Promoting psychosocial well-being following a stroke: developing a theoretically and empirically sound complex intervention

Psychosocial well-being after stroke in Aotearoa New Zealand: a qualitative metasynthesis

PURPOSE

Psychosocial well-being is key to living well after stroke, but often significantly affected by stroke. Existing understandings consider well-being comes from positive mood, social relationships, self-identity and engagement in meaningful activities. However, these understandings are socioculturally located and not necessarily universally applicable. This qualitative metasynthesis examined how people experience well-being after a stroke in Aotearoa New Zealand.

MATERIAL AND METHODS

This metasynthesis was underpinned by He Awa Whiria (Braided Rivers), a model which prompts researchers to uniquely engage with Māori and non-Māori knowledges. A systematic search identified 18 articles exploring experiences of people with stroke in Aotearoa. Articles were analysed using reflexive thematic analysis.

RESULTS

We constructed three themes which reflect experiences of well-being: connection within a constellation of relationships, being grounded in one's enduring and evolving identities, and being at-home in the present whilst (re)visioning the future.

CONCLUSION

Well-being is multi-faceted. In Aotearoa, it is inherently collective while also deeply personal. Well-being is collectively achieved through connections with self, others, community and culture, and embedded within personal and collective temporal worlds. These rich understandings of well-being can open up different considerations of how well-being is supported by and within stroke services.

Preventing depression in aphasia: A cluster randomized control trial of the Aphasia Action Success Knowledge (ASK) program

BACKGROUND

Stroke patients with aphasia and their caregivers have higher incidence of depression than those without aphasia.

AIMS

The objective of the study is to determine whether a tailored intervention program (Action Success Knowledge; ASK) led to better mood and quality of life (QoL) outcomes than an attention control with a 12-month end point at cluster and individual participant level.

METHODS

A multi-site, pragmatic, two-level single-blind cluster randomized controlled trial compared ASK to an attention control (secondary stroke prevention program). Ten metropolitan and 10 non-metropolitan health regions were randomized. People with aphasia and their family members were recruited within 6 months post-stroke who scored ⩽12 on the Stroke Aphasic Depression Questionnaire Hospital Version-10 at screening. Each arm received manualized intervention over 6-8 weeks followed by monthly telephone calls. Blinded assessments of QoL and depression were taken at 12 months post-onset.

RESULTS

Twenty clusters (health regions) were randomized. Trained speech pathologists screened 1744 people with aphasia and 373 participants consented to intervention (n = 231 people with aphasia and 142 family members). The attrition rate after consent was 26% with 86 and 85 participants with aphasia in the ASK arm and attention control arm, respectively, receiving intervention. Of those 171 who did receive treatment, only 41 met the prescribed minimum dose. Multilevel mixed effects modeling under the intention-to-treat protocol showed a significant difference on the Stroke and Aphasia Depression Questionnaire-21 (SADQ-21, N = 122, 17 clusters) in favor of the attention control (β = -2.74, 95% confidence interval (CI) = -4.76 to -0.73, p = 0.008). Individual data analysis using a minimal detectable change score for the SADQ-21 showed the difference was not meaningful.

CONCLUSION

ASK showed no benefit over attention control in improving mood and preventing depression in people with aphasia or their family members.

Interventions for improving psychosocial well-being after stroke: A systematic review

BACKGROUND

Up to one third of all stroke patients suffer from one or more psychosocial impairments. Recognition and treatment of these impairments are essential in improving psychosocial well-being after stroke. Although nurses are ideally positioned to address psychosocial well-being, they often feel insecure about providing the needed psychosocial care. Therefore, we expect that providing nurses with better knowledge to deliver this care could lead to an improvement in psychosocial well-being after stroke. Currently it is not known which interventions are effective and what aspects of these interventions are most effective to improve psychosocial well-being after stroke.

OBJECTIVE

To identify potentially effective interventions - and intervention components - which can be delivered by nurses to improve patients' psychosocial well-being after stroke.

