Introduction

Stroke is a neurological condition that occurs suddenly and is identified by the abrupt onset of symptoms and clinical manifestations related to brain function1. Globally, the prevalence of stroke is estimated at 62 million and is expected to reach 77 million by 20302. Stroke is the second most common cause of global disability-adjusted life-years (DALYs) In 20163. Disability is a common stroke complication that affects patients’ ability to perform daily activities and imposes a heavy burden on patients, families, and society4. Stroke rehabilitation is an effective method for reducing disability and is an essential key element in the organized management of stroke5. However, many stroke patients do not receive appropriate rehabilitation services, and the utilization rate of post-stroke rehabilitation services varies greatly across different regions and countries6,7,8. Major barriers to stroke rehabilitation in China include systemic inequities in resource distribution, financial constraints, and fragmented care pathways. Critically, pervasive gaps in public awareness regarding stroke symptoms, the necessity of early intervention, and the long-term value of rehabilitation significantly delay care initiation and undermine the effectiveness of existing services. In the management of chronic diseases, several studies9,10 investigate the awareness, treatment, and compliance rates of patients, with a particular focus on hypertension. These studies typically explore patients’ knowledge of their diagnosis, medication adherence, and the efficacy of treatment. The management of post-stroke disabilities shares similarities with chronic disease management, as both require long-term management. No integrated study has concurrently investigated stroke patients’ awareness, participation, and satisfaction regarding rehabilitation in Xuzhou—a region with distinct healthcare access challenges. This gap impedes understanding of region-specific barriers to rehabilitation uptake and directly prevents targeted interventions to improve both accessibility and clinical outcomes in this population. This research aims to fill the aforementioned gap and provide data support for policy makers.

Patients and methods

Patients

Between January 2021 and April 2022, a total of 1654 stroke patients were admitted to the Affiliated Hospital of Xuzhou Medical University and randomly selected for this study. All participants were previously admitted patients at our institution who had been discharged prior to recruitment. Patients were systematically enrolled at 6 months post-stroke to ensure clinical stability and capture standardized. Eligible participants were initially identified by extracting all patients meeting the study’s inclusion/exclusion criteria from our hospital’s stroke registry database. From this comprehensive cohort, a simple random sample was selected using computer-generated random numbers to ensure equal selection probability for all qualified individuals. The inclusion criteria were as follows: (1) diagnosis of stroke according to computed tomography or magnetic resonance imaging, (2) patients who completed the telephone interview. The exclusion criteria were: (1) severe consciousness or mental disorders in the past that were not caused by stroke. (2) Other diseases causing disabilities. The Ethics Committee of the Affiliated Hospital of Xuzhou Medical University approved this research (XYFY2021-KL269-01), and the study methods followed the principles of the Declaration of Helsinki. This study was registered in the China Clinical Trials Registry (4/7/2021, No. ChiCTR2100048154).

Methods

The research team independently designed a survey questionnaire based on the experimental objectives, focusing primarily on three aspects:① Basic information, including age, gender, marital status, residential area, educational level, etc.; ② Medical details, such as disability severity, type and frequency of strokes, hypertension, diabetes, etc.; ③ Awareness, participation, and satisfaction rates regarding rehabilitation: 1. Awareness:‘Were you informed about the necessity of post-stroke rehabilitation?’ (Dichotomous: Yes/No)0.2. Participation: ‘Did you engage in any structured rehabilitation program after discharge?’ (Dichotomous: Yes/No). 3. Satisfaction: ‘How satisfied are you with the functional outcomes achieved through rehabilitation?’(3-point Likert scale: ① Dissatisfied, ② Fairly Satisfied, ③Quite Satisfied). The study-specific questionnaire was developed through an iterative process by a multidisciplinary expert panel including neurologists, neurosurgeons, and rehabilitation specialists. Content validity was established through three rounds of Delphi consensus (≥ 80% agreement on all items). Pilot testing was subsequently conducted with 35 post-stroke patients meeting inclusion criteria, demonstrating excellent feasibility (97% completion rate), internal consistency (Cronbach’s α = 0.89), and test-retest reliability (ICC = 0.92 at 7-day interval). Minor refinements were made to ambiguous items based on pilot feedback. The modified Rankin Scale (mRS) was used to assess patients’ disability levels, with 0 and 1 representing no disability, 2 indicating slight disability, 3 indicating moderate disability, 4 indicating moderately severe disability, and 5 indicating severe disability. To ensure consistency and accuracy in questionnaire completion, the surveyors underwent standardized training to clarify principles and guidelines for filling out the questionnaire. The survey was conducted via telephone, and patients who did not answer calls on three separate occasions at different times were considered lost to follow-up.

Statistical analysis

The data were analyzed using SPSS 23.0 software. Categorical variables were presented as number (percentage) while continuous variables were reported as mean and standard deviation (SD). Univariate analysis utilized chi-square tests and rank-sum tests, and multivariate analysis was performed using Logistic regression. Spearman correlation analysis was employed to explore the relationships between disability severity and awareness, participation, and satisfaction rates. A significance level of p < 0.05 was considered statistically significant.

