Stroke remains the leading cause of long-term adult disability internationally, and as of this year, the World Health Organization (WHO) estimates that more than 50 million healthy persons across the world will be lost as a result of stroke [1] . Stroke is often a life-changing event. Without new information, a patient survivor can be caught in a highly stressful state of unfamiliarity with a new reality [2] . Healthcare professionals frequently teach stroke information based on medical knowledge only, rather than the patients’ perceived or actual information needs [3] .

Many of the leading causes of disease and death are related to health beliefs and behaviors [4] . Therefore, studies focused on the role of beliefs and behaviors in the promotion of health and the prevention of disease [5] . Several health behavior models have been proposed to understand an individual’s health-related behavior. Most of these models assume that patients’ health behavior depends upon their beliefs regarding the impact of the illness and its consequences [6] . These models emphasized that a better understanding of the stroke from the patient’s perspective allowed for more effective management [7] .

Cultural models influence perceptions about the meaning of an illness, the types of treatment that are useful, and the likely outcome of health behaviors related to the prevention and control of a disease [8] . Cultural competence could be seen as a set of attitudes, behaviors and guidelines that came together in a continuum to enable a health care system or health professionals to function effectively in cultural interactions, and to be aware of the dynamics resulting from such cultural differences, and then to adapt services to meet culturally unique needs [9] .

Studies on behavior change suggest patients with correct beliefs about their symptoms are more likely to comply with prevention practices, compared to those with incorrect beliefs [10] . Correct beliefs provide a valuable basis to begin behavior modification strategies for stroke recovery [11] .

Etiological beliefs about causes of stroke and its management have a significant role in shaping recovery. A poor perception of health post-stroke is linked with lower functional abilities [12] [13] . Understanding post- stroke patients’ beliefs about their strokes provides a broader picture of how their perceptions impact their recovery.

Stroke terminology includes a large composition of pathophysiological entities that cover thrombosis, embolism, and hemorrhage. Ischemia and hemorrhage are the two major mechanisms causing brain damage in stroke [14] . Stroke rehabilitation ideally includes a returning process involving: (1) assessment, to identify and quantify the patient’s needs [15] ; (2) definition of an accurate and reasonable goal for improvement; (3) treatment and intervention, and (4) reassessment, to assess progress against agreed goal [16] . The common documented impairment caused by stroke is motor impairment, which limits function in muscle movement or mobility [17] . Other common impairments include those of cognition, speech and language, swallowing, vision and sensation.

Many stroke survivors do not make a full recovery and are left with residual long-term consequences, such as limitation of physical fitness, psychological symptoms, impaired cognition, and other post-stroke symptoms. The available literature emphasizes that rehabilitation providers are not sufficiently aware of stroke survivors’ own model of recovery, and of their perceptions of their health behaviors and management post-stroke [18] [19] . Little attention is given to qualitative studies that offer insight to post-stroke patients’ views on a model of management and beliefs [20] . Therefore, it is essential to explore patients’ beliefs about the causes of stroke, interventions post-stroke, and their model of recovery. Investigation of health knowledge, behavior, and beliefs related to stroke, with special attention given to the culture as an explanatory variable among Saudi, could fill a gap in our existing knowledge and practices. To the best knowledge of the author, there are no qualitative studies from Saudi Arabia or elsewhere in the region regarding belief models influencing health behaviors of stroke survivors.

A qualitative approach was chosen to gain an in-depth insight into the views and beliefs held by stroke survivors. Qualitative research is the ideal method when the objectives are exploratory, and the hypothesis emerging [21] . The researcher performed a semi-structured interview, with both closed and open questions, to explore patients’ beliefs about the etiology and management of their stroke. The semi-structured interviews allowed patients maximum opportunity to express their stories about stroke in terms of their own values and experiences [22] . Interviews were based on a topic guide developed from a literature search about health beliefs and stroke. The interview was piloted with the first participant and was not significantly changed thereafter.

The interviews took place in a quiet room at the rehabilitation hospital, in the outpatient clinics. Interviews were conducted in Arabic and lasted 45 to 60 minutes.

From the interviews, 45 stroke survivors were recruited from the outpatient rehab-psychology clinic, during their follow up (Table 2). They had been discharged from inpatient rehabilitation 6 - 18 months before the interviews.

From the 45 patients, there were 7 patients (2 males and 5 females) refused to participate in this study. The reasons given for refusing were having no time and unwillingness. On the other hand, some refused without express reasons. Four patients were interviewed but had not fulfilled the sample’s criteria, two because of cognitive limitation (≤27 MoCA) and one was dysphasic, and one could not hear well enough to participate.