METHODS

A systematic review and data synthesis of randomized controlled trials and quasi experimental studies was conducted. Papers were included according to the following criteria: 1) before-after design, 2) all types of stroke patients, 3) interventions that can be delivered by nurses, 4) the primary outcome(s) were psychosocial. PubMed, Embase, PsychInfo, CINAHL and Cochrane library were searched (August 2019-April 2022). Articles were selected based on title, abstract, full text and quality. Quality was assessed by using Joanna Briggs Institute checklists and a standardized data extraction form developed by Joanna Brigss Institute was used to extract the data.

RESULTS

In total 60 studies were included, of which 52 randomized controlled trials, three non-randomized controlled trials, four quasi-experimental studies, and one randomized cross-over study. Nineteen studies had a clear psychosocial content, twenty-nine a partly psychosocial content, and twelve no psychosocial content. Thirty-nine interventions that showed positive effects on psychosocial well-being after stroke were identified. Effective intervention topics were found to be mood, recovery, coping, emotions, consequences/problems after stroke, values and needs, risk factors and secondary prevention, self-management, and medication management. Active information and physical exercise were identified as effective methods of delivery.

DISCUSSION

The results suggest that interventions to improve psychosocial well-being should include the intervention topics and methods of delivery that were identified as effective. Since effectiveness of the intervention can depend on the interaction of intervention components, these interactions should be studied. Nurses and patients should be involved in the development of such interventions to ensure it can be used by nurses and will help improve patients' psychosocial well-being.

FUNDING AND REGISTRATION

This study was supported by the Taskforce for Applied Research SIA (RAAK.PUB04.010). This review was not registered.

A Study Protocol Exploring the Role of an Implantable Doppler Probe in Kidney Transplantation: A Feasibility Randomized Controlled Trial with an Embedded Qualitative Study

OBJECTIVES

Vascular complications in kidney transplant surgery constitute one-third of early graft loss, which can be prevented by timely diagnosis of vascular compromise. A blood flow monitoring device may have a beneficial role in the early identification of graft hypoperfusion critical to reducing graft loss. This research protocol aims to evaluate the potential of an implantable Doppler probe as a blood flow monitoring device in kidney transplant recipients.

MATERIALS AND METHODS

The potential study will be a mixed methodology, 2-arm feasibility randomized controlled trial with an embedded qualitative study. For the trial, we will compare demographic characteristics and outcome measures of kidney transplant patients receiving implantable Doppler probe monitoring (intervention group, n = 30) with those having standard clinical care (control group). For the qualitative study, we will conduct semi-structured interviews with stakeholders (n = 12) recruited by purposive sampling to explore experiences of participants. All interviews will be audio recorded with verbatim transcription.

RESULTS

Our results will use the summarized quantitative data and descriptive statistics to determine differences between the groups. We will use CONSORT guidelines to determine the suitability of the research processes, availability of research resources, and potential challenges faced during the feasibility randomized controlled trial. We will use thematic analysis and NVivo software to analyze the acceptability of the intervention in clinical practice. We will compile the results according to the consolidated criteria for reporting qualitative research checklist.

CONCLUSIONS

The goal of this protocol is to determine the feasibility of an implantable Doppler probe monitoring device in kidney transplant recipients. The feasibility study will collect preliminary information, fill gaps in evidence, and test research processes for the pragmatic future randomized controlled trial. The template of this study is transferable to other transplant centers across the United Kingdom.

Mediating effect of post-stroke depression between activities of daily living and health-related quality of life: meta-analytic structural equation modeling

BACKGROUND

Stroke survivors face various problems that affect their health-related quality of life (HRQoL). Reduced activities of daily living (ADL) may contribute to post-stroke depression (PSD) and low HRQoL, and depression might be associated with low HRQoL. However, these relationships are not well known. This study aimed to analyze correlations among ADL, PSD, and HRQoL in stroke survivors and further explore the mediating role of PSD between ADL and HRQoL.

