicating that ADL were on
average ‘a bit difficult’ for participants (refer to Figure 4.6). The average score for self-care tasks
was 3.9 (closest to 4 – ‘a bit difficult’), and for domestic tasks 3.1 (closest to 3 – ‘quite difficult’).
Heavy home maintenance tasks – such as vacuuming and gardening – remained the most difficult
for participants, who rated 2.5 on average (between ‘quite difficult’ and ‘very difficult’). The
importance of the execution of ADL to participants was highlighted by the fact it was so frequently
mentioned as being a positive effect of the group, despite it scoring relatively poorly on the SIS v3.
4.3.2.3 Strength
Another commonly reported area of improvement was in strength.
“Ja, en my bene begin te sterk raak... My hand ook. Elke keer was dit pap, nou is dit
sterk.”
“Yes, and my legs are beginning to get stronger... My hand too. It was always weak, but
now it's strong.”
“Toe ek begin het was ek maar baie swak. Ek het baie, baie gedoen. Die ‘stroke’ groep
het my baie lewe gegee wat ek kan beweeg en so aan.”
“When I started I was very weak. I did a lot. The stroke group gave me a lot of life so
that I could move and so on.”
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“Dat ek kan staan lank op die been. Ek kan my arm ‘move’, ek kan dit vorentoe en
agtertoe sit. Groot verskil!”
“That I can stand on the leg for a long time. I can move my arm, I can put it forward and
back. Big difference!”
The average response for participants on the SIS v3 (See figure 4.6) was 3.5, indicating that
participants felt they had, on average, ‘a bit of strength’, or ‘moderate strength’ in their affected
arm, hand, leg, and foot.
4.3.2.4 Mobility
Only four participants reported mobility in the home and community to be ‘not at all difficult’ on
the SIS v3 (See figure 4.6). The remaining participants experienced varying degrees of difficulty –
particularly with walking fast (50 % of participants reporting this to be impossible). There were,
however, many comments attributing improvement in mobility to stroke group involvement. An
example is as follows:
“Die groep het my gehelp om te stap. Want ek kon nie loop het nie. Ek wou nie in die
rystoel gewees het nie.”
“The group helped me to walk. Because I couldn't walk. I didn't want to be in the
wheelchair.”
Whilst walking is crucial for most, it becomes even more so when walking is one’s dominant mode
of transport. As discussed previously (refer to 1.4), this was the case in this community, and for the
study population in particular (refer to 4.2.3.1).
4.3.2.5 Thoughts and memory

According to the SIS v3, participants experienced, on average (rating 4.1), only ‘a bit of difficulty’
with their thoughts and memory (See figure 4.6). The greatest amount of difficulty was noted
around the ability to think quickly (average rating of 3.1 – ‘quite difficult’). The impact of group
participation on thoughts and memory was not mentioned spontaneously by participants. However,
when this topic was raised during the SIS v3 section of the questionnaire, it emerged that
participants noted improvement at this level, which they attributed to group involvement.
“(Die geheue) verbeter omdat ek kan nou dinge wat gesê word, dinge wat gedoen word, ek
kan alles onthou.”
“(The memory) is improving because I can now remember things that are said, things that
are done, I can remember everything.”
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“Hulle help ons baie. Baie met die gedagtes saam. Hulle weet dat ons gedagtes nie elke
dag die dieselfde is.”
“They help us a lot. A lot with the thoughts. They know that our thoughts are not the
same every day.”
4.3.2.6 Communication
Improvement in communication emerged as a theme. This category on the SIS v3 (See figure 4.6)
is closely related to Yalom’s54 curative factor of development of socialising techniques (refer
4.3.1.5).
4.3.2.7 Mood and emotions

Several participants mentioned improvement in their mood and emotions. Words used to desribe
mood included ‘plesierig’ (pleasurable), ‘safe’ and ‘tevrede’ (satisfied). Members attributed their
improved mood to their participation in the group programme. The SIS v3 quantified participants’
ratings of their mood and emotions in terms of how often they experienced certain negative and
positive emotions. On average, the participants scored 4.3 for this category, meaning that they only
occassionally experienced negative moods and emotions (See figure 4.6). Most of the participants
reported that they smile everyday.
4.3.2.8 Hand function

Although several mentioned that their hand function had improved as a result of their group
attendance, a few mentioned that it had not improved at all. Hand function was the lowest scoring
section of the SIS v3, with an average of 3 (See figure 4.6). This means that, on average, study
participants experience ‘quite a bit’ of residual difficulty in terms of hand function. Hand function
is known to have a poor outcome in post-stroke recovery,80 so this was not a surprising result.
4.4 Factors influencing attendance or non-attendance of the BLRC

stroke group
The data gathered from each of the three groups did not vary sufficiently to warrant their individual
analysis towards the realisation of this objective. The findings are, therefore, presented below in an
integrated manner.
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4.4.1 Positive influence
The meaning that the stroke group has to participants, as discussed in 4.3, can be considered to have
positively affected their attendance. In addition to this, the following themes emerged:
4.4.1.1 Personnel
The comments made indicate that the style of group facilitation was important for the success of the
programme. It appeared that the skill of the group facilitator to encourage attendance and
compliance was a key factor.
“Net (die terapeute se) vriendelikheid al klaar trek vir jou om te kom. Dis nomer een.”
“Just (the therapists’) friendliness alone draws you to come. That’s number one.”
“Dit was altyd ‘n plesier om vir (die arbeidsterapeut) te ontmoet, en vir (die fisioterapeut).
Hulle was bedagsaam, vriendelik en mens se hart het eintlik uitgegaan. Hulle was… hulle
weet om met jou te praat, te gesels. Daar’s baie dae, as ek by die huis is, dan dink ek ‘aai,
ek wonder wat maak (die arbeidsterapeut)’.”
“It was always a pleasure to meet (the occupational therapist) and (the physiotherapist).
They were thoughtful, friendly and one’s heart actually went out. They were... they know
how to talk to you, to chat. There are many days, when I’m at home, that I wonder,
‘what’s (the occupational therapist) doing now?’.”
This sentiment came through even more strongly in the focus group discussion, in which
participants alluded to the consistency and approachability of staff.
“En nooit een dag of een week wat ons gekom het ek gesien (die fisioterapeut) se gesig is
suur of (die arbeidsterapeut) se gesig is suur nie. Altyd die vriendlikheid, altyd die
vriendlikheid wat ‘n mens trek... Dit wat ‘n mens so vry voel – vry om met hulle te praat
as jy vir hulle iets wil vra... Ja, en hulle sal nooit vir jou afjak nie – daai is so wonderlik.
Nee, daai is so inspireerend, ja, ja.”
“And not one day or one week that we came did we see (the physiotherapist) or (the
occupational therapist) with a sour face. Always the friendliness, always the friendliness
that attracted one... That's what makes one feel so free – so free to talk to them if you
wanted to ask them something... Yes, and they would never break you down you – that's
so wonderful. No, that's so inspirational, yes, yes.”
“Baie mense kom en kom en kom want hulle die ‘dinges’ hierso kry... sê maar hulle kry
die liefde hier [agreement from other members of group]. Want as hulle (die
arbeidsterapeut) se stem hoor dan ‘smile’ hulle. Dit het ek opgelet.”
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“Many people keep coming and coming and coming because they get something here...
let’s say they get love here [agreement from other members of the group]. Because when
they hear (the occupational therapist’s) voice, they smile. I’ve noticed that.”
The emphasis on staff attitude was not unexpected, given that interpersonal aspects of health care
provision form an important part of client satisfaction. Research has revealed assurance and
empathy to be the third and fourth highest ranking quality dimensions, respectively, in satisfaction
with human service programmes.81 Both of these dimensions are related to staff attitude towards,
and interaction with, the client. Assurance refers to politeness and friendliness of staff, and
describes whether or not staff is considerate and knowledgeable. Empathy refers to the staffs’
attempt to understand the perspective of the client, and to provide individualised attention.81 From
the responses of clients, highlighted above, it would appear that they were satisfied with these
dimensions of service delivery at the BLRC stroke group.
4.4.1.2 Activities
There were several comments regarding the overall content of the programme on an activity level.
However, certain activities stood out above the others as being favourites among the participants.
These are discussed below.
4.4.1.2.1 Exercises
Exercise was the activity reported to be enjoyable by the most participants in response to the
questionnaire. This was also true for the focus group, where several participants listed exercise
amongst their favourite activities of the group. The exercise component of the group was the most
consistently appearing activity of the group, occurring weekly during the physiotherapy aspect of
the group programme. This might account for it receiving the highest number of positive responses.
Other activities are repeated on a monthly basis (or less frequently) and can, therefore, be
considered as minor activities of the group. Another possible reason for exercise rating so highly is
its perceived effects on weakness, mobility and ADL - these being areas on which participants place
high value.
A few of the participants also mentioned continuing at home with the exercises that they were
taught in the group. This was positive, as one of the aims of the exercise component of the group
was to encourage home programme compliance and self-management.
“Die oefening, want wat ek hier leer kan ek weer oor gaan doen by die huis.”
“I can go and do the exercises that I learn here at home.”
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This point was raised again during the focus group
“Dan gaan ons huis toe, dan gaan doen ons daai selfde ding. Ja, dan gaan doen jy daai
selle ding daar en ek het dit - so baie goed.”
“Then we go home and we go and do the same thing. Yes, then we do the same thing there
- and I did - so many things.”
4.4.1.2.2 Games
Fewer participants commented on the games element of the group. However, those that commented
did so with non-verbal indication of excitement and joy. The competitive element of games
appeared to be the most enjoyable for participants.
“Ons speel baie mooi games. En nou en dan, dan wen jy. Dat ons vanoggend gehad het,
dan sê jy, ‘BINGO!’ …ek het amper gewen! Amper gewen. Ja, ek gaan eendag… die een
langs my… dis baie lekker.”
“We play very nice games. And now and then you win. The one we played this morning,
you say ‘BINGO!’… and I almost won! Almost won. Yes, I will one day… the person next
to me… it’s very nice.”
In addition to distraction from their problems, these activities provide opportunities for fun and
relaxation.
“Ja, (die speletjies) is lekker… ons speel en lag!”
“Yes,( the games) are nice… we play and laugh!”
4.4.1.2.3 Health education talks

