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T H E Soweto Stroke Q Uestionnaire

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T H E Soweto Stroke Q Uestionnaire R esearch A rticle T h e S o w e t o S t r o k e Q uestionnaire ABSTRACT A questionnaire was designed for a recent survey into the outcome LA HALE CJ EALES VU FRITZ of stroke patients in Soweto, named the Soweto Stroke Questionnaire (SSQ). It was based on the Barthel ADL Index (BI) but modified to suit the local context. This paper introduces the SSQ, and reports on its inter-rater reliability and its concurrent validity. Fifty-four subjects, in the age range 30 to 75 years, were interviewed and nineteen re-interviewed using the SSQ. Four different scores were calculated: a total score, a Barthel Index score, an Impairment score, and a Quality of Life score. The Pearson’s Correlation Coefficient was found to be high between the total score and the BI score. (r=0.948) which supports the concurrent validity of the developed questionnaire. In assessing the reliability of the SQQ, the Wilcoxin Test showed that there was no signifi­ cant difference between the initial and repeat interviews for the total score, the Barthel Index score, and the Impairment score (p<0,05). The Quality of Life Score came closer to a difference, but not statistically significantly so. These tests were collaborated by Bland and Altman graphs which showed that in 95% of the time, the questions were repeatable. Me Nemar’s Test of Symmetry showed that 34 out of 38 questions asked were found to have over 70% correlation. Four questions showed a lower correlation, the lowest being 63.16%. The SSQ was found to have inter­ rater reliability, and to be concurrently valid to the Barthel Index. It is quick and easy to use, requiring no sophisti­ cated equipment or training. It still requires to be investigated for sensitivity and predictiveness, and to be validated in a more general South African stroke population. KEY WORDS: STROKE OUTCOME, BARTHEL INDEX, SOUTH AFRICA Although stroke is ranked as the to hygiene, dressing, transfers, resources, as well as dealing with second most common cause of ambulation, continence and societal limitations (Whiteneck, death in South Africa its prevalence feeding) include the Barthel Index 1994). The CIQ (Community in South Africa is not well known (Collin et al, 1988) and the Katz Integrated Questionnaire) designed (Fritz, 1997). The Central Statistical Index of ADL (Brorsson and Asberg, by Wilier et al (1994) is an example ) . Services (1980) reported that cere­ 1984). Instrumental ADL, for of a scale which measures handicap. 3 1 brovascular accident accounted for example the Functional The CIQ was developed for persons 0 2 298/100,000 deaths in Coloured Independence Measure (FIM) with traumatic head-injury and d e South Africans aged 35-74 years, (Ham ilton et al, 1994; Glott, 1995), deals primarily with instrumental t a and 100/100,000 deaths in the explores higher degrees of ADL ADL and handicap. Although it d ( White population. The statistical such as domestic chores, transporta­ measures the success of outcome, r e data for the Black population of tion and communication. The FIM is namely, social integration, it gives h s i South Africa is imprecise (Fritz gaining popularity in South Africa. little assistance in the planning of an l b 1997). Putteril et al (1984) predicted However, it requires appropriate intervention (Wilier et al, 1994). In u P that the incidence of non-fatal training and trainer testing before a order for a rehabilitation measure­ e stroke in South Africans over high level of reliability can be ment scale to be versatile and effi­ h t 75 years of age was likely to increase achieved (Hamilton et al, 1994). cient, it needs to measure y b from 100-200/100,000 to Data can be converted from ordinal impairment (in order to plan the d e 2 000 100 000 ratings to a linear scale with interval intervention), disability and hand­ / , . t n A review of the literature revealed properties using Rasch analysis. icap (to measure the outcome of the a r numerous stroke outcome This data can be plugged into a data intervention). g e measuring scales. Some scales bank built up of over 100 000 FIM Dr Derek Wade of the Rivermead c n predominantly measure impair­ ratings in order to predict manage­ Rehabilitation Centre in Oxford e c i m ent and m otor recovery (Carr et al, ment, length of hospital stay and suggests that one of the best "buys" l r 1972; Gowland et al, 1993). outcome (Glott, 1995). However, as on the market is the Barthel Index e d Disability measures of basic activi­ the FIM scale appears not to have (Collin