METHODS

This study utilized meta-analytic structural equation modeling (MASEM) on systematically searched articles from six electronic databases, namely PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure (China), Wanfang database (China), and SinoMed (China), from inception up to July 31, 2021. Two researchers independently assessed study eligibility, and data from the eligible studies were encoded and assessed for quality. MASEM was utilized to examine correlations among ADL, PSD, and HRQoL, with an estimation of a pooled correlation matrix under a random-effects model. The matrix was directly fitted to a structural equation model using webMASEM.

RESULTS

In total, 8580 articles were screened, and data from 27 studies involving 33 effect sizes were used in the MASEM analysis. Correlations among the three variables were significant (both P < 0.01). Furthermore, PSD partially mediated the correlation between ADL and HRQoL (β = 0.24, 95% confidence interval 0.15-0.30).

CONCLUSIONS

The findings suggest that both decreased ADL and PSD may reduce HRQoL, while a decrease in ADL tends to cause depression after stroke. Therefore, ADL and PSD reductions should be improved to achieve better HRQoL of stroke survivors. Future studies should continue to discuss other factors affecting HRQoL to achieve optimal recovery in stroke survivors.

The HEADS: UP Development Study: Working with Key Stakeholders to Adapt a Mindfulness-Based Stress Reduction Course for People with Anxiety and Depression after Stroke

BACKGROUND

Following stroke, rates of mood disorder are and remain high at five years (anxiety 34.4%; depression 23%). Structured mindfulness-based stress reduction (MBSR) courses are effective in a range of health conditions, but stroke survivors find adherence challenging. We aimed to adapt a standard MBSR course specifically for people affected by stroke.

METHODS

We recruited stroke survivors and family members with symptoms of anxiety and/or depression to take part in a co-development study comprising two rounds of MBSR 'taster' sessions, followed by focus groups in which views were sought on the practices sampled. Data were collected in October 2017 and May 2018 and were analysed using framework analysis, informed adaptations to mindfulness materials and delivery.

RESULTS

Twenty-eight stroke survivors and seven family members participated. Nineteen (76%) stroke survivors had anxiety; 15 (60%) had depression. Five (71.4%) family members reported anxiety; n = 4 (57.1%) depression. Thirty participants attended the first round of taster sessions and focus groups; twenty (66%) the second and three (10%) were unable to attend either round. Framework analysis informed adaptations to course delivery, practices, and materials, ultimately resulting in a stroke-specific MBSR course, HEADS: UP (Helping Ease Anxiety and Depression after Stroke).

CONCLUSIONS

HEADS: UP may provide a feasible, appropriate, and meaningful self-management intervention to help alleviate symptoms of mood disorder.

The development of a self-management intervention for stroke survivors - My Life After Stroke (MLAS)

PURPOSE

Long-term needs of stroke survivors (especially psychosocial needs and stroke prevention) are not adequately addressed. Self-management programmes exist but the optimal content and delivery approach is unclear. We aim to describe the process undertook to develop a structured self-management programme to address these unmet needs.

MATERIALS AND METHODS

Based on the Medical Research Council framework for complex interventions, the development involved three phases: "Exploring the idea": Evidence synthesis and patient and public involvement (PPI) with stroke survivors, carers and healthcare professionals. "The iterative phase": Development and iterative refinement of the format, content, underpinning theories and philosophy of the self-management programme My Life After Stroke (MLAS), with PPI. MLAS consists of two individual appointments and four group sessions over nine weeks, delivered interactively by two trained facilitators. It aims to build independence, confidence and hope and focusses on stroke prevention, maximising physical potential, social support and managing emotional responses. MLAS is grounded in the narrative approach and social learning theory. "Ready for research": The refinement of a facilitator curriculum and participant resources to support programme delivery.

RESULTS

Through a systematic process, we developed an evidence- and theory-based self-management programme for stroke survivors.

