This research was an integrative review, chosen because it permits the analysis of both empirical and nonempirical literature (Whittemore & Knafl, 2005). The methodological rigour of this research was enhanced by utilizing a five-stage research framework including 1) identification of research problem (introduction, research questions and objectives), 2) search of literature, 3) evaluation of data, 4) analysis of data, and 5) presentation of results [18] .

A search strategy was developed in consultation with a librarian with expertise in systematic reviews. The search strategy was adapted for each information search and utilized a combination of keywords and controlled vocabulary. The databases searched were MEDLINE (Ovid), CINAHL (EBSCO), PsycINFO (ProQuest), Scopus (Elsevier), ProQuest Nursing & Allied Health, and ProQuest Dissertations & Theses Global. References and citations of included studies were retrieved in Scopus to ensure no key literature was missed. Results were reported using guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) [19] (see Appendix A).

With the use of keywords, subheadings, and MeSH terms, three primary constructs (reintegration to normal living, stroke, and outpatient/community rehabilitation) were searched for relevant literature. The complete MEDLINE (Ovid) search strategy has been displayed in Appendix B (online supplementary content). During the search, two sets of articles were emergent. Observational studies that focused on the characteristics or abilities of stroke patients as they reintegrate into the society during outpatient rehabilitation, and interventional studies that focused on testing the effects of protocols and specific interventions on patient’s reintegration into the society during outpatient rehabilitation. To address context-specific research questions, we chose to separate the reviews into two distinct studies. This review addresses the functional abilities of stroke patients admitted to outpatient rehabilitation programs and reintegrating into the community.

The inclusion criteria were as follows: a) the study was aimed at examining post-stroke community reintegration after discharge from inpatient rehabilitation programs, b) the setting was an outpatient rehabilitation environment, defined as patient’s home or other community setting, c) the stroke patients had some functional abilities and participated in life activities after stroke, d) Perspectives were sought from patients and functional abilities measured by health care professionals, and e) the articles were English language publications. The following papers were excluded from the review: theoretical articles, descriptions of treatment or program approaches, literature reviews, methodological protocols, non-systematic reviews, conference proceedings, published abstracts, clinical practice guidelines, and textbook chapters.

All included articles were critically evaluated for methodological rigour, using a list of nine domains outlined by Hawker and his colleagues [20] . The items in each of the nine domains were assessed on a four-point ordinal scale: 1) good, 2) fair, 3) poor, and 4) very poor. The overall score ranged from 9 to 36, with scores of 28 - 36 indicating good quality articles, 20 - 27 indicating fair quality, 10 - 19 indicating poor quality, and scores below 10 indicating very poor quality articles [20] . The critical appraisals were completed by two authors to establish inter-rater reliability. Any discrepancies in the ratings were discussed by the two authors until consensus was reached.

All articles retrieved from the included databases were first exported to Covidence ( https://www.covidence.org/ ), where duplicate articles were removed. Two authors screened a total of 4314 articles, examining their titles and abstracts for relevance to the topic under review. Afterwards, they reviewed 54 full-text articles, with any disagreements resolved through discussion. Sixteen studies in total met the inclusion criteria ( Figure 1 ). Using a data extraction form, the authors independently extracted data from the included articles, preserving the original wording and language (verbatim). Extracted data included title, authors, study aims/objectives, number of participants, method of data collection, method of data analysis, and results/themes. To prepare for results synthesis, data were transferred from the extraction form to tables where they were summarized.

The process of identifying and synthesizing themes followed the framework described by Whittemore and Knafl [18] . The authors conducted a line-by-line review of individual studies, generated brief codes, and applied the codes to study findings to succinctly summarize them. The coded findings were then reviewed iteratively, comparing, and contrasting for conceptual similarity. Subsequently, the codes were grouped and organized into three themes determined deductively. The first theme (Physical and Psychosocial Functions of Stroke Patients) answered research question 1: What specific physical and psychosocial functions have been identified as predictors of successful reintegration into normal living after stroke? This theme refers to the physical and psychosocial

abilities (related to self-care or individual functioning) of stroke patients at the onset of reintegration into the community. The physical functions included improved mobility skills, independence in performance of daily activities, and reduced disability; the psychological functions included psychological well-being, self-efficacy, self-perception, and health status; and the social functions included age, social support, personal relationships, and employment [21] .