The final sample was composed of 34 patients, 19 males and 15 females. Age ranged from 37 to 73. Approximately 80% of the patients were between 55 and 73. About two-thirds of the patients completed secondary school or higher, and 11.8% held postgraduate degrees. A large portion of females held secondary school certificates or below. All patients were married in a stable relationship (i.e. neither divorced, nor separated).

Most of the patients described their health as very good prior to their strokes. In fact, more than half of them were surprised they received a diagnosis of stroke, as they had generally being feeling well before.

“I felt things began to be change in my health. I don’t know what happened or came over me, but I was ok.” Another patient said, “I have not been ill for a long time, even, you know? I have not been hospitalized before, but overnight I became a customer at clinics.”

Patients’ beliefs were investigated at least six months after their first stroke. This technique gives the sample the advantage of exploring the long-term impact of strokes.

Qualitative methods were selected as the ideal approach for the preliminary exploration of such a complicated issue, and to obtain the deepest understanding of stroke survivors’ beliefs. Previous Saudi studies reported the advantage of gathering data from in-depth qualitative interviews [25] . The qualitative design provided a greater understanding of the particular experiences of this population, rather than what could be captured with standardized instruments.

Issues of culture and avoiding contact with men are frequently barriers to collecting information from females in previous Saudi studies (. Including a female psychologist in the current study, in order to collect data from female stroke survivors, avoided such cultural barriers and encouraged female patients to report their beliefs easily.

Saudi Arabia, as a developing country, is undergoing numerous changes. Lifestyles are changing quickly, including changing food habits and decreased physical activities. In Saudi Arabia and neighboring countries, this unhealthy lifestyle increases the prevalence of risk factors for stroke, such as diabetes, hypertension and cardiovascular diseases [26] .

It was found that patients tend to be more enthusiastic, particularly when they relate their disease to their lifestyle habits or health-related behavior [6] . Health-related behavior is something they can manage and it could be their own psychological way to cope with their stroke.

Psychological factors were also blamed by most stroke survivors as a cause of their stroke. Patients might have holistic belief systems within which psychological problems are attributed potentially to physical disease [27] . It should be noted here that blaming the psychological element as the source of a stroke, might cause psychological distress itself. Inaccurate beliefs about stroke could be leading a patient to develop anxiety and fear [11] . Psychological, social or environmental needs are given minimal attention during rehabilitation [20] and frequently are not addressed in the early stages of post-stroke.

Stroke survivors acknowledged that the diagnosis of stroke is a wakeup call to absolve oneself from sins. Patients frequently described numerous religious coping strategies, such as praying to Allah or reciting verses from the Quran. Consistent with this result, religiosity has been found to be one of the widespread strategies among stroke patients coping with post-stroke symptoms [28] . As was mentioned above, some patients reported that their stroke could be a good thing. In the Muslim culture, there is a religious belief which sees the person who is in good health for a long time as underprivileged because this indicates that Allah does not want to wipe out his or her sins [29] .

The evil eye was also a very common belief. This is regarded as emerging from another person, or rather from the bad soul which inhabits that person. Belief that stroke or other illnesses are caused by the evil eye is widespread across all ethnic and religious groups [30] [31] .

A few patients linked their strokes, mainly after they had post-stroke epilepsy, to spirit possession. In spite of increasing health facilities and the rising educational level of patients, the belief in a supernatural existence is widely accepted in the Saudi culture, not only among the illiterate, but also among well-educated people [25] [29] . Believing that one has been possessed or cursed supernaturally might lead stroke survivors to psychological problems [32] . It is also possible that being psychologically distressed makes people more vulnerable to suspect supernatural processes. Alternatively, it is possible that supernatural causes provide a culturally valid way of explaining the problems these patients described [33] .

Frequently, the failure of Western medicine to offer a cure or adequate improvements to a stroke condition encouraged people to turn elsewhere for help. A recent survey highlighted that about half of the patients have used traditional interventions, at some point, usually for the treatment of long-term chronic conditions [34] . It has been reported that the common cause for seeking traditional therapies was the lack of a definitive medical cure [29] [34] . However, some use traditional therapies based on their own strong personal beliefs [34] .