CONCLUSIONS

MLAS warrants evaluation in a feasibility study.Implications for rehabilitationMy Life After Stroke(MLAS) has been developed using a systematic process, to address the unmet needs of stroke survivors.This systematic process, involved utilising evidence, theories, patient and public involvement, expertise and guidelines from other long-term conditions. This may further help the development of similar self-management programme within the field of stroke.MLAS warrants further evaluation within a feasibility study.

Depression and a lack of socialization are associated with high levels of boredom during stroke rehabilitation: An exploratory study using a new conceptual framework

This exploratory sub-study aimed to develop a framework to conceptualize boredom in stroke survivors during inpatient rehabilitation, establish the effect of an activity promotion intervention on boredom, and to investigate factors that are associated with boredom. A framework was developed and explored within a cluster non-randomised controlled trial. Self-reported boredom was measured in 160 stroke survivors 13 (±5) days after rehabilitation admission; 91 participants received usual-care (control) and 69 had access to a patient-driven model of activity promotion (intervention). Individuals with pre-existing dementia or unable to participate in standard rehabilitation were excluded. Hierarchical logistic regression analysis was used to identify demographic, health and activity measures associated with boredom. Results indicated 39% of participants were highly bored. There was no statistically significant difference in boredom levels between treatment groups (difference -11%, 95% CI -26% to 4%). The presence of depression (OR 6.17, 95% CI 2.57-14.79) and lower levels of socialization (OR 0.96, 95% CI 0.92-0.99) predicted high boredom levels. This comprehensive framework provides a foundation for understanding the many interacting factors associated with boredom. Results suggest managing depression and improving opportunities for socialization may support meaningful engagement in rehabilitation to optimize recovery following stroke.

Exploring the Potential of Creative Museum-led Activities to Support Stroke In-patient Rehabilitation and Wellbeing: A Pilot Mixed-methods Study

BACKGROUND

This paper proposes a framework for studying the potential of museum-led interventions for supporting stroke rehabilitation goals.

METHODS

The intervention was based on Kirvevold et al.'s model for interventions for post-stroke wellbeing. Mixed-methods data was collected to review benefits in a pilot study, including retrospective video observations for six sessions with four patients; interviews with patients, carers and facilitators; pre-post patient assessments; and facilitator diaries.

RESULTS

Systematic analysis of videos showed high levels of concentration and engagement with museum objects, low levels of social interaction, and positive or neutral mood throughout. Thematic qualitative analysis suggested patients felt engaged in meaningful activities, which lifted negative mood, provided positive distraction from the ward, and increased self-esteem, including belief in patient abilities.

CONCLUSION

Further research is needed to fully establish the potential of museum-led interventions for stroke rehabilitation.

Use of narrative methods in rehabilitation and palliative care in Scandinavian countries: A scoping review

BACKGROUND

Although narratives-including an ill person's life story, life situation and future perspectives-seem to lie at the core of rehabilitation and palliative care in Scandinavian countries, we lack a scope of how, when and where narrative methods are used. Such a scope could provide knowledge and inspiration on a practical as well as a policy level. The objective of this study is to explore the literature on the use of systematic, narrative methods in rehabilitative and palliative care for people with life-threatening illness in Scandinavian countries.

METHOD

We conducted a scoping review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) where applicable. We performed a systematic search in CINAHL, Medline, PsychInfo, SOCIndex and SveMed+using the search terms 'life threatening illness', 'narratives', 'rehabilitation', 'palliative care' and 'Scandinavia', followed by a search for grey literature. We found 42 records to be eligible for this scope and extracted the data via piloted extraction tables.

RESULTS

We identified 17 narrative methods and present findings concerning four themes: (1) a record of the narrative methods used; (2) an objective and theoretical framework for the narrative methods; (3) the content and form of the narrative methods; and (4) the significance of the narrative methods used.

CONCLUSION

Narrative methods are used in systematic ways in rehabilitation and palliative care in Scandinavian countries and cover a wide variety of objectives, theoretical frames, forms and outcomes. Further development may benefit from more elaboration on definitions and the relationships between objectives, theoretical frameworks and outcomes.