Participants attributed improvement in knowledge, as mentioned in 4.1.3.4, to health education
talks. They identified the activity as having meaning, as well as the outcome thereof.
“Die geselsies. Ons was baie lief vir die geselsies. Daai het vir my baie geleer. Want ek
kan altyd vir die anders gaan vertel, ‘ons het vandag oor dit gesels’, en dit was goed.”
“The talks. We loved the talks very much. Those taught me a lot. Because I could always
go and tell the others, ‘today we spoke about that’, and it was good.”
The topic was also raised during the focus group, where the effects of the health education talks
were described by one participant as follows:
“Ja, my mind… maak jou mind ope. Dan kan jy beter dink en jou woorde beter sê.”
“Yes my mind... opens my mind. Then you can think better and say your words better.”
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4.4.1.2.4 Relaxation
Relaxation activities, in the form of relaxation therapy, were enjoyed by participants. This
participant described her perception of the process of relaxation therapy as follows:
“En wat ek ook baie van gehou het as (die arbiedsterapeut) vir ons ingeroep het, dan
moet ons doodstil sit en mens kry elk een ‘n kussing ... ‘n kussing, ja. Nou moet ons sit en
ons se oe toe maak, en dan speel die musiek ...”
“And what I also liked a lot was when (the occupational therapist) called us in, and then
we must sit very quietly, and each person gets a cushion… a cushion, yes. Now we must
sit and close our eyes and then the music plays…”
4.4.1.3 Structure
Positive comments relating to the structure of the group were made. These focused on the
consistency of the format, as well as the variety of the programme.
“Daar’s elke week ‘different’ goed wat ons gedoen het. (Dit) was baie goed gewees om
verskillende goed te kom leer.”
“There were different things that we did every week. (It) was very good to come and learn
different things.”
4.4.2 Negative influence

4.4.2.1 Transportation
Most of the responses relating to this objective were around difficulties associated with accessing
the centre. This was consistent with the literature,67,68 citing practical barriers (of which lack of
transportation is one) as a barrier for group involvement. This theme appeared the most strongly -
with transport difficulties being related to either financial constraints or absence of an appropriate
attendant to propel their wheelchair. Examples are as follows:
“Ek het nie weg gebly nie... Daar is niemand om vir my in te stoot nie.”
“I didn't stay away... there was no one to push me here.”
“Ek het nie altyd geld om vir mense te vra om my te neem nie. En ek kan nie op my eie
hier af gaan nie.”
“I don't always have money to ask people to take me. And I can't go down from here by
myself.”
The focus group discussion also revealed that access-related issues were the main cause of
absenteeism.
“Die groep het baie vir my beteken, ek kan dit weer sê, want ek verlang altyd so om te
kom, maar ek het geen een om my tot hier te bring.”
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“The group meant a lot to me, I could say it again. Because I always miss coming, but I
don’t have anyone to bring me here.”
Participants commented on the high costs of transportation when having to ask for lifts from friends
and neighbours (approximately twenty to thirty rand per trip). Very few of those attending pay
more that ten rand per trip, so it was assumed by the focus group that those with no alternative but
to pay the high rates stay away. Those who were able to walk, or who were within reach of the
BLRC by attendant propelled wheelchair, and who had an attendant available, accessed the BLRC
by these means (refer to 4.2.3.1). This agrees with the demographic findings of the population of
Bishop Lavis in general as well.
4.4.2.2 Family responsibility

One participant cited family responsibility, in the form of caring for a grandchild, as her reason for
non-attendance. Another reported this responsibility in the form of caring for her child with
disabilities. These informal work issues are also included in the literature as barriers to group
inclusion.68
4.4.2.3 Weather
Wet weather was given as another reason for non-attendance. This may be because the drainage
systems of the area are insufficient, leading to flooding of the road in front of the BLRC in heavy
rains. This occurs several times each winter. Paving and road surfaces in the area are also in a state
of disrepair (refer to 1.3), which result in difficult and muddy travel in wet weather. Stroke group
members with mobility limitations (the majority of the group participants) are also slower, and,
therefore, may become very wet if attempting to access the BLRC on foot, or by wheelchair, in wet
weather. The low socio-economic status of the area may also mean that people cannot afford to buy
appropriate rainwear.
4.4.2.4 Emotional/personal
Low levels of motivation for participation in all activity, which included group attendance, were
also reported as a reason for absence. This agrees with the literature stating that lack of personal
motivation serves as a barrier to group involvement.68 It was also consistent with the increased
rates of depression and decreased participation in social activities that are often characteristic of
stroke.44 One participant reported to be experiencing a personal crisis that limited his ability to
attend.
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4.4.2.5 Personnel
The dislike of receiving therapy from students, and the involvement of volunteers, was also cited as
a reason for poor attendance. Participants felt that the presentation of exercises was inconsistent as
they were presented by a wide variety of people over the course of time. Over the course of 18
months, the stroke group would be exposed to seven teams of students. This is a high level of
turnover of group presenters, but is inevitable, as part of the terms of the agreement between
Stellenbosch University and the Department of Health (refer to 1.4).
4.5 Recommendations regarding improvement of the programme

Of the high and medium attendees, Groups B and C, none reported anything they did not enjoy
about the group. Responses were positive. Some examples are:
“Ek het gehou van alles wat gedoen is. Ek was een honderd persent tevrede.”
“I liked everything that was done. I was one hundred percent satisfied.”
“Ek kan nie eintlik sê daar is niks lekker nie, want alles wat ek hier doen geniet ek.”
“I can't actually say there was anything about the group that I didn't enjoy, because I
enjoy everthing that I do here.”
“Ek het nog nie so ver gekom dat ek kan sê wat nie reg is nie. Die een wat nie tevrede is
met daai oefeninge is dom.”
“I haven’t yet gotten as far as being able to say what’s not right. The person who is not
satisfied with those exercises is stupid.”
Few direct suggestions for improvement were forthcoming. From those given, no trend could be
established.
One suggestion was that there should be more consistency between the exercises presented by the
various students and therapists involved with the group.
“Die studente doen nie almal dieselfde oefeninge nie en dit gaan jou verwar. Wat ek
eintlik bedoel, wat ek wil probeer sê - hulle moet nou net almal die selfde doen. Want leer
ons dan baie meer daar uit.”
“The students don't all do the same exercises and that will confuse you. What I actually
mean, what I'm trying to say - they must all just do the same exercises. Because we'll
learn much more from that.”
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Another suggestion was that another centre such as the BLRC should be established so that more
people could be helped.
“Hulle moet maar nog ‘n sentrum opsit. Die selfde wat hulle... die vriendelikheid van die
personeel wat daar werk, en nog mense kies om nog meer vir die mense te kan sê wat
moet hulle doen... want ons is so baie mense.”
“They must erect another centre. The same as they... the friendliness of the staff that work
there, and choose more people to be able to tell the people even more what they should
do... because there are so many of us.”
Expansion of the topics for health education talks was suggested. A specific request to provide
more information regarding pain was made.
“Kan daar nie ‘n student wat met die arm pyn of die been pyn - wat nou daai studente wat
nou daar in leer - ek dink hulle moet eintlik meer in kom vir die mense te verduidelik
hoekom pyn jou been en so, of hoekom sal jou been styf is en so.”
“Can't a student who is learning about arm pain or leg pain - I think they should actually
come to explain to the people more often why your leg pains and so, or why your leg is so
stiff.”
More group outings were suggested.
“Meer uitstappies. As... mense hier bymekaar kom, en ‘n mens kan nou uitgaan - oor twee
maande gaan ons na soontoe – na ‘n plek toe. Ons besluit nou watter plek nou saam... Op
die oomblik gaan ons net een keer in ‘n jaar uit. Meer uit gaan – die mense geniet dit om
uit te gaan.”
“More outings. If people could get together here, and then go out - in two months time
we're going there – to such a place. We'd decide where to go together. At the moment we
only go out once a year. Going out more - the people like going out.”
Two participants, who were attending the community stroke rehabilitation group at the time (having
recently completed eighteen months at the BLRC stroke group) suggested more exercise at the
community group.
“Daar onder by die dinges daar, oefen ons nie baie nie... Daar’s nie genoeg oefeninge daar
nie. Net hier.”
“There, at that other place, we don't exercise a lot... There is not enough exercise. Only
here.”
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“Man, ek dink nou, ons sit ‘n bietjie baie stil. Ons sit ‘n bietjie baie stil. As hulle iets kan
maak soos bal speel of so.”
“I think we sit a bit too still. We sit very still. If they did something like playing ball
games or so.”
There were no suggestions for improvement from the group of low attendees (Group A), all of
whom stated there was nothing they did not enjoy about the group.
“You know, I think the way you’re going on now, it will make anybody a pleasure to go
there. I can’t give advice what experience I have, that excellent group.”
In-depth exploration of these topics in the focus group revealed no further suggestions. The group
provided an overwhelmingly positive response, and could not contribute even one suggestion,
despite prompting. Some of the focus group participants had made some of the suggestions
mentioned above in their questionnaire completion. When asked about these particular suggestions,
they provided no further information. This may mean that the focus group applied a form of peer
pressure. The other alternative for the failure to provide suggestions is that changes to the
programme may have been made during the time lapse between questionnaire completion and focus
group (approximately six months). Although there had been no major changes to the group in this
time, the centre does continually strive to improve its standards of care. Therefore, some smaller
changes may have occurred. There have been group outings arranged to Table Mountain, the
Planetarium and Kirstenbosch Gardens, for example.
The focus group was asked about factors pertaining to the organisational level of the group –
specifically size of the group, day and time, as well as duration and frequency of sessions. There
was general satisfaction regarding these factors, although a few participants did feel that sessions
could be longer.
From the averages of participant’s scores on the SIS v3 (See fig 2.6), it has been identified that
participants experience the highest level of residual deficit in the areas of hand function, physical
ability and mobility. These areas could perhaps receive increased focus during the group
rehabilitation process. It must, however, be noted that these are the areas in which stroke survivors
are most likely to experience residual difficulties,80 and so will not necessarily be improved by
increased attention. Interestingly, these areas of recovery coincide with certain participants’
recommendations of increasing the exercise component of the group.
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4.6 Other results
One of the benefits of qualitative studies is the opportunity for the emergence of data not originally
aimed for. In the case of this study, two interesting themes emerged from the focus group that have
not been mentioned thus far. These results do not have direct bearing on the study objectives, but
are interesting and potentially useful observations, and have, therefore, been included.
4.6.1 Personal responsibility for rehabilitation