Results

Basic information

From the initial random sample of 1,654 eligible patients, 556 were lost to follow-up. The final analytical cohort thus comprised 1,098 participants with complete baseline data. In the 1098 valid samples, the average age was 63.79 ± 10.95 years. Among them, there were 677 males (61.66%) and 421 females (38.34%). Urban residents accounted for 51.55%, Table 1.

Table 1 Analysis of influencing factors on disability status of stroke patients.
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Disease characteristics and disability status

The main type of stroke was ischemic, accounting for 867 cases (78.96%), while hemorrhagic stroke occurred in 231 cases (21.04%). There were 195 cases with a history of stroke (17.76%). The prevalence of hypertension was 54.19%, and the prevalence of diabetes was 25.32% (Table 1). According to the mRS score, 170 individuals had slight disability (15.48%), 95 had moderate disability (8.65%), 90 had moderately severe disability (8.20%), and 65 had severe disability (5.92%). Age, marital status, education level, living area, stroke type, stroke frequency, hypertension, diabetes and time for rehabilitation are the influencing factors (p<0.05) of disability in stroke patients as shown in Table 1. Logistic regression analysis showed that age, living area, stroke type, stroke frequency, hypertension, diabetes, and time for rehabilitation were independent influencing factors as shown in Table 2 (p<0.05).

Table 2 Multivariable analysis of factors influencing disability in stroke patients.
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Awareness, participation, and satisfaction rates regarding rehabilitation

In 1098 stroke patients, the awareness rate and participation rate of stroke rehabilitation were 36.98% (n = 406) and 27.87% (n = 306). Among the patients who received rehabilitation treatment, 199 were satisfied (including fairly and quite satisfied), resulting in a satisfaction rate of 65.03%, Among the 107 patients who reported dissatisfaction, the main reasons were as follows: 80 cases (74.77%) attributed it to unsatisfactory rehabilitation effects, and 27 cases (25.23%) cited poor service attitudes of medical staff. A univariate analysis was conducted, revealing statistically significant differences (p < 0.05) in the awareness and participation rates of rehabilitation among stroke patients based on various factors, including age, marital status, residential area, stroke type, stroke frequency, hypertension, and mRS score (Table 3). Additionally, statistically significant differences (p < 0.05) in satisfaction with rehabilitation were observed among patients of different ages and mRS scores (Table 4). The significant variables identified in the univariate analysis were assigned as dependent variables. Logistic regression analyses were performed with awareness, participation, and satisfaction as separate dependent variables. The results indicated a significant correlation between age, stroke type, and mRS score with patients’ awareness and participation in rehabilitation (p < 0.05), as shown in Tables 5 and 6. The modified Rankin Scale (mRS) score was significantly associated with patients’ satisfaction rate with rehabilitation (P < 0.05), while age (P = 0.460) and total duration of receiving rehabilitation (P = 0.597) were not significantly associated with the satisfaction rate with rehabilitation(Table 7).

Table 3 Awareness and participation in post-stroke rehabilitation among stroke patients with different characteristics.
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Table 4 Satisfaction with post-stroke rehabilitation among stroke patients with different characteristics.
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Table 5 Multivariable analysis of factors affecting awareness of post-stroke rehabilitation.
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Table 6 Multivariable analysis of factors affecting participation of post-stroke rehabilitation.
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Table 7 Multivariable analysis of factors affecting satisfaction of post-stroke rehabilitation.
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The relationship between disability and awareness, participation and satisfaction with stroke

Spearman correlation analysis shows that the mRS score was positively correlated with awareness (r = 0.635,P<0.001) and participation(r = 0.589,P<0.001), but negatively correlated with satisfaction(r=-0.503,P<0.001), suggesting that patients with higher mRS scores had higher levels of awareness and participation, but lower levels of satisfaction.

Discussion

The disability rate of stroke patients was 38.25% in this survey, which is similar to the results of other studies. In a survey of stroke patients in homes and healthcare institutions in France11 ,the disability rate among stroke patients was found to be 34.4%. The results of a community-based study12 in India suggest that the disability rate after first-ever stroke at 28 days is 38.5%. However, it should be noted that since this study was based on a hospital population, the disability rate is likely higher than that of studies based on community populations. This is because hospital populations generally have more severe conditions and higher disability rates compared to community populations. Potential explanations for the finding that the disability rate was not higher than those reported in community-based studies12,13 are that most patients had been discharged for more than six months and returned to their homes and communities, which could have impacted the disability rate, as patients with mild conditions who recovered well after discharge were not included in the disabled population. Additionally, patients who passed away with severe conditions were also not included in the disabled population, which could have influenced the statistical results of the disability rate.