The second theme (Self-Care Performance and Individual Functioning of Stroke Patients) addressed the research question 2: How do physical and psychosocial functions promote successful reintegration into normal living after stroke? This theme refers to patient’s constant performance of physical and psychosocial functions related to self-care and individual functioning during reintegration into the community. Constant physical functions may include mobility improvement, self-care independence, and disability management; constant psychological functions may include emotional well-being, self-motivation, self-efficacy, and sense of purpose; and constant social functions may include age, social support, relationships, and employment influence [21] . The third theme (Factors that Hinder Stroke Patients’) answered research question three: What factors have been identified that hinder stroke patients’ reintegration into normal living after stroke? Specific examples from included studies were described to shed light on the importance of reported themes.

Of the 16 studies included, 14 were quantitative [6] - [11] [13] [16] [22] - [27] and two were qualitative studies [2] [12] . Two studies were from Canada [22] [26] , five were from the United States of America [8] [16] [23] [24] [27] , six were from Nigeria [2] [6] [7] [11] [13] [25] , one was from New Zealand [12] , one was from China [10] , and one was from the Republic of Benin [9] . The publication years spanned from 2007 to 2023, with sample sizes varying from 8 to 336 (total = 1561). All studies were evaluated for methodological quality and considered to be good.

Three main themes and sub-themes emerged from the data. Table 1 presents the results associated with Theme 1: Physical and psychosocial functions of stroke patients that predict successful reintegration into normal living post- stroke? Table 2 displays study results related to Theme 2: Self-care performance and individual functioning of stroke patients to promote successful reintegration into normal living post stroke? Table 3 displays study results related to Theme 3: Factors that hinder stroke patient’s reintegration into normal living post-stroke?

Regarding post-stroke patients’ physical functions, data for the sub-theme improved mobility, independent performance of daily activities, and reduced disability emerged from thirteen of the sixteen included studies. Four of these studies indicated that enhanced functional mobility promotes a better reintegration to normal living [7] [10] [11] [27] , and two studies reported that increased motor function post-stroke promotes successful reintegration into the community [6] [22] . Functions such as greater walking ability [22] , improved foot capability [11] [26] , and increased walking endurance (6-minute walk time) [16] reportedly facilitated social integration into the community. In one study, the use of mobility devices (e.g., cane, walker) was reported as an important facilitator of community reintegration [7] . In some studies, independent performance of daily activities increased participation in social roles [12] [26] , and increased participation in meaningful activities was reported as the strongest predictor of successful community reintegration [13] . Independent driving at 1-year post-stroke was reported in two studies as an important facilitator of community reintegration following stroke events [23] [24] . Other physical functions that reportedly facilitate post-stroke community reintegration are lower stroke severity measured using the RNL scores [22] , decreased physical disability [25] , increased community balance, and increased cadence [11] .

Regarding post-stroke patients’ psychological functions, data for the sub-themes improved psychological well-being, increased self-efficacy, and increased self-perception emerged from twelve of the included studies. In three studies,

Continued

Continued

Continued

Continued

fewer post-stroke depressive symptoms were the strongest predictors of social participation and successful reintegration into the community [6] [22] [27] . In two studies, increased participation self-efficacy emerged as an important predictor of individual participation in community activities [10] [26] . In other studies, improved balance self-efficacy independently predicted personal satisfaction with community reintegration [11] [26] . Identified perceptual facilitators of community reintegration were positive perception of self [7] , higher visual perception [22] [26] , and positive perception of the relationship with individual self. [12] . The stroke patients’ perception of their purpose in life and the re-establishment of normality (new and old) were identified as important facilitators of community reintegration after stroke [12] . Regarding patients’ health status, perceived recovery from stroke, absence of diabetes [7] , fewer medical problems [23] , and lesser fatigue symptoms [27] reportedly improved patients’ participation performance during community reintegration. Post-stroke psychological functions like increased acceptance of stroke [22] , creation of a positive mindset, and encouragement from family members and the society promoted participation in community activities, thereby facilitating reintegration into the society [2] .