A Muslim repeatedly seeks help from Allah, prays and recites the Quran in all conditions. The majority of Muslim patients used spiritual healing, such as prayers and reading the Quran for curing all illness [34] [27] . Interestingly, it was reported that religious beliefs and practices are important to many rehabilitation patients after their strokes, because life satisfaction and quality of life can be positively influenced [35] .

In the current study, skin cauterization is the third cultural intervention reported by stroke survivors for treating their strokes. Generally, skin cauterization is frequently used in Saudi Arabia to heal chronic medical problems [36] . It is usually performed by firing a bar until it glows red and then cauterizing parts of the body based on underlying causes. In a regional study, stroke survivors [26] reported they preferred to be treated at home with traditional treatments, including cauterizations.

Hijama was reported by some patients as a traditional process of using a vacuum on different areas of the body in order to gather the blood in that area. It is one of the remedies recommended by the Prophet Muhammad, (Peace Be Upon Him) [37] . Such traditional intervention is commonly used in Saudi Arabia [34] .

Traditional interventions in Saudi Arabia are sought by patients for several reasons. Lack of evidence-based scientific data on its effectiveness or safety usually does not prevent Arab patients from flocking to traditional healers [38] . There is a common belief that traditional and herbal medicine is risk-free, and this has led to the development of traditional medicine as the most frequently used [39] .

Healthcare in Saudi Arabia has shown remarkable development. However, patients still flock to traditional healers for relief from minor or major health problems, hoping for a permanent cure to their ailments. According to the WHO, more than three-quarters of the world’s population depend on traditional medicine [39] . Health professionals have been encouraged to be culturally competent, addressing psychosocial, cultural and spiritual dimensions of the patient [40] [41] ; Saha et al., 2008). For example, health professionals in Saudi Arabia should acknowledge that religion affects all aspects of their patients’ lives and cannot be separated when delivering medical care and rehabilitation [41] .

Despite being a common disorder, stroke is perhaps the neurological condition least well understood by patients and most likely to be associated with a wide range of cultural beliefs.

As seen above, stroke survivors in this study believed that the sources of their strokes were cultural, and their decision for treatment would be according to their beliefs, though this did not mean that they were anti-science. Several patients were looking for management of symptoms rather than a cure [34] . All of these alternative interventions were typically used as an adjunct rather than an alternative to medical care. Traditional interventions, however, could offer hope that Western medicine was unable to provide.

What we need here is cultural competency, understanding the social and cultural influences that affect the quality of medical services and treatment. Cultural competence is a set of behaviors, knowledge, and beliefs that come together in a specific population to enable healthcare to provide effective work in cross-cultural situations [42] . This study recommends that model of Campinha-Bacote [43] which highlights the factor of cultural competence during providing healthcare service. It is a model that views cultural competence as the ongoing procedure to reach the ability of working and providing healthcare service effectively within the cultural context of the patients [44] . This study provides basic contribution to health professionals regarding the importance of culture competence prior to designing any educational or rehabilitation programs [40] for stroke survivors.

In Arab countries, health professionals have generally been educated very differently from most of their patients [45] , or come from different cultural groups. Consequently, they don’t have cultural competency or they may not know the kinds of beliefs that their patients have about their strokes.

The current results can help to educate such health professionals about what their patients might believe. Physicians and all rehabilitation professionals who seek to apply the Western model in Arabic culture are at risk of treatment failure [29] [46] . Health professionals need to be aware that cultural beliefs and their management are common problems for stroke survivors undergoing rehabilitation in a hospital. Every effort should be made to fill this gap, and to facilitate better cultural communication and education on stroke rehabilitation units to provide scientific knowledge and proper rehabilitation management.

This study did not screen for psychological improvements or functional recovery, so it is possible that some of the patients’ beliefs might have been explained, at least in part, by depression, anxiety or by functional recovery. Future quantitative studies could investigate these factors.

The main limitation was the small number of patients recruited, though for a qualitative study, this is not particularly small. Patients were recruited from KFMC-RH only. But it should be known that KFMC-RH is a tertiary referral hospital which is the main rehabilitation center in Saudi Arabia. It is intended to admit and provide complex rehabilitation care to patients referred from lower level hospitals from all areas of Saudi Arabia.

The author is grateful to the patients who participated in the study, and to the outpatient clinic staff, KFMC-RH, Rehab-Psychology clinic, who helped conduct this study.

MohammedM. J. Alqahtani, (2015) Understanding the Sociocultural Health Belief Model Influencing Health Behaviors among Saudi Stroke Survivors. Neuroscience & Medicine,06,149-159. doi: 10.4236/nm.2015.64023