Perceived study-induced influence on the control group in a randomized controlled trial evaluating a complex intervention to promote psychosocial well-being after stroke: a process evaluation

BACKGROUND

A commonly applied control condition in trials evaluating complex interventions in rehabilitation research is "usual care." The main challenge is to ensure that the control group receives genuine usual care as delivered in everyday clinical practice. The assessment interviews and dialogues with the data collectors may influence the control group participants' reflections on their condition and adjustments. This represents a threat to the internal validity of the trial. Thus, the aim of this study was to explore the perceived study-induced influence of assessment interviews on the adjustment of the members of a control group in a randomized clinical trial. The aim of the trial was to test a dialogue-based psychosocial intervention aiming at promoting the psychosocial well-being and adjustment of stroke survivors.

METHODS

Fifteen participants in the control group of a multicenter stroke rehabilitation trial participated in narrative semi-structured interviews. Ricoeur's interpretation theory guided the analysis.

RESULTS

The perceived study-induced influence of the assessment interviews on the adjustment process of members of the control group varied considerably. The results demonstrated that the assessment interviews facilitated some participants' feelings of control and their ability to cope. Other participants' statements indicate that they relied on their existing personal capacity to cope and adjust and that the assessment interviews did not make any difference either on their coping ability or on their process of adjustment. Five themes were identified that described the perceived study-induced influence of the assessment interviews in the control group. The themes illustrated that the assessments served as a safety net, enhanced awareness and understanding, encouraged seeking support, allowed the opportunity to vent disappointment, or did not make any difference either way.

CONCLUSIONS

RCT assessment interviews may influence the adjustment process and represent a serious problem in measuring interventions over time in trials of complex interventions in rehabilitation research. To uphold rigor and stringency, the usual care control conditions should be thoroughly assessed and described. Informing participants only about the treatment they were allocated to receive might counteract the potential to dilute the difference between the two arms of the trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02338869. Registered on October 4, 2014.

Nurses' and occupational therapists' experiences of conducting a home-based psychosocial intervention following stroke: a qualitative process evaluation

Background

Persons with stroke are susceptible to psychosocial problems, and express disappointment at how health care professionals fail to meet their psychosocial needs following discharge to home. The responsibility of nurses and occupational therapists in stroke rehabilitation is to assist the persons and their families during the recovery and adjustment process. A home-based dialogical intervention aiming to enhance psychosocial support was therefore developed and tested in a randomized controlled trial. This study is a part of the process evaluation conducted alongside the trial. The aim was to explore the nurses’ and occupational therapists’ experiences of conducting the intervention.

Methods

Eighteen nurses and four occupational therapists participated in six focus groups to explore their experiences when providing the intervention. The themes discussed in the focus groups were the aspects that facilitated the delivering of the intervention and the challenges they encountered during the study period. The interviews were analysed using qualitative content analysis.

Results

The analysis generated two themes. The theme Developing a supportive relationship to facilitate the adjustment process following stroke had two subthemes: Getting personally involved and Handling challenges. This theme reveals how the nurses and occupational therapists experienced their relationship with the persons with stroke and potential threats which challenged them while conducting the intervention. The theme Developing professional skills in providing psychosocial support had two subthemes: Becoming confident in conducting dialogues and Integrating psychosocial topics. This theme reveals the aspects that the nurses and occupational therapists perceived as facilitating the development of their professional skills in conducting the dialogues.

Conclusion

Delivering the psychosocial intervention was perceived as deeply meaningful and increased the nurses’ and occupational therapists’ understanding of how to support stroke survivors to live with the consequences of stroke. However, balancing the professional and the personal relationship was challenging. A basic educational programme, training, supervision and having dedicated time were crucial elements to instil confidence in professionals conducting theme-based dialogues to promote post-stroke psychosocial well-being. Individual clinical experience and knowledge of stroke care were considering important to enable professionals to integrate psychosocial rehabilitation into community health care.