Twelve of the sixteen included studies reported data on post-stroke patients’ social functions. In five studies, younger age was identified as an important facilitator of patient’s reintegration into the community [6] [7] [13] [22] [23] . The presence and extent of social support from friends, family, and the community reportedly played an important role in facilitating patients’ reintegration into the community [2] [7] [12] [24] . Other support systems such as availability of helpful environmental resources [27] and establishment of good personal relationships with others [7] [12] contributed to successful reintegration into the society. Social activities like playing games with friends and family, and visitation from friends, family, and community members [2] promoted successful reintegration into normal living. Being employed pre- and post-stroke [7] and having a strong financial role as well as motivation (being a breadwinner) in the family [10] were identified as relevant functions towards a positive experience during community reintegration. Other social functions (skills) like ability to drive [23] , ability to read [22] , having a higher level of education, and being married [10] were identified as vital to effective reintegration to society. Patients with reduced participation restrictions reportedly experienced greater success in societal reintegration [25] .

Regarding post-stroke patients’ physical functions, eight studies identified mobility improvement as a major facilitator of patient’s reintegration to normal living [6] [7] [11] [16] [22] [24] - [26] ; self-care independence was identified in eleven studies [6] [10] - [12] [16] [22] - [27] ; and one study identified proper disability management as an important facilitator of community reintegration [22] . In Olawale et al.’s [11] study, enhanced mobility post-stroke led to greater participation in social activities and increased satisfaction with reintegration to normal living [11] . Improved lower extremity motor coordination facilitated patients’ movement at home and in the community [6] . Walking independently without assistive devices increased confidence in patients [10] [11] , promoted productive use of their time [24] , and facilitated the use of public transportation to attend medical appointments and social events [23] . A stable balance reportedly led to efficient coordination of movement (gait training) [11] and encouraged physical exercises, thus strengthening limb muscles, improving motor coordination, and reducing the risks of falling [6] [7] [11] . For patients with low levels of physical and motor functioning, mobility devices (e.g., canes, walkers, wheelchairs, powerchairs) provided support and stability in moving at home and in the community [7] . Independence in self-care improved the stroke patient’s performance of daily activities [6] [7] [11] [16] [22] [24] - [26] , gave patients a sense of freedom, promoted participation in social roles, and enabled the patients to decide what things to do and when to do them [6] [10] - [13] [16] [22] [23] [25] [27] . Proper disability management reportedly contributed to reduced disability, increased performance of daily activities, and better reintegration into the community [22] . Stroke patients who drove were more mobile within the community and utilized their time more productively than those who did not drive [24] . Resumption of work post-stroke increased financial independence and reduced reliance on others for financial assistance [12] .

Regarding post-stroke patients’ psychological functions, four studies identified emotional well-being as an important facilitator of successful community reintegration [9] [10] [25] [26] . Other facilitators were self-motivation (three studies) [9] [10] [26] ; self-efficacy (five studies) [11] [16] [22] [27] ; and sense of purpose (eight studies) [2] [6] [7] [12] [16] [22] [25] [28] . Emotional well-being of post-stroke patients contributed to successful community reintegration by preparing patients to effectively manage stress, anxiety, and frustrations [9] [10] [25] [26] . Stress management efforts like promotion of therapy and engagement in therapy sessions (e.g., physical exercises) contributed to greater success in the patient’s reintegration to normal social life [9] [10] [26] . Attributes of emotional well-being including improved mood, increased acceptance of stroke, reduced anxiety, and decreased depressive symptoms helped to reduce the feelings of isolation and encouraged stroke patients to actively engage with others and participate in daily activities [9] [10] [22] [25] .

Individual patient’s motivation to mobilize and perform daily activities promoted engagement in social activities leading to successful reintegration into the community [9] [10] [26] . Self-efficacy, described as a person’s assessment of his or her ability to plan and carry out specific tasks, and to overcome challenges [28] , promoted social reintegration by increasing a patient’s confidence in moving around home and community, motivating patients to apply fall prevention strategies [11] [16] , promoting patient’s participation in daily activities, and increasing patients’ ability to plan and organize tasks [22] [27] . In one study, increased self-efficacy enabled patients with fewer medical conditions to resume driving [23] .

