Table Of ContentLIFE SATISFACTION, SELF-EFFICACY AND RELIGIOUS FAITH
IN STROKE PATIENTS LIVING IN KUWAIT
A thesis submitted for the degree of Doctor of
Philosophy
By
Miss Onutobor (Tobi) Omu
School of Health Sciences and Social Care
Brunel University
October 2010
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Abstract
Aims:
Life satisfaction and self-efficacy are psychosocial experiences that appear to profoundly
influence the rehabilitation of a stroke patient. However, relevant studies have been mostly
carried out on Western stroke survivors, with limited reports on stroke experience in the
Middle East. Reviewed literature suggests a positive correlation between religious faith and
health outcome, however studies investigating relationships among religious faith, self-
efficacy and other psychosocial variables in stroke patients are limited. The aims of this study
were therefore to (1) explore stroke experience and factors associated with life satisfaction
post-stroke in Kuwait, (2) to investigate the relationships between self-efficacy, life
satisfaction and religious faith in female stroke patients living in Kuwait, and (3) to identify
cultural influences on stroke survivors in Kuwait from the health professionals‘ point of view.
Method: The study was carried out in these four phases.
1) Phase 1:- Exploring stroke experience in patients in Kuwait with semi-structured
interviews
2) Phase 2:- Client-Centred Adaptation of a Self-Efficacy measure for stroke patients
living in Kuwait
3) Phase 3:- Assessing quantitative relationships between the three variables (self-
efficacy, life satisfaction and religious faith) with questionnaires
4) Phase 4:- Exploring perceptions of health professionals regarding the world of the
stroke patient and effects of culture on recovery and rehabilitation with semi-
structured interviews
Qualitative data were analysed with thematic analysis.
Results:
Significant correlations were found between general self-efficacy, and psychosocial
adaptation self-efficacy. Self-efficacy (both general and psychosocial adaptation) showed
significant correlations with life satisfaction post-stroke. Religious faith was not related to
either life satisfaction or self-efficacy. Health professionals‘ interviews identified cultural
characteristics specific to stroke patients living in Kuwait. These included family
involvement, prevailing attitude towards stroke, dependency and access to maids, religious
beliefs, and social stigma.
Conclusion: Psychosocial self-efficacy was identified as having the strongest relationship to
life satisfaction compared with the other variables tested. This study failed to show any
significant relationship between religious faith and self-efficacy or life satisfaction in female
stroke patients living in Kuwait. However, results from patient and health professional
interviews identified religious beliefs as playing an important role in recovery, behaviour
during rehabilitation and in interaction with the health professions. The qualitative aspects of
this study, in particular, highlight the importance of taking into consideration religious and
cultural influences during the rehabilitation of stroke patients in Kuwait.
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Contents
Chapter 1: Introduction and Overview of Study ........................... 10
1.1: Stroke and Rehabilitation .................................................... 12
1.2: Setting ....................................................................................... 17
1.3: Aims of Study ............................................................................ 19
1.4: Research Questions ................................................................ 19
1.5: Outline of Thesis ................................................................ 20
Chapter 2: Self –Efficacy and Life Satisfaction in Stroke Rehabilitation 22
2.1: Development of the Self-Efficacy Concept ............................ 23
2.2: Locus of Control ................................................................. 25
2.3: Literature Search ................................................................. 33
2.4: Self-efficacy in Stroke Rehabilitation ......................................... 35
2.5: Life Satisfaction in Stroke ……………….............................. 50
2.6: Factors Associated with life Satisfaction post-stroke: a Narrative Review 53
Chapter 3: The Role of Culture and Religion in Health Outcomes 92
3.1: Introduction ............................................................................ 93
3.2: Culture and Neurological Rehabilitation ......................................... 96
3.3: Religious Faith, Coping with Illness and Health Outcome.............. 107
3.4: Factors mediating the relationship between religious faith and health 122
Chapter 4: Methods ................................................................. 146
4.1: Introduction .................................................................. 147
4.2: Phase 1- Exploring the Stroke Experience in Patients in Kuwait..... 158
4.3: Phase 2- Development of a Self-efficacy- scale for the
Kuwaiti Population ............................................... 173