Trial registration

ClinicalTrials.gov, NCT 02338869, registered 10/04/2014.

An Integrative Review Considering the Impact of Storytelling and Sharing Interventions in Stroke

Background: Review-based research is needed which can establish the psychosocial outcomes and mechanisms of “storytelling and sharing” interventions for people with stroke. This information will act to inform the value and development of such interventions. Methods: An integrative review was conducted in three stages: (a) a systematic search strategy was undertaken to focus on articles between 2009 until January 2020 to locate articles the considered storytelling and sharing interventions for people diagnosed with stroke; (b) critical appraisal was undertaken to assess study quality; and (c) synthesis within three stages including data reduction, data display and conclusion. Results: Fourteen articles (including 727 participants) were identified that met the eligibility criteria. Five themes were identified that represented the outcome and mechanisms that appeared to be associated with a stroke intervention. These included introducing the concept of hope and learning to be positive, the enhanced ability to cope, the impact of loneliness and social interaction, impact on emotions, depression and related emotions such as fear. Conclusions: Storytelling interventions appear to impact loneliness, introduce positivity and hope and enable coping through knowledge exchange. The main mechanisms which appeared to influence these outcomes were social comparisons and social control.

Quantification of the Masseter Muscle Hardness of Stroke Patients Using the MyotonPRO Apparatus: Intra- and Inter-Rater Reliability and Its Correlation with Masticatory Performance

BACKGROUND Chewing dysfunction is one of the most common serious complications after a stroke. It may be influenced by the hardness of the masseter muscle and masticatory performance; however, the association between these 2 factors is not explicit. Thus, it is meaningful to explore the functional status of the masseter muscle among stroke patients. The main objectives of this study were to examine the intra- and inter-rater reliability of the MyotonPRO apparatus in measuring masseter muscle hardness in stroke patients and to investigate the correlation between the bilateral masseter muscle hardness and masticatory performance in these patients. MATERIAL AND METHODS A total of 20 stroke patients participated in our study. The hardness of the masseter muscle was measured by 2 physiotherapists using the MyotonPRO apparatus. Overall, each patient masticated 2 pieces of red-blue bicolor chewing gum for 20 chewing cycles each. The chewing pieces were analyzed using ViewGum software for masticatory performance. RESULTS The intra- and inter-rater reliability of the MyotonPRO apparatus for measuring bilateral masseter hardness of stroke patients was excellent. The correlation analysis showed that the hardness index of the masseter muscle on the affected side was moderately correlated with the masticatory performance of the same side. CONCLUSIONS The MyotonPRO device can be used for measuring the masseter muscle hardness of stroke patients, with excellent reliability. This study established the construct validity between the stiffness of the masseter muscle and masticatory performance.

Creating therapeutic relationships through communication: a qualitative metasynthesis from the perspectives of people with communication impairment after stroke

PURPOSE

Communication between patients and clinicians influences the development of therapeutic relationships. Communication is disrupted when the patient has communication impairments after stroke. However, how these communication disruptions influence therapeutic relationships is not well-understood. This qualitative metasynthesis explores the perspectives of people with communication impairment to understand how interpersonal communication influences therapeutic relationships.

MATERIAL AND METHODS

Four databases were searched for qualitative studies which discussed how communication influenced therapeutic relationships from the perspectives of people with aphasia, dysarthria or apraxia of speech. Additional papers were identified through citation searching and subject experts. Nineteen eligible papers were included and analysed using thematic analysis.

RESULTS

Four themes were constructed from the analysis: (1) Relationships provide the foundation for rehabilitation; (2) Different relational possibilities arise from "reading" the clinician; (3) Creating therapeutic relationships through validating interactions and connections; and (4) Creating therapeutic disconnections through invalidating, exclusionary interactions.