In eight studies, researchers reported that stroke patients who have a sense of purpose and a positive self-perception develop greater satisfaction in life and with reintegration into the community [2] [6] [7] [12] [16] [22] [25] [27] . Some patients reportedly demonstrated relationship with self through self-respect and a positive, life-affirming attitude. Being cheerful to others enabled these patients to maintain good relationships with others in the community [12] . Stroke patients who had a positive mindset, those who expressed happiness to be alive, and those thankful to God for keeping them alive were more satisfied with their reintegration into the community [2] . Having a stronger faith in God lessened stroke patients’ worries, encouraged prayers for healing, and reinforced the patient’s belief that recovery is possible [2] . Stronger faith in God also promoted humility and openness to receiving help and support from others [7] . Researchers also reported that having a purpose in life brings meaning into life and leads individuals to feel valued and appreciative of what they can contribute to society [12] .

Nine studies addressed the influence of social functions on community reintegration in relation to age, social support, personal relationships, and employment influence. Younger age was reported as a facilitator of societal reintegration because younger patients were more likely to attend social events, support groups, and recreational activities [6] [7] [13] [22] [23] . Researchers reported that younger patients lived a more active lifestyle, had stronger support networks, and had greater involvement in community activities [6] [7] [13] [22] . Some researchers noted that expanding an individual’s social network by cultivating greater social connections strengthens the individual’s support systems (including peer support) and increases the individual’s self-management support for problem-solving and goals setting [10] [11] [27] .

Good personal relationships with others (such as playing with friends and receiving visits from them) reduce the feeling of isolation and promote emotional healing/bonding with friends and family, thus increasing the individual’s love for treatment/rehabilitation [2] [6] [7] [13] [22] [27] . The presence of community resources enables patients to receive help from caregivers when performing daily activities, and to adhere to physical exercises like walking regularly [12] [24] . These levels of assistance promote greater satisfaction with life and better reintegration into the community. In some studies, researchers noted that patients who drive (e.g., younger patients who are more likely to pass driving test and learn to drive early) and those with pre-stroke employment history were more likely to return to work and to be financially independent, as employment post stroke leads to social inclusion and alleviation of the family’s financial burden [6] [7] [22] [25] . Driving post-stroke also enabled survivors to occupy their time by participating in previous hobbies, leading to social identity among peers, psychological well-being, and satisfaction in life [12] .

Nine studies addressed the physical function-related barriers affecting stroke patients’ reintegration to normal living. These barriers include longer stride time, poor motor function, impaired balance and mobility, driving cessation, presence of comorbidity, longer duration of stroke, inability to perform daily activities, non-use of walking devices, hemorrhagic or combined ischemic and hemorrhagic stroke, frequent and/or severe stroke, activity limitation, and speech and language challenges [2] [6] - [11] [23] [24] . Poor functional mobility (including decreased distance mobility) and activity limitations reportedly decreased stroke patients’ participation in social activities and lessened their satisfaction in life [2] [6] [7] [9] [11] . Decreased motor function and poor balance were also reported to reduce the patient’s performance of daily activities, leading to less successful reintegration into the community [2] [6] [7] [11] . Unassisted walking and inability to use walking aids reportedly prevented patients from moving at home and in the community, leading to poorer reintegration into the society. Speech and language challenges were reported as communication barriers that limit the patients’ ability to express their needs, interact with others in the community, and participate in social activities [2] . The presence of ischemic or hemorrhagic stroke (which results in neurological injuries and impacts motor, speech, and cognitive function), existence of lesions on both sides of the brain (which disrupts language processing, spatial awareness, and motor coordination), higher frequency of stroke (which may lead to severe functional impairment due to cumulative neurological damage), and greater severity of stroke (which may result in profound physical, cognitive, and communication difficulties) were reported as significant barriers to community reintegration efforts [8] [10] . Inability to drive (or cessation of driving) was reported as a predictor of loss of autonomy, loss of control over daily activities, and inability to transport oneself to work, medical appointments, and social events, leading to reduced engagement in community life [23] [24] .