4.4: Phase 3- Relationships between Self-Efficacy, Life satisfaction and
Religious Faith in Female Stroke Patients Living in Kuwait................ 190
4.5: Phase 4- Exploring Health Professionals‘ views of the influences
of Culture on Stroke Experience in Kuwait............................................ 199
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Chapter 5: Results of Phase 1and 2 .................................................. 205
5.1: Physical and Speech Difficulties .................................................. 208
5.2: Social Changes Post-stroke .................................................. 214
5.3: Psychological Challenges .................................................. 220
5.4: Perceptions of Rehabilitation (mainly physical therapy) .......................... 224
5.5: Kuwaiti /Non Kuwaiti Differences .................................................. 228
5.6: Male/ Female Differences .................................................. 231
5.7: Self-Efficacy and Control Issues .................................................. 232
5.8: Adaptation of the Chronic Disease Self-efficacy Scales .............. 233
Chapter 6: Results of Phase 3 ............................................................... 245
6.1: Profile of the Phase 3 Study Sample ................................................... 246
6.2: Descriptive Statistics of Phase 3 Study Variables ........................... 248
6.3: Descriptive Statistics of Kuwait and Non Kuwaiti Sub Sample .............. 254
6.4: Correlational Analysis of the Phase 3 Study Variables ........................... 260
6.5: Comparative Analysis of Kuwaiti and non-Kuwaiti subsamples ............ 264
6.6: Multiple Regression Analysis of the Predictors of Life Satisfaction ........ 269
Chapter 7: Results from Phase 4 (Part 1) ........................................ 275
7.1: Factors Perceived by therapists to Determine
Quality of Life in Stroke patients ..................................................... 278
7.2: Life Satisfaction Post-stroke ................................................................. 291
7.3: Cultural Issues Related to Kuwait ..................................................... 304
Chapter 8: Results of Phase 4 (Part 2) ................................................... 327
8.1: Comments on Relationship between Self-Efficacy and Life Satisfaction 328
8.2: Clinical Applications of the Relationship between
Self-efficacy and Life Satisfaction .................................................. 332
8.3: Association between Religious faith and Self-efficacy/Life Satisfaction 345
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Chapter 9: Discussion of Findings ................................................... 358
9.1: Impact of Stroke in Patients Living in Kuwait ....................................... 360
9.2: Discussing Results of Phase 2 and 3 ................................................... 380
9.3: Cultural Differences Perceived by Health Professionals. ..................... .... 394
9.4: Clinical Applications of the Findings ................................................... 398
9.5: Critical Evaluation of the Study .................................................. 424
9.6: New Findings from Current Project .................................................. 448
9.7: Suggestions for Further Research ................................................. 450
Chapter 10: Conclusion ......................................................................... 452
Appendices and References ............................................................. 458
1) Map of Kuwait
2) Ethics Approval Documents (Consent form, info sheet)
3) Ethics Approval Letters
4) Questionnaires used in this project
5) Translated Documents
6) Example of coded health professionals‘ interview
7) Self-Efficacy Scales
8) Additional results of phase 3
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List of Figures
Figures are numbered according to the chapters in which they are to be found.
Figure 2.1: Flow diagram of Literature Search (Self-efficacy in stroke)
Figure 2.2: Flow diagram of Literature Search (life satisfaction in stroke)
Figure 4.1: Flow Chart of the Various Phases of the Project
Figure 5.1: Initial PSE Scale
Figure: 5.2: Bar Graph Showing Relevance of Questionnaire Items to stroke patients in
Kuwait as Rated by Therapists
Figure 6.1: Histogram of the distribution of the GSE Score for 40 Female Stroke Patients
Figure 6.2: Distribution of the Total Psychosocial Adaptation Self-efficacy Score (PSE) for
40 Female Stroke Patients
Figure 6.3: Distribution of scores of Life satisfaction Measure for 40 Female Stroke Patients
Figure 6.4: Distribution of Religious Faith Score for 40 Female Stroke Patients
Figure 6.5: Box plot showing GSE of Kuwaiti and Non Kuwaiti subgroups
Figure 6.6: Box plot showing Total PSE of Kuwaiti and Non Kuwaiti subgroups
Figure 6.7: Box plot showing Life Satisfaction of Kuwaiti and Non Kuwaiti subgroups
Figure 6.8: Box plot showing Total Religious faith Scores of Kuwaiti and Non Kuwaiti
subgroups
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List of Tables
Tables are numbered according to the chapters in which they are to be found.
