Evaluating in-person clinician versus patient-reported modified Rankin Scale scores among adults with stroke in Zambia

• In Zambia, clinician and patient-reported mRS matched in half of stroke cases. • Cultural, linguistic, and contextual factors drove mRS discrepancies in LMICs. • Moderate mRS agreement highlights challenges of disability assessment in LMICs. In Zambia, clinician and patient-reported mRS matched in half of stroke cases. Cultural, linguistic, and contextual factors drove mRS discrepancies in LMICs. Moderate mRS agreement highlights challenges of disability assessment in LMICs. The modified Rankin Scale (mRS) is widely used to assess functional status after stroke, yet prior work in Zambia has shown low agreement between clinician assessments and patient-reported scores. To identify cultural, linguistic, and other factors contributing to discrepancies between clinician-determined and self-reported mRS scores among adults with stroke in Zambia. Consecutive adults hospitalized with stroke were recruited into a mixed-methods cross-sectional study. A neurologist assigned an in-person mRS score. Within seven days, a verbal mRS questionnaire was administered in the participant's preferred language (English, Nyanja, or Bemba). Semi-structured interviews explored how respondents interpreted and justified their answers. Transcripts were analyzed for themes related to comprehension, health perceptions, and observed behavior. Among 51 participants, in-person and self-reported mRS scores matched in 51% of cases (weighted kappa = 0.548). Self-reported scores were 1 point higher in 19% and 1 point lower in 11% of cases; 8% reported scores 2 points higher. Agreement for dichotomized outcomes (good <2; poor >3) was moderate (k = 0.60). Discrepancies arose from translation challenges, caregiver responses based on incomplete knowledge, patients' fear of attempting tasks such as sitting or walking, underestimation of non-motor deficits, and mismatches between patient and clinician interpretations of mRS criteria. Clinician and patient-reported mRS scores aligned for only half of participants. Improving translations and better understanding how patients perceive their abilities may enhance interpretation of both clinician-assigned and self-reported mRS scores in this setting.