et al, 1988). It is has been n u ties of daily living (ADL) (attention been validated in South Africa, this used extensively in stroke outcome y data prediction facility is invalid as studies. This ordinal scale measures a w one cannot equate data collected in basic functional outcome, requires e t the United States of America to the very little training and has been a CORRESPONDENCE: G South African context. found to be both reliable and valid t Mrs L A Hale e Measuring handicap is a lot more for stroke (Wade and Hewer, 1987). n Physiotherapy Department i complex as it has to take into However, it's limitations include the b Faculty of Health Sciences a account the many individual char­ fact that it only measures disability. S University of the Witwatersrand y acteristics that affect an individual's The BI has not, to the best of my b 7 York Road, Parktown, social role fulfilment, for example, knowledge, been validated in South d e 2193, South Africa education, family support, financial Africa; it is unable to measure c u d o r p 16 SA J o u r n a l o f Physiotherapy 1998 V ol 54 No 4 e R quality of recovery; and has been The aim of this paper is to intro­ scored on an ordinal scale, giving a found to be insensitive in the higher duce the Soweto Stroke Question­ total score of fifty points. This total scores with a low ceiling of measure naire, and to report on its inter-rater score can then be subdivided into (Smith, 1993). reliability and its concurrent four sections, there being no The Soweto Stroke Questionnaire validity. weighting to the distribution of the was designed for a recent survey into scoring (see Table 1): the problems facing Sowetan stroke THE SOWETO STROKE QUESTIONNAIRE 1. Data relating to the patients' patients post-discharge from Chris Although the questionnaire has home circumstances: whether their Hani (CH) Baragwanath Hospital both qualitative and quantitative toilet is located inside the house or and may prove to be a basis from aspects (see Table 1), only the quan­ outside; do they have running water which to design a more specific titative side will be dealt w ith in this and electricity in the home. This South African measuring scale. paper. The quantitative section is data was deemed necessary to collect so that the context of the home could be invisualised. TABLE 1: SOWETO STROKE QUESTIONNAIRE 2. Data relating to the known complications of stroke, for QUANTITATIVE QUALITATIVE example, pain in the hemiplegic shoulder and knee; pressures sores Total score (50) (coded) and contactures. This is known as the Impairment Score. Muscle tone, strength and sensory status were Home Impairment Quality of Life Expanded not measured. Circumstances Score Score Barthel Index 3. Data relating to the patient's (8) (31) (Embedded BI = 20) (3 ) (8) disability - the Barthel Index (BI) is incorporated into the questionnaire, TABLE 2: CORRELATION OF TOTAL SCORES (n = 19) and is expanded in order to gain more insight regarding functional Total Score - Initial (50) Total Score - Repeat (50) ability, the BI being shown to be insensitive in the higher scores Mean 25.95 26.42 ) . known as the expanded Barthel 3 Std. Dev + /- 14.41 + /- 13.10 1 Index score. 0 2 Range 5-46 4-47 4. Data relating to handicap: d WILCOXIN 0.93 e ability to help with household t a chores, socialisation, outings, ability d ( to catch a minibus taxi - known as r TABLE 3: CORRELATION OF IMPAIRMENT SCORES (n = 19) e the Quality of Life score. h s i l Total Score - Initial (8) Total Score - Repeat (8) INTER-RATER RELIABILITY AND b u Mean 4.05 4.16 CONCURRENT VALIDITY P e Std. Dev + /- 2.29 + /- 2.36 h t METHODOLOGY Range 1 - 8 0 - 8 y b WILCOXIN 0.87 All cerebrovascular accident d e (CVA) patients admitted to the t n medical admissions ward of CH a r TABLE 4: CORRELATION OF QUALITY OF LIFE SCORES (n = 19) Baragwanath Hospital over a four g e and a half month period were c Total Score - Initial (8) Total Score - Repeat (8) n screened for admission into the e c Mean 3.16 2.68 study. The inclusion criteria of the i l r Std. Dev +/- 1.92 +/- 1.73 study required that patients, of e d Range 0 - 7 0 - 7 either sex, who had their first and n only CVA in the region of the u WILCOXIN 0.084 y middle cerebral artery, and who a w resided in Soweto be included. e t TABLE 5: CORRELATION OF BARTHEL INDEX SCORES (n = 19) Patients had to be in the age range a G 30 to 75 years. The patients' names t e Total Score - Initial (20) Total Score - Repeat (20) were acquired from the ward's n i Mean 12.26 12.68 admission register, and information b a regarding their inclusion suitability S Std.
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