This study was approved by the Research Ethics Committees of Universiti Sains Malaysia with the reference number USM/JEPeM/22050285, and the Jordanian Ministry of Health. The study objectives were first explained to the patients and their caregivers, and then they filled out the consent form.

This study was a cross-sectional study. A total of 31 stroke patients with dysphagia were recruited from a number of outpatient rehabilitation facilities in Amman-Jordan between August 2022 and December 2022. The judgmental or purposive sampling method was used in this study. Inclusion criteria included a medically-confirmed diagnosis of stroke induced oropharyngeal dysphagia, at least two weeks after a stroke, and over 60 years old. Moreover, the exclusion criteria involved a history of other disorders that have an impact on swallowing (e.g., laryngectomy), feeding through a feeding tube, and extremely severe levels of depression, anxiety, and stress. Because not all stroke patients could communicate, read, and write well, caregivers were included in this study. Including caregivers ensured that all stroke patients were included and that any dysfunction detected was fairly representative of this specific group.

Patients with extremely severe depression, anxiety, or stress were excluded because their responses would indicate that dysphagia had a worse impact on QOL aspects due to their psychological state rather than their swallowing disorder. Levels of depression, anxiety and stress were determined by the Arabic version of the Depression Anxiety Stress Scales-21 (DASS-21) [20]. After evaluating patient’s depression, anxiety and stress, and excluding patients with extremely severe levels of depression, anxiety and stress, the effect of dysphagia on QOL aspects was determined using the Arabic version of the DHI [21].

The DASS-21 is a set of three self-report scales designed to assess the emotional states of depression, anxiety and stress. The three DASS-21 scales each have seven items. Response options are on a 4-point scale: (0=did not apply to me at all; 1=applied to me to some of the time or some degree; 2=applied to me to a good part of the time or a considerable degree; and 3=applied to me most of the time). The DASS-21 divides patients’ levels of depression, stress, and anxiety into five categories: normal, mild, moderate, severe, and extremely severe [20].

The Arabic version of the DHI is an instrument to measure the impact of dysphagia on the emotional, functional, and physical aspects of QOL. It is a 25-item questionnaire divided into three subsections: physical (9 items), Functional (9 items), and emotional (7 items). The total score of the DHI ranges from 0 to 100, and a higher score indicates that dysphagia has a worse effect on the patient’s QOL. Moreover, the physical subscale ranges from 0–36, the functional subscale from 0–36, and the emotional sub-scale from 0–28 [21].

Data input and analysis were carried out using IBM SPSS statistics software version 28. The normality of the distribution of each variable was examined. The mean and its standard deviation (SD) were reported for numerical variables. The frequency and its proportion were supplied for categorical variables. The two groups were compared using the independent t-test. Moreover, ANOVA was used to compare three groups or more.

Thirty-one stroke patients with dysphagia met all the inclusion criteria. Most of the patients (61.3%) were male, and 67.7 % were between the ages of 60–70. Additionally, 17 patients (54.8%) had a high school degree or less, and the annual family income for 41.9% of the patients was 501–1,000 JOD. Furthermore, the time post-onset of dysphagia for the majority of the patients (61.3%) was less than 3 months (Table 1).

The results of the DHI showed that the mean±SD of the DHI total score was 53.5±9.6, indicating that dysphagia negatively affects QOL in stroke patients. Table 2 shows the mean±SD of the DHI total score and its subdomain scores.

The findings revealed no significant mean differences in the DHI total and its subscales based between male and female, age groups, annual income brackets, or educational levels. However, significant mean differences were observed in the emotional subscale (p=0.020), physical subscale (p=0.003), and the DHI total score (p=0.005) among groups categorized by time elapsed since the onset of dysphagia (Table 3).

The DHI is an effective tool because it is regarded as the gold standard for measuring the many aspects of QOL in individuals with dysphagia. Moreover, it involves a thorough evaluation of dysphagia, regardless of the cause, as well as monitoring the effectiveness and progress of rehabilitation from the patient’s viewpoint. Using the DHI in conjunction with the medical diagnosis could provide a thorough, relevant picture of the patient’s health. It can help healthcare professionals in the decision-making process for care.

Our findings indicated that dysphagia negatively affects emotional, functional, and physical aspects, indicating that dysphagia reduces the QOL of stroke patients. Our findings were in line with previous research that measured the impact of dysphagia on QOL components. Although different studies have used different methods to examine how dysphagia affects the various QOL components, dysphagia has consistently had a negative influence on all areas of QOL. Therefore, early diagnosis and treatment are crucial for stroke patients with dysphagia to minimize disability and improve QOL.

Our findings did not reveal significant mean differences in the DHI total score and its subscale scores between male and female. This finding was in line with Bakhtiyari et al. [22]. Moreover, the results did not show significant mean differences between age groups, indicating that the effect of dysphagia on QOL aspects does not change with age. This finding was consistent with [23,24]. However, Pontes et al. [1] found a negative correlation between age and the “selection of food” domain of the Swallowing Quality of Life questionnaire (SWAL-QOL). Pontes et al. interpreted this observation in terms of altered chewing function, which is typically linked to periodontal disease, and decreased salivation, which lessens the sensitivity of fundamental flavors like acid, bitterness, and sweetness. The nutritional status of the elderly is influenced by age-related and stroke-related factors, in addition to socioeconomic and psychological issues.

Our findings did not reveal any significant mean differences among groups with varying annual income levels. However, Alshahrani, AM [25] observed that stroke patients with higher annual incomes tend to experience a better quality of life. This could be because individuals with higher annual incomes might have greater access to healthcare resources and support services, which could contribute to an overall improved quality of life. It’s worth noting that this apparent discrepancy in results may be attributed to differences in the populations we studied in addition, our findings revealed no significant mean differences in the DHI total score and subscale between educational levels, which means that the effect of dysphagia on QOL aspects does not differ based on the educational level. This result contradicts Bakhtiyari et al. [22] found that the effect of dysphagia on the functional aspect increases with increasing educational level. On the other hand, Mercier et al. [26] demonstrated that stroke patients with a higher level of education have a higher QOL. Each study has been conducted in a different geographical region or population, which may explain why their results varied.

Additionally, the findings of this study showed significant mean differences in the physical subscale, emotional subscale, and DHI total score between groups with various onsets of dysphagia, demonstrating that the effect of dysphagia diminishes with longer post-dysphagia periods. This is due to the fact that dysphagia therapy and rehabilitation interventions after a stroke significantly minimize dysphagia severity.

Therefore, it would be helpful to use the DHI during treatment to measure the efficiency of dysphagia therapy and rehabilitation in decreasing the effect of dysphagia on the physical, functional, and emotional aspects and in improving QOL.

This outcome was consistent with some earlier studies [27–30], which discovered that as post-stroke duration increased, its effect on patients’ QOL diminished.

The main objective of rehabilitation and treatment for patients with dysphagia following a stroke is to improve their QOL. Therefore, clinicians should consider several QOL aspects besides clinical and instrumental dysphagia assessments.

This study has some limitations. Stroke patients with dysphagia who use a feeding tube were excluded. Thus, the findings of this study couldn’t be generalized. Moreover, the judgmental or purposive sampling method was used in this study, which may cause some bias. Furthermore, there was no control group to compare QOL between stroke patients with dysphagia and those without dysphagia.