A strong theme of individual motivation and the importance of taking control of circumstances, as
well as responsibility for one’s own rehabilitation, were revealed. This was a most encouraging
observation, as it indicates that the particular population was accepting the social model of
disability, and was taking over the leading role in their own rehabilitation. This is a welcome shift
from the previously observed reliance on health professionals within the historical medical model.
“En nog ‘n ding – dan moet jy jou eie kant bring… Jy moet jouself kan gehelp het. Hulle
het jou gehelp met alles, maar jy moet jouself kan gehelp het.”
“And another thing – then you must play your part. You must help yourself. They helped
you with everything, but you must have helped yourself.”
“Dit hang baie van ‘n mens se mind af. As jy wakker skrik, dan dink jy, ‘wat gaan ek doen
vandag.’.”
“It depends on one’s mind. When you wake up, you think, ‘what am I going to do today’.”
“Daar’s altyd iets nuuts en jy leer baie daar uit as jy net notisie neem – notisie neem
daarvan.”
“There’s always something new and you learn a lot from that, if you just take notice – take
notice of it.”
4.6.2 The role of the community in rehabilitaiton

As discussed in Chapter 2, the community should retain primary responsibility for the rehabilitation
process. The focus group discussion highlighted several inadequacies in the community in
fulfilling this role. Firstly, a perceived inadequacy in meeting the support needs of the stroke group
participants and their caregivers was highlighted. This was found lacking on an instrumental level
as well as on an emotional level. It was demonstrated by the following comment that was made by
an elderly lady, with an above knee amputation, who cares for her husband who had recently
sustained a second stroke:
“Die twaalfde het hy die stroke gehad, en toe het ek nou vir die hele maand gesukkel
alleen met hom. Want ek dink toe ek kan hom heen toe bring, maar nou weer die
‘gesukkelry’ met die trap en almal daai. Met die gevolg dat ek maar met die help van die
Here self probeer, en die ‘neighbours’ gevra om te help en so aan. En gelukkig het sy
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skoonsuster vir my ‘n kommode geleun en dit - dit kon ek gebruik het om vir hom... maar
ek moet hom help daarop en ek moet hom help met alles...”
“He had the stroke on the 12th. And then I had to struggle alone with him for a whole
month. Because I thought I’d bring him here again, but there again was the struggle with
the steps and so on. With the result that, with the Lord’s help, I tried on my own. I asked
the neighbours to help and so forth. And, luckily, his sister-in-law lent me a commode –
and I could use that to... but I have to help him onto it and I have to help him with
everything...”
The comment demonstrates the determination of caregivers, and provides hope that when caregivers
seek assistance, it is at times forthcoming. However, it would seem that more could be done to pre-
empt this type of situation. This couple should have been identified by the health care facility in
question as in need of assistance from other community resources – for example home-based care
and Meals on Wheels. They should also have been referred to the BLRC, where a home visit and
the provision of assistive devices may have been arranged. Referrals would have been accepted by
the BLRC from any person in the community – including a doctor, the client himself, or a
neighbour.
The perception of the group was that support was lacking for many stroke survivors.
“Almal staan mos nie mekaar by soos ons families ons bystaan. Baie mense worry nie
met jou nie, jy moet kyk na jou self. Nou lê hulle maar daar.”
“Not everyone supports each other like our families support us. Many people don’t worry
about you, you have to look after yourself. So now they just lie there.”
A further inadequacy was shown through several mentions of the inaccessibility of the community
because of physical barriers. These included stairs at stations and inaccessible public transport
systems. In this sense, the insufficiency of basic services in the community is hindering the
rehabilitation process (refer to 5.3.1).
Societal attitude arose as another barrier to rehabilitation. The potential of people with disabilities
often being underestimated was mentioned in Chapter 2 as a reason for the low prioritisation of
rehabilitation. This phenomenon was highlighted by two participants.
“Dit maak my dan hartseer. Soos wat hulle doen, kan ek nie volgens hulle nie. Hulle sê
ek kan niks doen nie En ek sê, ‘ek was maar ‘n ‘nurse’, want dink julle dan’.”
“It makes me sad. What they can do, I can’t do according to them. They say I can’t do
anything. And I say ‘I used to be a nurse, what do you think?’.”
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“Nou, party mense dink mens kan nie onthou nie. Maar jy kan onthou wat gesels gewees
het en wat gesê gewees het.”
“Now, some people think a person can’t remember. But you can remember what was
spoken about and what was said.”
Perhaps the mind-shift in this area has yet to occur in the community of Bishop Lavis. Given the
high incidence of disability in this area, it would seem a priority to effect changes in this regard.

The overall demographic profile of the study population is similar to the general population of
Bishop Lavis in terms of ethnicity, language and most common mode of transportation, but it
differs in average age, given that the study population is older than the average population of
Bishop Lavis, and younger than the average age of stroke survivors. There is little notable
difference between each of the three sub-groups in terms of demographic profile.
The stroke group provided meaning to participants on two levels. The first was a psychosocial
level, which was explored according to Yalom’s54 curative factors. In this area, universality,
development of socialising techniques, imparting information and cohesiveness emerged strongly.
The second level was meaning related to improvement in areas of stroke-related recovery, discussed
according to subsections of the SIS v3. Here, improvement in ability to execute ADL, mobility
and strength were most frequently mentioned.
Transportation issues were revealed to be the most commonly mentioned factor limiting attendance
of the stroke group at the BLRC. Of all the participants, only one reported staying away because of
negative associations with the centre and group. All other reasons were related to logistical issues
and environmental barriers. The problems relating to group attendance were common to all three
participant groups, whether high or low attendees.
Very few suggestions were forthcoming regarding improving the group programme. These will be
discussed in more detail in Chapter 5.
In addition to the above information emerging around the stated objectives, other points of interest
also emerged. These were around the empowerment of participants to take personal responsibility
for their rehabilitation, and the role of the community in the rehabilitation process.
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Chapter 5
CONCLUSIONS AND RECOMMENDATIONS
5.1 Introduction
This chapter brings the study to a close with the conclusions drawn from the data collected and
from the literature reviewed. Based on these conclusions, recommendations are made with regards
to improvement of the stroke group programme. Limitations of the study are highlighted and
recommendations regarding further study are made.
5.2 Conclusions
5.2.1 Meaning that the stroke group has to participants
It emerged that the BLRC stroke group was positively experienced by the majority of the study
participants. The programme held meaning to participants on two distinct levels:
Firstly, the group was meaningful on a psychosocial level, which largely corresponded to the
curative factors of groups identified by Yalom.54 Although it was not a study objective to compare
the experiences of group participants with these curative factors, the possible link between these
factors and stroke recovery, suggested by the literature, was explored. It became evident that the
curative factors of instillation of hope, imparting information, universality, development of
socialising techniques, and cohesiveness were experienced by the study population in the group
context. From the comments made by participants, it can be concluded that this was a cohesive
group, with members experiencing warmth and trust. This warmth and trust create an atmosphere
of acceptance, necessary for effective sharing. The process of disclosure was further aided by the
participants’ experience of universality within the group – knowing that they were not alone with
their problems. The afore-mentioned factors resulted in the group being an effective forum for
imparting information – both formally and informally. Members particularly placed value on the
opportunity to learn from each other. The group also provided a context for the development of
socialising techniques, which was especially meaningful to those with communication difficulties.
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Secondly, the group held meaning for the participants by virtue of the improvements that they noted
in their own abilities. The most frequently mentioned improvements, attributed to group
involvement, were in the ability to execute ADL – particularly in the areas of self-care and domestic
tasks. Other areas of improvement noted were in strength and in mobility, as well as in thoughts
and memory.
It can be concluded that stroke group involvement had meaning to participants, and that they
perceived their group involvement to have had positive effects on their post-stroke recovery on both
a physical and a psychosocial level.
5.2.2 Factors influencing group attendance