Seven studies addressed the psychological functional barriers of stroke patients during the reintegration to normal living process. These barriers are related to depression, fear of falling, inadequate self-efficacy, low meaningful activities participation, missing relationships, negative relationship experiences, and apathy [6] - [8] [11] - [13] [16] . In one study, researchers reported that increased depression worsens feelings of sadness, hopelessness, and despair, making it difficult for stroke survivors to participate in daily living activities [6] . In four studies, increased fear of falling reportedly leads to anxiety, stress, avoidance of social activities perceived as risky or unsafe, reduced mobility, and increased dependence on caregivers or family members for help with daily living activities [7] [11] [13] [16] . Some studies indicated that inadequate balance of self-efficacy contributes to a lack of confidence and self-perceived competence in the individual’s ability to navigate the environment [7] [11] [16] . The lack of confidence increased the individual’s risk of falls or fall related injuries. Missing relationships and negatively experienced relationships were reported as barriers to effective community reintegration [12] . Negatively experienced relationships such as strained family dynamics or conflicts can cause stress, anxiety, and depression among stroke survivors, and increase the feelings of loneliness, isolation, decreased self-worth, and the inability to participate in community activities [12] . In one study, apathy (characterized by the lack of interest or motivation to engage in daily activities) was reported as a barrier to successful community reintegration [8] . Apathy contributes to feelings of sadness, frustration, low self-esteem, and inability to derive pleasure or satisfaction from previously enjoyed activities [12] .

Eleven studies addressed barriers related to social functions of stroke patients. These barriers included older age, lack of social support, history of diabetes or heart disease, low educational level, activity limitation, loss of meaningful activities, driving cessation, inability to return to work, social isolation or separation, severe stroke, and chronic stroke [2] [6] - [10] [12] [13] [16] [23] [24] . Four studies reported that older patients often have smaller social networks and less social support compared to younger stroke patients [6] [7] [13] [16] . The lack of social support leads to social isolation or separation, difficulties coping with emotional and psychological challenges, and difficulties participating in community activities [2] [24] . Driving cessation leads to inability to work, consequently increasing financial dependency on caregivers and family. Loss of meaningful daily activities (related to patient’s inability to participate in community activities like going to church and attending social clubs), and loss of meaningful purpose (related to lack of interactions with others in the community) were significant barriers to community reintegration [12] . Some researchers reported that lower educational level may be associated with lower socioeconomic status and limited access to community resources like transportation, healthcare services, and social support networks [10] . The lower educational level may limit employment opportunities and financial resources, leading to financial strain and stress for stroke patients and their families [10] .

The findings from this review have significant implications for outpatient stroke rehabilitation and patient’s reintegration into the community. First, there is a need for tailored rehabilitation programs that address both the physical and psychosocial functions identified as predictors of successful reintegration into normal living after stroke. These programs should focus on improving post stroke functions like mobility, independence in performing daily activities, psychological well-being, self-efficacy, social support, and personal relationships of stroke patients. Due to the interconnectedness of physical, psychological, and social functions following stroke, a holistic approach to rehabilitation would be essential.

Second, there is needed for recognition of the critical role of family and the importance of social support in the rehabilitation process. Healthcare professionals should actively involve family members and caregivers in decision making related to rehabilitation care of stroke patients, educate and support these families/caregivers to effectively assist stroke patient’s during recovery and reintegration into the community. Collaboration with community members and the timely use of community resources may create opportunities for social engagement and participation, thus promoting successful reintegration into the community.

Third, there is needed to address emotional and psychological challenges that hinder patient’s reintegration into the community by creating programs that focus on managing depression, anxiety, and fear of falling. Provision of counselling and psychoeducation, and creation of support groups for stroke patients may enhance stress management skills, promote coping, and improve the patient’s overall wellbeing. In addition, interventions aimed at promoting patients’ self-efficacy and motivating patients to interact socially and engage in daily activities are critical to fostering independence and promoting community reintegration.

Lastly, continuous education and training of rehabilitation professionals on the application of evidence-based practice are necessary to align outpatient rehabilitation interventions with the best current research evidence. Advocacy efforts are needed to raise awareness about the importance of comprehensive outpatient stroke rehabilitation and advocate for policy changes that prioritize funding and vital resources for stroke patients reintegrating into the society.