Optimizing Post-Stroke Functioning: Using Mixed Methods to Understand the Role of Built and Social Environments for Physical Activity, Quality of Life, and Lived Experience

Abstract

An estimated 6.6 million Americans over age 20 have experienced a stroke, making it a leading cause of serious long-term disability in the United States. Medical advances in treatment of acute stroke and an aging population have increased stroke prevalence. Many stroke survivors return directly home with changes in neurological functioning. Although a greater number of people are living independently in community-based settings post-stroke, little is known about the role of built and social environments on post-stroke experience. This dissertation used a mixed-methods approach to examine relationships between features of built and social environments and post-stroke functioning.

The first dissertation aim examined macroscale environmental features (e.g. nearby destinations) and their association with post-stroke physical activity. In a sample of stroke survivors with wide geographic variability, the project used objectively measured community characteristics, data on outdoor climate, and objectively measured physical activity to overcome limitations of previous research. Extreme cold weather was associated with lower post-stroke physical activity, whereas, higher neighborhood socioeconomic status and more destinations for intellectual stimulation were associated with higher post-stroke physical activity. However, many environmental destinations were not associated with post-stroke physical activity. Examination of microscale features in the built environment is needed to understand why some destinations were associated with physical activity and others were not.

The second aim examined microscale features of the built environment and their interaction with stroke severity to shape trajectories of physical quality of life post-stroke. Longitudinal data on a national sample of stroke survivors were linked with microscale audits of pedestrian streetscapes using Google Street View images. The majority of participants lived in environments with few walkable features promoting outdoor mobility. Features at nearby crossings (e.g. curb cuts) were associated with higher physical quality of life post-stroke, but not with changes in physical quality of life over time. Environmental features along the segment (e.g. sidewalk quality) and route (e.g. destinations) were not associated with physical quality of life post-stroke. Crossings lacking pedestrian friendly features may cut off a primary conduit between the individual and society. Interventions to improve built environment accessibility are needed for the growing post-stroke population, and priority should be placed on features at pedestrian crossings.

The third aim of this dissertation uses rich qualitative data to understand how stroke survivors’ lived experience is shaped by their outdoor environment. Semi-structured interviews were conducted with community-dwelling stroke survivors. Using interpretative phenomenological analysis, themes pertaining to the lived post-stroke experience traversing the outdoor environment were identified. Findings highlight that post-stroke lived experience navigating the outdoor environment included vigilance, adaptation, and management of dynamic relations. In order to reduce post-stroke feelings of apprehension and hypervigilance while walking in the outdoor environment, investments in the public outdoor infrastructure should be made to remove barriers (e.g. uneven sidewalks) and install facilitators (e.g. benches).

Collectively these findings reveal that features of the outdoor environment are important for post-stroke mobility and quality of life. Although new construction must adopt accessibility standards, the majority of participants lived in environments lacking infrastructure to support post-stroke mobility and quality of life. Creative solutions are needed to bridge old development into new development. Flexible design strategies (e.g. sidewalks flush with the street) are one approach to support diverse users, such as stroke survivors, who have variation in functioning. Stroke survivors can thrive in outdoor environments if given proper support.