Factors which positively and negatively influenced attendance were identified.
Attendance was positively affected by the favourable attitude of staff members, who were described
as friendly, inspiring, up-building, and approachable. Other positive factors identified were the
activity programme – particularly the exercises, health education talks, and the games. The variety
of the programme, together with the consistency of the format, was also stated as a positive factor.
Attendance was, to a large extent, negatively affected by issues related to transportation in this low
socio-economic community. These issues included: limited availability of suitable transportation;
limited availability of caregivers to push wheelchairs; and limited ability to afford transportation
costs. Family responsibility, as well as personal circumstances, also had a negative effect on group
attendance. This was also true for adverse weather conditions – specifically, wet weather. On a
personnel level, attendance was negatively influenced by inconsistency in the style of exercise
presentation by the various students and staff members.
5.2.3 General conclusions

The aims of the stroke group programme, as mentioned in Chapter 1, are as follows:
Maintaining physical abilities – range of motion, tone normalisation, balance and
endurance.
Reviewing home exercise programmes
Monitoring physical status
Provision of a forum for socio-emotional support
Intellectual stimulation
Promotion of autonomy
Health education
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All of these aims emerged as having had meaning for the study participants. From this, it can be
deducted that the stroke group programme, in its existing format, is achieving its aims and that
these aims are appropriate for the clients involved. However, the question of whether the BLRC
stroke group is useful as part of the solution to the problems facing stroke rehabilitation in South
Africa, as a developing nation, remains. Based on the following factors, the author suggests that it
is:
The stroke group – with its emphasis on self management and empowerment – is
congruent with the social model of disability, which is gaining increasing popularity
within the medical field.22 As mentioned in 2.2.1, the social model of disability
emphasises the degree of control held by the individual, which places him/her in the centre
role for his/her health care. Responses of participants indicate their empowerment, and
resulting acceptance of responsibility for their rehabilitation, which shows their movement
towards the social model of disability. Certain of the participants made reference to this
being, at least in part, due to their involvement with the group.
Involvement in the stroke group programme can span 18 months, after which clients have
the option of attending the community stroke support group. This time frame was selected
by the involved therapists in the absence of definitive literature regarding the use of
therapeutic groups for stroke rehabilitation. Literature shows the most motor recovery
occurring within one year post stroke, although functional recovery can continue for
years.60 After initial, more intensive, individual rehabilitation, the BLRC stroke group
programme aims to help maintain participants’ achieved levels of physical and
psychosocial functioning. This is in line with the literature46 stating that a sustained
approach to intervention reduces deterioration in stroke survivors. This sustained
intervention is not possible on the level of individual intervention due to resource
constraints. Participants acknowledged that this role was fulfilled by the group
programme when they attributed long term improvement and maintenance of abilities to
their involvement with the group. Rehabilitation is a dynamic process. Within the group
programme, individuals can also be monitored and referred for further individual
intervention or to secondary or tertiary rehabilitation services, if necessary.
The stroke group is locally available and culturally appropriate, as is required of stroke
rehabilitation strategies by the Melbourne Declaration of the Asia Pacific Consensus
Forum on Stroke Management,50 and of rehabilitation in general by South Africa’s
National Rehabilitation Policy.17 Although it is well documented that there are cultural
84
differences in perceptions of post-stroke disability and rehabilitation,82 it is not a simple
task to determine whether or not interventions are culturally appropriate.
The Conceptual Framework for the Provision of Culturally Competent Services in Public
Health83 outlines several systems that need to be addressed in order to ensure the cultural
competence of a programme. These include the context, the organisation, service
delivery, and the client and his/her family. This framework states that, amongst others, a
service is culturally competent where the client has an influence on service delivery,
where members of staff have a positive attitude towards working with culturally diverse
clients, and where service providers have a good understanding of their own cultural
background, and can acknowledge that other cultures may be different from their own. It
also requires having a culturally diverse staff, ongoing capacity to gain information on the
population’s culture, and flexibility in policy and procedures.
Many of these criteria are met by the BLRC, which has a culturally diverse staff and
strives towards understanding the cultural group it serves. This understanding is achieved
by means of a close interaction with clients, their families, and volunteers from the
community. Clients influence service delivery by their participation in satisfaction
surveys, which are acted upon to improve the programs of the BLRC on an ongoing basis,
made possible by the flexibility of the BLRC’s programmes. Given that the study
participants approved of the activities of the programme, as well as of the staff attitude, it
is concluded that this programme is culturally appropriate to the population it serves. The
importance of this must not be underestimated, as one’s culture defines how one lives
socially – not just as an individual – and shapes the identity of that individual.84 By
understanding a client’s worldview, a therapist is better able to understand their behaviour
and to motivate them.
The stroke group fits the profile of PHC services, which requires maximum use of
resources, participation of the patient and the community, as well as affordable and
accessible services, which integrate all levels of disability prevention.4 It is evident from
the findings of the study that the participants are actively involved in the group
programme through their role in the informal imparting of information. The sense of
responsibility that participants have towards each other, and the encouragement they draw
from each other, is demonstrated by the strong cohesiveness and the sense of universality
of the group. Members are actively involved in the development and sustainability of the
programme by means of their completion of bi-annual satisfaction surveys. They report to
be benefiting from strategies of disability prevention, on various levels, that are offered
85
within the group programme – from primary intervention (offered through health
education), to tertiary (by means of rehabilitative exercises). The community is also
involved in the BLRC’s group programme, with volunteers assisting in group-facilitation,
and family members and carers of clients attending health education sessions periodically.
The community also supports the BLRC in organising and executing annual events – such
as the BLRC Big Walk, and the Christmas party.
The stroke group also aligns with the Western Cape Province’s 2010 health care plan to
focus services at community level – providing basic level services for more people, rather
than specialist services for the minority.9 The group programme undoubtedly reaches
more people than the same number of therapists could reach on an individual level. The
positive response of participants to the programme indicates that this basic level of service
is, at the very least, acceptable to them.
The stroke group is a stepping-stone in a complete rehabilitation process, in which there

should be a graded withdrawal of support – as is required by definition of rehabilitation.21
All stroke clients referred to the BLRC first receive individual intervention, which is later
combined with, and then retrograded to, less intensive intervention that is provided by the
group programme. Thereafter, intervention is further graded to a community support
group, facilitated by volunteers. One participant mentioned that she no longer felt she
needed the group intervention, and was, therefore, able to self-discharge. Other
participants referred to their increasing responsibilities that kept them from attending the
group programme regularly. This is positive, given that the final outcome of successful
rehabilitation is the full reintegration of the individual into his or her community, which
includes the fulfilment of relevant roles. The above examples highlight the ability of the
group programme to allow for graded withdrawal of support in rehabilitation.
Given the participants’ positive response to the group programme, and its ability to save
time and money, it would seem an appropriate supplement to individual therapy. The
literature suggests the use of the most cost-effective method of stroke rehabilitation in the
absence of conclusive findings around the superiority of any particular approach. The
stroke group can certainly be considered a treatment option in this case, as those involved
perceive the group to be effective in both physical and psychosocial aspects of
rehabilitation.46
The literature35 calls for innovative rehabilitative strategies which are appropriate,
necessary, and accessible. The BLRC stroke group appears to be well on its way to
achieving these strategies.
86
Finally, if motivation and hope are, indeed, critical to stroke recovery,57 then the BLRC
provides an excellent forum for stroke rehabilitation, given that the global impression of
the group participants is positive, optimistic, hopeful, and inspired. These are the
ingredients for sustained involvement in rehabilitation services and programme
compliance.
5.3 Recommendations
5.3.1 Access-related difficulties
The BLRC, together with its clients, has a role to play in advocacy for the rights of people with
disabilities. One of the aims of the BLRC is the empowerment of the community. It is fitting, then,
that the BLRC should empower the disabled people of this community to take action in this vital
area of community integration. The study can be used as an advocacy tool to this end.
Innovative strategies are required to overcome the access difficulties (such as inaccessible transport
systems and the poor state of roads) that face stroke group participants, as well as others with
disabilities, in this community. Access-related difficulties are a large-scale problem, and require an
integrated approach. It is, therefore, recommended that the municipal council of the Bishop Lavis
area be approached with regards to the use of these findings as part of an Integrated Development
Plan (IDP). An IDP requires a municipality to take the existing, and needed, resources into account
to develop the necessary infrastructure and services in a community. The IDP aims for municipal
districts to devise long-term development strategies, based largely on the needs identified by
relevant communities’ themselves.85 As such, the findings of this study should be welcomed by the
Bishop Lavis municipality.
This approach should be taken in collaboration with the local health committee, as well as with the
relevant disabled persons’ organisations, as the difficulties experienced by the BLRC stroke group
participants are likely to be universal to other people with disabilities in this community. In
collaboration with these organisations, problems can be prioritised before submission to the
municipality. These problems would, ideally, include: addressing the difficulties associated with
inaccessible transport; and the poor state of roads and paving in the area.
5.3.1.1 Transport
In addition to the above, there are other possible, alternative, solutions to the problems associated
with transportation:
‘Dial-a-ride’, a transportation service for people with disabilities, is available to people in
this community. However, the BLRC has lodged several complaints, on behalf of their
87
clients, for waiting times for lifts in excess of four hours. In its current state of operation,
this service cannot be recommended as a viable solution for the transportation needs of
this group. This study can be used to make recommendations with regards to extending
and improving this service – and particularly regarding the acquisition of additional
funding for the service, given that a need has been identified in this area.
The Department of Health can be approached to extend the availability of patient