Table 2.1: Differences in the concepts of Self-Efficacy, Locus of control and
Health locus of control (Perceived control)
Table 2.2: Differences between Narrative Reviews and Systematic Reviews
Table 2.3: Studies focusing on multiple variables related to life satisfaction.
Table 2.4: Studies on Well-being and Stroke
Table 2.5: Research on Participation in meaningful activity and return to work
Table 4.1: Demographic data of the Validation Study
Table 5.1: Profile of Study Participants
Table 5.2: Themes and Subthemes for Stroke Survivor Interviews in Kuwait
Table 5.3: Relevance of Questionnaire Items to stroke patients in Kuwait as Rated by
Therapists
Table 5.4: Descriptive Statistics for Validation Study
Table 6.1: Descriptive Statistics of Age and Time since Stroke
Table 6.2: Descriptive Statistics of Phase 3 Study Variables
Table 6.3 Descriptive Statistics of Subgroups based on Nationality
Table 6.4: Correlations between the Phase 3 Study Variables
Table 6.5: Correlations between Variables with Age Controlled
Table 6.6: Correlations between study Variables amongst Kuwaiti and Non Kuwaiti
subgroups
Table 6.7: Correlational Analysis with Age Controlled
Table 6.8: Summary of Multiple Regression Analysis
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Table 6.9: Results of Multiple Regression Analysis
Table 6:10 Summary of Stepwise Multiple Regression Models
Table 6.11: Results of Stepwise Multiple Regression Analysis
Table 7.1: Profile of Health Professionals
Table 7.2: Subthemes of Perceived Determinants of QOL and Life Satisfaction Post-Stroke
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Acknowledgements
Warmest gratitude to my supervisors: Prof. Lorraine DeSouza and Dr. Frances Reynolds.
Thank you for support and guidance without which I never would have reached this point.
Thanks for your unwavering support Mum. My fan club, Dad, Alek, Efe, Keno thanks for
being there.
Special thanks to all the obstacles in the way, had it not been for you who knows where this
project would have ended up. You helped present wonderful, far more exciting new
opportunities. Thank you!!
Thank you Almighty God, for the strength to keep going and going and going!! You are
my strength, joy and everything!! Love you!
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Chapter 1: Introduction and Overview of Study
Overview of Study
Experiences of stroke and psychosocial recovery from stroke are issues that could possibly be
influenced by cultural beliefs, values and norms, although available evidence is sparse.
Available research in traumatic brain injury (which will be discussed in chapter 3) suggests
that culture influences how individuals report experiences post-injury, how their families
react and provide support, and interactions between individuals, family members and health
professions (Simpson, Mohr and Redman, 2000). Life satisfaction and locus of control during
rehabilitation are two specific psychosocial variables that are influenced by cultural and
religious beliefs as identified by results from other non-stroke studies (Saltapidas and
Ponsford, 2007; Hampton and Marshall, 2000). Most of the available evidence about people‘s
experience of stroke and stroke rehabilitation has been gained in Western countries, with
predominantly Christian or secular belief systems. Stroke experience and attitudes to
recovery in the Arab culture have not been investigated in the past. Available research studies
on the influence of culture on neurological rehabilitation, in addition to being carried out on
individuals affected by conditions other than stroke, have also been restricted to Japanese and
Western participants, making generalisation to stroke survivors living in an Arabian culture
difficult.
The Arabian culture is distinctive because the Muslim religion plays an important role in
every issue of people‘s lives (Rashidi and Rajaran, 2001). This project specifically focuses
upon the stroke experience in Kuwait. This is a unique culture, as in Kuwait an interplay
between the Muslim religion, and widespread access to funds to purchase care and
rehabilitation services abroad, may result in an experience of stroke and rehabilitation that is
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