The results of this study indicate that the awareness rate of rehabilitation among stroke patients in the Xuzhou region is 36.98%, implying that less than half of the stroke patients are informed about stroke rehabilitation. This may be due to insufficient education about rehabilitation or a lack of awareness among patients regarding the importance of rehabilitation. The participation rate is 27.87%, which could be attributed, on one hand, to some patients perceiving their physical condition as satisfactory and not seeing the necessity for rehabilitation. On the other hand, it might be because some patients with severe disabilities remain skeptical about the effectiveness of rehabilitation, believing that the outcomes may not meet their expectations, leading to their non-participation. Finally, there are also patients who are unaware of the need for rehabilitation. The satisfaction rate is 65.03%, indicating that although a certain proportion of patients participated in rehabilitation, many are still dissatisfied with the rehabilitation process. This dissatisfaction may stem from rehabilitation plans that do not cater to their needs, insignificant rehabilitation outcomes, or a lack of adequate support and feedback. Enhancing awareness, participation, and satisfaction rates among stroke patients is crucial. This requires a series of measures, including improved promotion and education, personalized rehabilitation plans, additional feedback mechanisms, and possibly a more comprehensive healthcare system. Additionally, interdisciplinary teamwork should be strengthened, extending rehabilitation beyond rehabilitation medicine to fields such as neurology. Finally, establishing a comprehensive rehabilitation team comprising doctors, nurses, physical therapists, psychologists, and other professionals can better meet the diverse rehabilitation needs of patients.

It found that while rural stroke patients had higher awareness and participation rates, their satisfaction rates were lower than those of urban patients. This may be attributed to the more severe disability status of rural patients, their strong desire to receive training, but limited access to quality rehabilitation training due to the shortage of medical resources and economic reasons in rural areas. The survey found that many stroke patients living in rural areas received rehabilitation training at the county-level hospital or even at the township health center, which indicates that although rehabilitation medicine has developed rapidly in Xuzhou and has reached the township level on a large scale, it is not yet strong enough. This, to some extent, also reflects certain phenomena in the development of rehabilitation medicine in China.

Age, stroke type, and mRS (Modified Rankin Scale) score show significant correlations with patient awareness and participation in rehabilitation (p < 0.05). Patients of different ages and mRS scores exhibit statistically significant differences in stroke rehabilitation satisfaction rates (p < 0.05). Older patients tend to have lower awareness, participation, and satisfaction rates in stroke rehabilitation. Advanced age may be associated with less understanding of health management and rehabilitation concepts. As patients age, some may be less familiar or comfortable with modern technology, such as smartphones or computers, potentially affecting their ability to access rehabilitation information and leading to insufficient awareness of rehabilitation. Older patients may face physical limitations that hinder active participation in rehabilitation activities. Factors like pain, reduced mobility, or chronic conditions could impact their rehabilitation progress. Moreover, older patients may be more prone to feelings of anxiety, depression, or a negative attitude toward the rehabilitation process. Their rehabilitation needs may not be as strong as those of younger individuals, leading to lower levels of participation and satisfaction. Similar patterns may be observed among patients with varying degrees of disability. This study found that stroke patients with higher mRS (Modified Rankin Scale) scores have higher awareness and participation rates but lower satisfaction rates. This suggests that patients with more severe disabilities have higher expectations for improving their functional abilities, enhancing their quality of life, and reintegrating into family and society. However, due to the severity of their condition, unrealistic expectations, or insufficient understanding of rehabilitation, these expectations are not always met. Therefore, rehabilitation professionals and therapists must enhance their skills and provide education on rehabilitation knowledge to patients and their families, allowing for a better understanding of rehabilitation concepts.

This study also has certain limitations. Firstly, it adopts a cross-sectional study design, where all data and information are collected simultaneously, limiting causal inferences. The study can only propose hypotheses regarding the factors related to the awareness, participation, and satisfaction rates of stroke patients in rehabilitation, without establishing causal relationships. Secondly, the study is a single-center research, which restricts the generalizability of the results, as there may be variations across different regions and medical institutions. Future research could employ more rigorous study designs for long-term follow-ups to delve deeper into the relationships among awareness, participation, and satisfaction rates of stroke patients in rehabilitation, as well as the associated factors.

Conclusion

The awareness, participation, and satisfaction levels of stroke patients regarding stroke rehabilitation remain less than ideal. Patients with higher levels of disability have a greater awareness of and participation in stroke rehabilitation. However, their satisfaction rates tend to be lower. Government should take measures to promote the high-quality development of rehabilitation medicine. Healthcare workers should strengthen education and dissemination of rehabilitation knowledge to help them better support patients and their families in establishing correct rehabilitation concepts. Governments must prioritize upgrading rehabilitation infrastructure—especially in rural areas—while training more professionals and deploying tele-rehab; healthcare systems should implement mandatory clinician education and mobile follow-up teams; alongside establishing community peer networks and caregiver training programs. Structured family conferences at the start to set realistic long-term goals, with biweekly short-term goal adjustments. This aligns medical expectations with families, complementing broader measures to boost efficacy and satisfaction. By taking these steps, we can improve the quality of life and outcomes for stroke patients.