transportation services. This should be motivated on grounds of the increased resource
allocation to PHC facilities. A disabled-accessible service would be required. This
option, however, does not encourage the integration of services called for by the
philosophy of PHC and CBR, and so is not the solution of choice.
A better option, perhaps, would be for the community to approach The Department of
Transportation with regards to the improvement of the accessibility of public transport
vehicles and train stations. Should these services become more inclusive, the necessity for
specialist services for people with disabilities would be diminished. This would assist in
removing environmental barriers, hereby decreasing disability in this community as a
whole, whilst benefiting the stroke group as well.
The above recommendations are on a large and long-term scale. On a more immediately
feasible level, the BLRC should aim to create a pool of volunteers who can push people to
the centre in their wheelchairs. The BLRC already has an extensive network of volunteers
who are managed by the staff of the centre. This pool could be further expanded, with
existing strategies of sustainability applied, to meet this identified need.
Issues of volunteer sustainability in this low socio-economic community have largely been
overcome by the BLRC staff seeking to understand each person’s motive for volunteering,
and then attempting to meet their needs by appropriately matching the person to the task.
Volunteers are encouraged to expand their skills at the BLRC, and so are provided with
regular supervision and informal skills training. This helps to sustain the volunteers’
interest in their work, and can increase their employability in the long-term. It is
considered a success when a volunteer leaves the BLRC for paid employment where they
are able to utilise some of the skills they have acquired. New volunteers often approach
the BLRC to offer assistance, and so the cycle continues. Although the BLRC is not in a
position to financially compensate the volunteers, they are acknowledged in numerous
ways. Volunteers are nominated for awards, taken on outings (for example, to Table
Mountain), given small gifts, and treated to special meals at the BLRC during the year.
88
5.3.1.2 Weather-related difficulties
An alternative strategy suggested to overcome access-related difficulties due to wet weather is:
The sourcing of rainwear at an affordable rate for stroke group members. This can include
raincoats, plastic boots and waterproof wheelchair capes. The BLRC is not unaccustomed
to requesting donations. The acquisition of these items can form part of the BLRC’s
ongoing aim to meet the rehabilitative needs of the community. Attempts can be made to
source these items from local factories. Additionally, organisations can be approached for
cash donations to this end.
5.3.2 Childcare facilities

An informal system of child-minding should be established at the BLRC to tend group members’
dependant minors whilst they participle in the group. This service should be free-of-charge, and
could be run by volunteers, who are appropriately referenced and trained
5.3.3 Health education

The stroke group programme has created an effective environment for imparting information.
Given the increased emphasis on preventative care, it would seem an ideal opportunity to involve a
greater number of the health care team in educating the group members. This would aid in
providing a greater variety of topics, as was suggested by one member. A survey should be
conducted to ascertain the interests of the stroke group around health topics, as well as to identify
areas of insufficient knowledge. Further opportunities can be created for peer learning. For
example, group members can be invited to lead discussions around topics within their frame of
reference, or to share testimonies of their post-stroke experience.
5.3.4 Focus of input

Greater attention can be paid to those areas on the SIS v3 in which participants expressed the
greatest amount of remaining difficulty. It must be borne in mind that certain of these aspects are
known to have poorer outcome – particularly hand function. However, an increased emphasis on
weight bearing and bilateral hand use, as well as other strategies to address hand function could be
trialled in order to ascertain whether they have a positive effect. Possible strategies for improving
hand function, that can be incorporated in a group setting, based on the Bobath technique, are
incorporation of the affected hand in bilateral activities, by using the protective extension reaction,
and by application of specific neurodevelopmental techniques of tone normalisation.86
89
Other areas that would benefit from increased attention, according to the SIS v3, are physical
strength and mobility. This would indicate an increased emphasis on exercises during the group
programme, which coincides with the activity most frequently cited as enjoyable and beneficial by
the group. This aspect of the group already enjoys a substantial amount of attention, so it is
doubtful that further expansion in this area would have further effect. It could, however, be
researched in future to ascertain if increased exercise in the group context has an effect on strength
and mobility of participants.
5.3.5 Personnel
The attitude of staff should remain positive. This must be achieved by existing staff modelling the
desired attitude and interaction style to all new students, volunteers and paid staff who become
involved in the programme. The impact that staff attitude has on the attendance of group
participants should be highlighted to the staff in order to encourage ongoing positive attitudes.
Strategies must be put in place to monitor the consistency of exercises presented by students in
order to ensure that group participants experience security during group sessions, and that they are
comfortable in the knowledge that they can perform these exercises correctly at home.
It is imperative that all role-players clearly state their own, and understand each other’s, needs and
expectations. Negotiations must be undertaken by Stellenbosch University, the BLRC and its
clients, with regards to the role of students at the BLRC. A valuable forum for such negotiations
would be an annual general meeting at the BLRC. Such meetings are not currently held. A
recommendation of the study is, therefore, to schedule such meetings in order to promote
communication between all stakeholders, and to clarify needs and expectations.
5.3.6 Group outings

The frequency of group outings must be increased, as this is a good opportunity to highlight
accessibility issues in Cape Town, increase the life-area of participants, and to create further
opportunities for the development of socialising techniques. It is also a good opportunity to address
attitudinal barriers by increasing awareness of disability. It is recommended that a minimum of two
group outings be held per annum for the stroke group.
5.3.7 Group structure and activities

The current structure and activities of the group should be maintained, given that the participants
responded positively with regards to the existing programme.
90
5.3.8 Community stroke group
The Bishop Lavis community stroke group is an extension of the BLRC stroke group programme.
Its volunteer facilitators are trained and supervised by the staff of the BLRC. The suggestion for
increased exercise in the community stroke group has already been effected since the data collection
phase of this study, when new volunteers took over the facilitation of this group. Volunteer training
has included more input regarding the importance of exercise, and the format of the community
group is now more in line with the format of the BLRC stroke group.
5.3.9 Facilitation of curative factors not identified by participants

The aims of the stroke group programme can be amended to ensure that they cover the spectrum of
Yalom’s54 curative factors. In this study, there was limited evidence of altruism, catharsis,
recapitulation of the family group, and existential factors. This is possibly because no specific
probing was done into these areas. However, as these have been shown as curative factors by
Yalom,54 they warrant attention within the existing group programme. In some of these factors, the
assistance of team members with specialised, psychological training may be required. The mental
health team at the CHC should therefore be invited to give input into the stroke group programme.
5.3.10 The role of the BLRC in educating the community

The role of the community in stroke rehabilitation remains to be developed in terms of creating
opportunities for stroke survivors and eradicating barriers. Buffers (as discussed 2.2.1), in the way
of instrumental, educational, and emotional resources must be developed. Stroke group participants
experienced the underestimation of their abilities by others, which is a societal attitude that must be
overcome. As this issue emerged as being of importance to several of the participants, it could
become a project of the stroke group to raise awareness of environmental barriers in Bishop Lavis,
as well as to attempt to de-stigmatise disability. A project of this nature could help in the process of
empowerment, as well as in providing a task through which key aims of the group can be achieved.
It could also be an excellent opportunity for students based at the BLRC to gain experience in an
advocacy role.
5.4 Limitations of the study and recommendations for further

study
This study provided a generally positive evaluation of the participants’ experience of
stroke group involvement. Yalom54 comments that negative experiences of group
involvement sometimes only emerge years after involvement with a group has ceased.
This study involved people with current, or recent, involvement in the group programme.
91
It is, therefore, recommended that a follow-up study be conducted with the study
population in order to re-evaluate their experience of stroke group involvement after
approximately four years, as was done in Yalom’s54 study. A possible problem around
this recommendation is the high mortality rate of stroke survivors. During data collection,
it also proved difficult to trace people no longer associated with the group programme, due
to them moving away, and there being underdeveloped formal communication systems in
the community. Given that the study population is already small, these factors might yield
too few possible study participants after that sort of time period has elapsed.
This study has limited use in terms of generalisability. The study population has placed
their own values on their experiences. Therefore, what is true for this population cannot
necessarily be considered important for other populations. Whilst results could be
extrapolated to other communities with comparable demographic profiles, it is
recommended that other group programmes in differing contexts be studied to determine
the meaning that group involvement has to them.
The study population was relatively small. This meant that little could be statistically
proven in terms of significance, due to large margins of error. This was an unavoidable
situation for the study, but perhaps can be overcome, in future, by the application of an
alternative study design, should the research question be different. For example, the
qualitative aspects of this study can provide a foundation for further quantitative study,
which uses the themes that have emerged to form the research hypothesis. The data
collected from the study participants was fairly repetitious, suggesting that a larger
population would not necessarily provide more extensive results. The implication of this
is that the sample size was appropriate for the study, despite its relatively small size.
Yalom’s54 curative factors, and the impact that certain of these had on group participants,
was identified late in the study. As it was an emergent study design, this factor is not
necessarily a limitation. However, it is recommended that with further study, a
questionnaire be developed around Yalom’s54 curative factors in order to identify the
extent to which the remaining factors are experienced by the members of a stroke group.
The researcher was very closely involved with the study population. As discussed in
Chapter 3, and in line with practice-based research, this factor was used to advantage. It
must, however, be borne in mind that this can also be a limitation, in as much as it is a
potential source of bias. Participants may have wished to please the researcher by giving
favourable reports of their experiences. Researcher bias also becomes more difficult to
92
avoid. A recommendation is that the research be repeated with an uninvolved examiner in
order to ascertain whether or not the results correspond.
A limitation of the study is that no in-depth interviews were conducted, and only one focus
group discussion was held. This limits the depth of information obtained. Also, no
member-checking was done, so the interpretation of results is not necessarily accurate.
Purposive sampling was not used in selection of participants for the focus group, which
may also be considered a limitation.
Data was collected almost exclusively from the client, and took little cognisance of the
client’s family. Although primary caregivers were present during eight administrations of
the questionnaire, and one formed part of the focus group discussion, more could be done
to understand the perspective of this important set of stakeholders in future research
around this group programme.
The community of Bishop Lavis has low education levels (refer to 1.3). The study
population is, therefore, also likely to have had low education levels. Low education
levels often translate to a limited ability for abstract thinking.87 The data provided may,
therefore, have been limited by the limited ability of the population in question for
reflective thinking. However, the fact remains that the participants in this study have had
a particular experience because of their group involvement. This may, or may not, have
been influenced by their limited ability for abstract thinking. This experience may, or may
not, be drastically different from the experience of those with more advanced ability for
abstract thought. The recommendation would, therefore, be for further study of group
programmes, attended by people from a community with higher educational levels, in
order to determine their experiences of a group programme.
This study has tended to focus on the psychosocial aspects of group involvement, as these
are more exclusively attributable to the group programme. Physical aspects of
rehabilitation are more often confounded by external variables. This situation can be
overcome by the application of alternative methodology to future study around the group
programme. A case-control study, for example, could be executed.
It is recommended that further study be undertaken with this stroke group programme in
order to address some of the remaining questions around the effectiveness and
appropriateness of its use, raised in Chapter 1 (refer to 1.5). For example, an objective
assessment of progress made in terms of stroke recovery, comparing those attending the
93
group with those not attending, would reveal useful data around the effectiveness of the
group programme.
It is strongly recommended that stroke groups of similar and different format be developed
and researched at other CHC’s in the Western Cape. The data yielded from these
programmes, together with the results of this study, can then be used to make
recommendations regarding the modification of existing group programmes and the
development of new group programmes. This will contribute to the optimal use of stroke
groups, within rehabilitative programmes, at PHC level in the province.

Group members experienced meaning on both psychosocial and physical levels from their group
participation. Of the factors influencing attendance, the positive attitude of the staff was mentioned
most frequently. Transportation issues were most often mentioned as having negatively influenced
attendance. Given the positive response of study participants to the programme, and its ability to
sustain intervention with limited resources, it was concluded that the BLRC stroke group has a valid
place within stroke rehabilitation in the community of Bishop Lavis.
Recommendations were made in terms of the group programme, which included; investigating
methods of improving, or providing transportation; provision of childcare facilities; greater variety
in the content of health education talks; and reviewing the focus of input of the stroke group to
address areas of greatest remaining deficit, identified by the SIS v3. Further recommendations were
to maintain the positive staff attitude, as well as the current activities of the programme. More
group outings should be planned, and strategies for inclement weather explored.
The study had several limitations, including: a small population size; limited, or no time post-group
involvement of the participants; the examiner’s close involvement with the population; and the
limited ability of the study design to yield data, on an objective level, around stroke recovery.
Recommendations were made with regards to overcoming these limitations in future studies.
Group programmes at other institution should also be researched, and comparisons drawn, in order
to move towards a model of stroke group rehabilitation.
94
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103
Appendix I
Bishop Lavis Rehabilitation Centre
Group Planning and Progress
Group:____________ Year: ___________
Date Occupational Therapy Physiotherapy Other Att

Plan Report Plan & Report
Signed:
Signed: Signed:
Signed: Signed:
Signed:
a
Appendix II
Bishop Lavis Rehabilitasie Sentrum
GROEP TERUGVOER
Datum: _________________ Groep:_____________________
Ja, baie! ‘n bietjie/ Nee
soms
☺
Geniet jy die groep?
☺
Is die personeel behulpsaam en
vriendelik?
☺
Is die personeel altyd
voorbereid vir die groep en
begin dit stiptelik?
☺
Dink jy dat die groep goed is vir
jou gesondheid, en die qualiteit
van lewe wat jy het?
☺
Is die rehab sentrum se gebou,
apparaat, ens. voldoende vir die
groep se gebruik?
Waarvan hou jy die meeste in die groep?
_____________________________________________________
_____________________________________________________
_____________________________________________________
Waarvan hou jy nie in die groep?
_____________________________________________________
_____________________________________________________
_____________________________________________________
Watter voorstelle het jy om die groep te verbeter?
_____________________________________________________
_____________________________________________________
_____________________________________________________
Baie Dankie!
b
Appendix III
QUESIONNAIRE
Afdeling A - almal
Voorletters: ID no: Groep:
1) Hoe kom jy by die rehabilitasie sentrum uit? 1 = Loop onafhanklik (Met / sonder
How do you get to the rehabilitation centre? hulpmiddels)
2 = Stoot jouself in `n rolstoel
3 = Word deur iemand gestoot in rolstoel
4 = Privaat vervoer (iemand anders bestuur)
5= Privaat vervoer (bestuur self)
5 = Gebruik openbare vervoer onafhanklik
6 = Gebruik openbare vervoer met hulp
7 = Vervoer vir gestremdes
8 = Ander (Noem)………………………………
2) Hoeveel kos dit jou om na die rehabilitasie 1 = Niks

sentrum te kom ? 2 = R5,00 of minder
What does it cost you to attend the group? 3 = Tussen R5,01 en R10,00
4 = Meer as R10,00
3) Kom jy alleen na die rehabilitasie sentrum 1 = Ja

toe? Indien nie, wie kom saam met jou? 2 = Nee Wie: …………………………
Do you travel alone to the rehabilitation centre?
If not, who accompanies you?
4) Hoe lank neem dit vir jou om by die 1 = Minder as 10 minute

rehabilitasie sentrum uit te kom? 2 = Tussen10 en 29 minute
How long does it take you to get to the 3 = Tussen 30 minute en 1 uur
rehabilitation centre? 4 = Langer as 1 uur
5) Woon jy enige ander organisasies/groepe by? 1 = Ja

Indien ja, watter? 2 = Nee
Do you attend any other clubs/groups? If so, Verskaf besonderhede:
what? …….………………………
6) Wie is bedags saam met jou by die huis? 1 = Een naby familielid (ouer, kind, broer, ens)
Who is with you at home during the day? 2 = Een ver familielid
3 = Een onbetaalde versorger
4 = Betaalde versorger
5 = Meer as een persoon
6 = Ander:
Besonderhede………………………………..
7) Hoe lank neem dit vir jou om reg te maak om 1 = 10 minute

die groep by te woon? 2 = Tussen 10 en 29 minute
How long does it take you to get ready for the 3 = Tussen 30 minute en 1 uur
group? 4 = langer as 1 uur
8) Hoeveel volwassenes bly saam met jou in die 1 2 3 4 5 6 7 8 9 10

huis? Meer:………
How many adults live with you in the house?
9) Hoeveel van hulle het ‘n inkomste? 0 1 2 3 4 5 6
How many of those have an income? Meer: …….
10) Ontvang jy ‘n ouderdomspensioen of ‘n 1 = Ja
“disability” (ongeskiktheidstoelaag)? 2 = Nee
Do you receive a social pension?
c
Afdeling B – Groep A
1) Hoekom woon jy nie die “stroke” groep by nie?

Why do you not attend the stroke group at the
rehab centre?
2) Dink jy einige van die dinge waaroor ek al gevra

het jou bywoning beinvloed het? - bv. Geldsake,
vervoer, hoe lank dit neem om reg te maak, ens.
Indien ja, watter?
Do you think that any of the things I have already
asked about might have influenced your
attendance? E.g. Financial matters, transport,
how long it takes to get ready, etc.
If yes, which?
3) Was daar iets wat jou laat belangstelling veloor

het in die groep of laat besluit het om nie te kom
nie? Vertel vir my daarvan.
Was there something that made you lose interest in
the group or not want to attend it? Tell me about
this.
4) Indien jy ‘n paar keer die groep bygewoon het,

waarvan het jy gehou in die groep?
If you did attend a few group sessions, what did
you enjoy about the group?
5) Indien jy ‘n paar keer die groep bygewoon het,

wat omtrent die groep het jy nie geniet nie?/wat
was nie vir jou lekker nie?
If you attended a few group sessions, what did you
not enjoy/ what was not nice?
6) Watter voorstelle het jy om die groep te

verbeter?/Hoe kan ons die groep verander om dit
beter te maak?
What suggestions do you have to improve the
group?/ How can we change the group to make it
better?
d
Afdeling C – Groepe B & C
1) Dink jy dat enige van die dinge waaroor

ek nou gevra het beinvloed hoe gereeld jy
groep toe kom? In dien ja, watter?
Do you think that any of the things I have
already asked you might have influenced
how regularly you attend the group? If yes,
which?
2) Hoekom woon jy die “stroke” groep by?

Why do you attend the stroke group?
3) Waarvan in die groep het jy gehou, of

hou jy van?
What do you/did you enjoy about the
group?
4) Wat omtrent die groep geniet jy nie?/Is

nie vir jou lekker nie?
What do you not enjoy about the group?
5) Het jy enige verskil in jou vermoëns of

gesondheid gesien as gevolg van jou groep
bywoning? Vertel vir my daarvan.
Have you noticed any improvement in your

abilities or lifestyle as a result of attending
the group? Tell me about this.
6) Watter voorstelle het jy om die groep te

verbeter?/Hoe kan ons die groep verander
om dit beter te maak?
What suggestions do you have to improve
the group? How can we change the group
to make it better?
e
Afdeling D - Stroke Impact Scale (VERSION 3.0)
Die volgende vrae vra ek om van jou self te hoor hoe die “stroke” (beroerte) jou gesondheid en jou lewe
verander het. Ek wil jou oogpunt hieromtrent weet. Die vrae gaan oor die gestremdhede wat die “stroke”
veroorsaak het, sowel as oor hoe die “stroke” jou kwaliteit van lewe verander het. Laastens gaan ek vir jou
vra wat jy dink hoeveel jy herstel het na die “stroke”.
The purpose of this questionnaire is to evaluate how stroke has impacted your health and life. We want to
know from YOUR POINT OF VIEW how stroke has affected you. We will ask you questions about
impairments and disabilities caused by your stroke, as well as how stroke has affected your quality of life.
Finally, we will ask you to rate how much you think you have recovered from your stroke.
Die volgende vrae gaan oor die fisiese probleme wat jy ervaar as gevolg van jou “stroke” (beroerte).
1. In die afgelope week, wat sal jy Baie krag Matige ‘n Bietjie ‘n Klein Geen krag
sê was die krag van die.... krag krag bietjie
krag
a. Arm wat die meeste deur jou 5 4 3 12
“stroke” geafekteer was?
b. Greep van die hand wat die meeste 5 4 3 2 1
deur jou “stroke” geafekteer was?
c. Been wat die meeste deur jou 5 4 3 2 1
“stroke” geafekteer was?
d. Voet/enkel wat die meeste deur 5 4 3 2 1
jou “stroke” geafekteer was?
E1.1 Het jou fiesiese vermoë verbeter as gevolg van jou groep bywoning? ______________
E1.2 Hoe het dit verbeter? ______________________________________________________________
E1.3 Het jou fiesise vermoë jou bywoning beinvloed? _______
E1.4 Hoe?____________________________________________________________________________
Die volgende vrae gaan oor jou geheue en gedagtes.
2 In die afgelope week, hoe moelik was Glad nie ‘n klien ‘n bietjie Baie On-
dit vir jou om… moelik bietjie moelik moelik moontlik
nie moelik
a. Dinge wat mense nou net vir jou gesê 5 4 3 2 1
het te onthou?
b. Dinge wat die vorige dag gebeur het te 5 4 3 2 1
onthou?
c. te onthou om dinge te doen - soos jou 5 4 3 2 1
pille drink, of afsprake bywoon?
d. Die dag van die week te onthou? 5 4 3 2 1
e. Te Konsentreer? 5 4 3 2 1
f. vinning te dink? 5 4 3 2 1
g. alledagse probleme op te los? 5 4 3 2 1
E2.1 Het jou gedagtes en geheue verbeter as gevolg van jou groep bywoning? _____________
E2.2 Hoe? ___________________________________________________________________________
E2.3 Het jou gedagtes en geheue jou bywoning beinvloed?_________
E2.4 Hoe? ___________________________________________________________________________
f
Die volgende vrae gaan oor hoe jy voel, oor veranderinge in jou gemoed en jou vermoë om jou emosies
te beheer na jy jou “stroke” gekry het.
3. In die afgelope week, hoe dikwels het Nooit ‘n Klein ‘n bietjie Die Die hele
jy... bietjie van die meeste tyd
van die tyd van die
tyd tyd
a. Hartseer gevoel? 5 4 3 2 1
b. gevoel dat daar niemand is tot wie jy 5 4 3 2 1
aangetrokke is?
c. Gevoel dat jy ‘n las vir ander mense is? 5 4 3 2 1
d. Gevoel dat daar niks is om na uit te sien 5 4 3 2 1
nie?
e. Jouself geblameer vir die foute wat jy 5 4 3 2 1
gemaak het?
f. Dinge geniet soos altyd? 5 4 3 2 1
g. Angstig gevoel? 5 4 3 2 1
h. gevoel dat die lewe die moeite werd is? 5 4 3 2 1
i. elke dag gelag en geglimlag? 5 4 3 2 1
E3.1 Het jou gevoelens en gemoed verbeter as gevolg van jou groep bywoning? _____________
E3.2 Hoe het dit verbeter? _______________________________________________________________
E3.3 Het jou gevoelens en gemoed jou bywoning beinvloed? ________
E3.4 Hoe?____________________________________________________________________________
Die volgende vrae gaan oor jou kommunikasie vermoëns, so wel as hoe maklik jy goed wat jy lees of
hoor verstaan.
4. In die afgelope week, hoe moelik was Glad nie ‘n klein ‘n bietjie Baie Onmoontlik
dit vir jou om... moelik bietjie moelik moelik
nie moelik
a. Die naam van iemand wat voor jou 5 4 3 2 1
staan te sê?
b. Te verstaan wat iemand vir jou sê? 5 4 3 2 1
c. Op vrae te antwoord? 5 4 3 2 1
d. dinge op hulle regte name te noem? 5 4 3 2 1
e. In ‘n gesprek te wees saammet ‘n 5 4 3 2 1
groepie mense?
f. ‘n gesprek op die telefoon te voer? 5 4 3 2 1
g. Om iemand op die telfoon te bel – 5 4 3 2 1
insluitend die regte nommer te soek en in
te druk?
E4.1 Het jou komunikasie vermoëns verbeter as gevolg van jou groep bywoning? ____________
E4.2 Hoe het dit verbeter? _________________________________________________________________
E4.3 Het jou komunikasie vermoëns jou bywoning beinvloed?_______
E4.4 Hoe?
______________________________________________________________________________
g
Die volgende vrae gaan oor die aktiviteite/dinge wat jy moontlik in ‘n tipiese dag sal doen.
5. In die afgelope 2 weke, hoe moelik Glad nie ‘n klien ‘n bietjie Baie Onmoontlik
was dit vir jou om… moelik bietjie moelik moelik
nie moelik
a. Jou kos met ‘n mes en vurk te sny? 5 4 3 2 1
b. die boonste deel van jou liggaam aan te 5 4 3 2 1
trek?
c. Jouself te was? 5 4 3 2 1
d. jou toonnaels te knip? 5 4 3 2 1
e. Betyds by die toilet uit te kom? 5 4 3 2 1
f. Om jou blaas te beheer? (nie ‘n ongeluk 5 4 3 2 1
kry nie)
g. Om jou opelyf te beheer? (nie ‘n 5 4 3 2 1
ongeluk kry nie)
h. Om ligte huiswerkies te doen (soos 5 4 3 2 1
afstof, kooi opmaak, vuilus uitgooi,
skottelgoed was)?
i. Inkopies te doen? 5 4 3 2 1
j. Swaar huis werk te doen? (soos stofsuig, 5 4 3 2 1
wasgoed was, tuin skoonmaak)
E5.1 Het jou vermoë om dinge wat jy in ‘n tipiese dag sal doen.verbeter as gevolg van jou groep bywoning?
_____
E5.2 Hoe het dit verbeter? _________________________________________________________
E5.3 Het vermoë om dinge wat jy in ‘n tipiese dag sal doen jou bywoning beinvloed? _________
E5.4 Hoe? ______________________________________________________________________
Die volgende vrae gaan oor jou vermoë om in jou huis en gemeenskap te beweeg.
6. In die afgelope 2 weke, hoe moelik Glad nie ‘n klein ‘n bietjie Baie Onmoontlik
was dit vir jou om... moelik bietjie moelik moelik
nie moelik
a. te sit sonder jou balans te verloor? 5 4 3 2 1
b. te staan sonder jou balans te verloor? 5 4 3 2 1
c. te stap sonder om jou balans te verloor? 5 4 3 2 1
d. van jou kooi tot jou stoel te beweeg? 5 4 3 2 1
e. Een blok te stap? 5 4 3 2 1
f. Vinnig te stap? 5 4 3 2 1
g. Een ‘lot’ trappe te klim? 5 4 3 2 1
h. Meer as een “lot” trappe te klim? 5 4 3 2 1
i. in en uit die kar te klim? 5 4 3 2 1
E6.1 Het jou vermoë om te beweeg verbeter as gevolg van jou groep bywoning? _________
E6.2 Hoe het dit verbeter? ______________________________________________________________
E6.3 Het jou vermoeë om te beweeg jou bywoning beinvloed? ________
E6.4 Hoe?____________________________________________________________________________
h
Die volgende vrae gaan oor hoe jy die hand wat die meeste aangetas is gebruik.
7. In die afgelope 2 weke, hoe moelik Glad nie ‘n klein ‘n bietjie Baie Onmoontlik
was dit vir jou om die hand wat die moelik bietjie moelik moelik
meeste aangetas is te gebruik om… nie moelik
a. Swaar goed te dra? (Soos inkopies 5 4 3 2 1
sakke)
b. ‘n deurknop oop te draai? 5 4 3 2 1
c. ‘n blik of flessie oop te maak? 5 4 3 2 1
d. Skoene vas te maak? 5 4 3 2 1
e. ‘n muntstuk op te tel? 5 4 3 2 1
E7.1 Het die gebruik van jou hand verbeter as gevolg van jou groep bywoning? ______________
E7.2 Hoe het dit verbeter? _______________________________________________________________
E7.3 Het die gebruik van jou hand jou bywoning beinvloed? _____
E7.4 Hoe? ___________________________________________________________________________
Die volgende vrae gaan oor hoe die “stroke” jou vermoë om alledaagse dinge te doen beinvloed het –
die dinge wat jy gewoonlik doen, wat vir jou belangrik is, en wat die lewe sin gee.
8. In die afgelope 4 weke, hoe veel van Nooit ‘n klein ‘n bietjie Meeste Die hele
die tyd het die “stroke” jou… bietjie van die van die tyd
van die tyd tyd
tyd
a. in jou werk beperk? (betaald, vrywillig, 5 4 3 2 1
ander)
b. in jou sosiale geleenthede beperk? 5 4 3 2 1
c. in jou stil vryetyd aktiwiteite beperk? 5 4 3 2 1
(soos lees, TV kyk, handwerk)?
d. in jou aktiewe vryetyd aktiwiteite 5 4 3 2 1
beperk? (soos sport, uitstappies, reis)
e.in jou rol as familie lid of vriend 5 4 3 2 1
beperk?
f. deelname in geloofs aktiwiteite 5 4 3 2 1
beinvloed?
g. vermoë om jou eie lewe te beheer soos 5 4 3 2 1
jy wil beperk?
h. vermoë om ander te help beperk? 5 4 3 2 1
E8.1 Het jou vermoë om alledaagse dinge te doen verbeter as gevolg van jou groep bywoning? ________
E8.2 Hoe het dit verbeter?________________________________________________________________
E8.3 Het jou vermoë om alledaagse dinge te doen jou bywoning beinvloed? ________
E8.4 Hoe? ____________________________________________________________________________
i
9. Herstel na “stroke” (beroerte)
Hoe ver dink jy het jy herstel tot nou toe? 100 beteken heeltemal herstel, en 0 beteken geen herstel nie.
On a scale of 0 to 100, with 100 representing full recovery and 0 representing no recovery, how much have
you recovered from your stroke?
_____ 100 Heeltemal herstel

__
90
__
80
__
70
__
60
__
50
__
40
__
30
__
20
__
10
___
______ 0 Geen herstel nie
E9 Watter verskil het jou ‘stroke’ groep bywoning in jou lewe gemaak?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
j
Appendix IV
Focus group – Interview schedule
Topic 1: Meaning
Tell me about what the group has meant or means to you.
Vertel vir my wat die groep vir jou beteken het, of betken.
Prompts – Psychosocial level
Physical level
Topic 2: Stroke recovery

In which areas did you notice improvement because you came to the group? Where did you see the
most improvement? Tell me about the things you can now do that you couldn’t do before?
In watter areas het jy verbetering gesien omdat jy groep toe te kom het? Waar het jy die meeste
verbetering gesien? Vertel vir my van die dinge wat jy nou kan doen wat jy nie van tevore kon
gedoen het nie.
Prompts – SIS v3 categories
Topic 3: Activities of the group

Tell me about the things you do in the group – which things do you like about the group, and which
things not?
Vertel vir my van die dinge wat jy in die groep doen – watter van dit het jy van gehou, en watter
nie?
Topic 4: Issues of interaction

Is there anything that you can tell me about how the other people in the group help you? Do the
other members of the group mean something to you?
Is daar iets wat jy kan vir my sê van hoe die mense in die groep vir jou help? Het die ander lede
van die groep iets vir jou beteken?
Topic 5: Issues of organisation

Is there anything you would like to say about how the group is run and the facilities or staff?
Is daar iets wat jy wil sê oor hoe die groep gestruktureer is, of oor die fasiliteite of personeel?
Prompts – Staff
Timing issues
Punctuality, predictability
Topic 6: Factors influencing attendance

What are the reasons you think people don’t come to the group? What are the reasons that you
sometimes couldn’t come to the group?
Hoekom dink julle km die mense nie na die groepo toe nie? Wat is die redes dat julle party keer nie
kan gekom het nie?
Topic 7: Recommendations
If you were in charge of the group, and you could change it in any way you wanted to to make it
better – how would you change it? What other suggestions do you have for improving the group?
As jy in beheer was van die groep, en jy kon enige iets verander om dit te verbeter, wat sal jy
verander het? Watter ander voorstelle het jy om die groep te verbeter?
k
Appendix V
INFORMATION AND INFORMED CONSENT DOCUMENT
TITLE OF THE RESEARCH PROJECT:

Participants’ experience of the Bishop Lavis Rehabilitation stroke group.
REFERENCE NUMBER: ……………….…………………….
PRINCIPAL RESEARCHER: W. DE LA CORNILLÈRE

ADDRESS: BISHOP LAVIS REHABILITAITON CENTRE
LAVIS DRIVE, BISHOP LAVIS
DECLARATION BY OR ON BEHALF OF PARTICIPANT:

I, THE UNDERSIGNED, ………………………………………………………………….. (name)
[ID No: …………………..…………] the participant/*in my capacity as
…………………………………………. of the participant [ID No: …………………..……...] of
………………………………………...……………………….……………………..……………
………………………………………………………...…………………………………………….
(address).
A. HEREBY CONFIRM AS FOLLOWS:

1. I was invited to participate in the abovementioned research project, which is being
undertaken by the Centre for Care and Rehabilitation, Faculty of Health Sciences,
Stellenbosch University.
2. The following aspects have been explained to me/ the participant:
2.1 Aim of the study: To describe how participants experience the stroke group
programme, and how they feel their attendance has influenced their recovery after
a stroke. To investigate why people come or don’t come to the group. To make
suggestions about how the group can be improved.
2.2 Procedures: Approximately 30 people will take part in the study. Each
participant will attend one individual interview, where he/she will need to answer
questions about his/her strength, mobility, memory and thinking, activities of daily
life, mood and emotions and communication. The researcher will also ask
information regarding how the participant experiences the stroke group
programme.and how well the participant feels he/she has recovered from the
stroke. The interview will take approximately 45 minutes.
2.3 Confidentiality: All information collected will be treated as confidential. The
findings will be included in a thesis, possible publications and articles, but no
names of participants will be used.
2.4 Access to findings: Should the participant wish, he/*she may request to see the
findings of the study upon its completion in August 2006. No access to individual
results will be possible.
2.8 Voluntary participation/refusal/discontinuation: The participant has consented
to take part in this study of his/her own free will. He/*She may change his/*her
mind and refuse to participate at any time. If the participant chooses not to
participate, this will not be held against him/her for future treatment at the Bishop
Lavis Rehabilitation Centre.
3. The information above was explained to me/*the participant by W. de la Cornillère in
Afrikaans/*English/*other…………………………… and I am/*the participant is in
command of this language. I/*The participant was given the opportunity to ask
questions and all these questions were answered satisfactorily.
l
4. No pressure was exerted on me/*the participant to consent to participation and I/*the
participant understand(s) that I/*the participant may withdraw at any stage without any
penalization.
5. Participation in this study will not result in any additional costs to myself/*the
participant
B. HEREBY CONSENT VOLUNTARILY TO PARTICIPATE IN THE ABOVE-

MENTIONED PROJECT/*THAT THE PATIENT/*POTENTIAL PARTICIPANT
MAY PARTICIPATE IN THE ABOVEMENTIONED STUDY.
Signed/confirmed at ………………………………….. on …………………………20 …...

(place) (date)
…………………………………… ………………………………….…
Signature or right thumb print of Signature of witness
representative of the participnt/*participant
STATEMENT BY OR ON BEHALF OF RESEARCHER(S):
I, W. de la Cornillère, declare that

• I explained the information given in this document to ………………………………...……….
(name of the participant) and/*or his/*her representative …………………….……………….
(name of the representative);
• he/*she was encouraged and given ample time to ask me any questions;
• this conversation was conducted in Afrikaans/*English/*Xhosa/*Other ……...……… and no
translator was used.
Signed at Bishop Lavis on ……………………..………...200…

(date)
…………………………………………………… …………………………………………..
Signature of researcher/*researcher’s representative Signature of witness

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Participants’ experience of the

Bishop Lavis Rehabilitation Centre stroke group

Student number: 12776750

Thesis submitted in partial fulfilment of the requirements of the degree

Supervisor: Surona Visagie

Centre for Rehabilitation Studies

Full name: …………………………………………………

PARTICIPANTS’ EXPERIENCE OF THE BISHOP LAVIS

Recommendations in terms of the group programme included investigating methods of providing

GROEPLEDE SE ERVARING VAN DIE

Aanbevelings sluit in om ondersoek in te stel na moontlike metodes van vervoerverskaffing,

God, for being my strength and hope.

Siphokazi Gcaza, co-supervisor.

Gubela Mji, head of department.

Interdisciplinary team approach

Primary health care

Chapter 1 – Introduction and background 1

Chapter 2 – Literature review 13

Chapter 4 – Results and discussion 50

Table 1.1 Example of stroke group planner 9

Figure 3.1 Study population 38

I Interdisciplinary group progress sheet a

ADL Activities of daily living

1.1 Thesis outline

The emphasis of rehabilitation currently remains on individual intervention, even at community

1.3 The community of Bishop Lavis

1.4 The Bishop Lavis Rehabilitation Centre

1.4.2 Management of the stroke client

Group programme inclusion is voluntary, and supplementary to other intervention. Participation in

The aims of the group are:

Table 1.1 – Example of stroke group planner

Records of the group are kept as follows:

1.5 Research problem

1.6 Motivation for and significance of the study

1.7 Summary of Chapter 1

2.2 Rehabilitation - an overview

Community can be defined as a collection of people sharing an environment, recognisable as a

2.2.2 Rehabilitation policy trends in developing nations

“Cost-benefit ratio of providing services to those with disabilities”

Tertiary level prevention interventions are “measures to limit or reduce impairments or

2.4.2 Curative factors of therapeutic groups

2.4.2.1 Instillation of hope

2.4.2.3 Imparting information

Literature supports that education is crucial to successful outcome in stroke survivors.57 As

2.4.2.5 Corrective recapitulation of the primary family group

2.4.2.6 Development of socialising techniques

Stroke is associated with communication difficulty – whether this be as a result of expressive or

2.4.2.7 Imitative behaviours

2.4.2.9 Group cohesiveness

2.4.2.12 Impact of curative factors

2.4.3 Types of therapeutic groups

2.4.3.2 Social groups

2.4.3.4 Psychosocial groups

2.4.4 Characteristics of therapeutic groups

Table 2.1 - Advantages and disadvantages of smaller versus larger groups53

2.4.4.2 Member selection

TABLE 2.2 - Advantages and disadvantages of open and closed groups53

2.4.5 Barriers to therapeutic groups

2.4.5.1 Practical barriers