CONCLUSIONS

A therapeutic relationship develops, at least in part, in response to the clinician's communication and how this is received and experienced by the patient. Understanding the characteristics of relationship-fostering communication and knowing how communication influences relationships can help clinicians critically reflect on their communication and better develop therapeutic relationships with people with communication impairment.IMPLICATIONS FOR REHABILITATIONPractitioner-patient communication can facilitate therapeutic relationships or create therapeutic disconnections.Communication patterns that are commonly evident when a patient has communication impairments can impede therapeutic relationships.Clinicians need to attend to how their communication is received and how it influences people's sense of self.Communication partner training should address the existential and relational needs of people with communication impairment after stroke.

The effects of a dialogue-based intervention to promote psychosocial well-being after stroke: a randomized controlled trial

Objective:

To evaluate the effect of a dialogue-based intervention targeting psychosocial well-being at 12 months post-stroke.

Design:

Multicenter, prospective, randomized, assessor-blinded, controlled trial with two parallel groups.

Setting:

Community.

Subjects:

Three-hundred and twenty-two adults (⩾18 years) with stroke within the last four weeks were randomly allocated into intervention group (n = 166) or control group (n = 156).

Interventions:

The intervention group received a dialogue-based intervention to promote psychosocial well-being, comprising eight individual 1–1½ hour sessions delivered during the first six months post-stroke.

Main measures:

The primary outcome measure was the General Health Questionnaire-28 (GHQ-28). Secondary outcome measures included the Stroke and Aphasia Quality of Life Scale-39g, the Sense of Coherence scale, and the Yale Brown single-item questionnaire.

Results:

The mean (SD) age of the participants was 66.8 (12.1) years in the intervention group and 65.7 (13.3) years in the control group. At 12 months post-stroke, the mean (SE) GHQ-28 score was 20.6 (0.84) in the intervention group and 19.9 (0.85) in the control group. There were no between-group differences in psychosocial well-being at 12 months post-stroke (mean difference: −0.74, 95% confidence interval (CI): −3.08, 1.60). The secondary outcomes showed no statistically significant between-group difference in health-related quality of life, sense of coherence, or depression at 12 months.

Conclusion:

The results of this trial did not demonstrate lower levels of emotional distress and anxiety or higher levels of health-related quality of life in the intervention group (dialogue-based intervention) as compared to the control group (usual care) at 12 months post-stroke.

Finding the Way Forward: The Lived Experience of People With Stroke After Participation in a Complex Psychosocial Intervention

Stroke patients' well-being is threatened after stroke. A psychosocial intervention was developed for Norwegian stroke patients living in the community. Eight individual sessions between people with stroke and a trained health care professional were conducted 1 to 6 months post-stroke with one group of participants and 6 to 12 months post-stroke with another group. Subsequently, 19 of these stroke patients were interviewed to gain an in-depth understanding of their lived experience of the influence of the intervention on their adjustment process. Interview texts were analyzed using Ricoeur's interpretation theory. Two participants did not personally find the intervention useful. The remaining participants greatly appreciated dialogues with the empathetic intervention personnel, feeling free to discuss their fears and worries. The intervention raised these participants' awareness of their needs and resources. They were guided to resume their everyday life and adopt a future-oriented attitude. The intervention facilitated their meaning-making endeavors and post-stroke adjustment.

Implementation fidelity in a complex intervention promoting psychosocial well-being following stroke: an explanatory sequential mixed methods study

BACKGROUND

Evaluation of complex interventions should include a process evaluation to give evaluators, researchers, and policy makers greater confidence in the outcomes reported from RCTs. Implementation fidelity can be part of a process evaluation and refers to the degree to which an intervention is delivered according to protocol. The aim of this implementation fidelity study was to evaluate to what extent a dialogue-based psychosocial intervention was delivered according to protocol. A modified conceptual framework for implementation fidelity was used to guide the analysis.

METHODS

This study has an explanatory, sequential two-phase mixed methods design. Quantitative process data were collected longitudinally along with data collection in the RCT. Qualitative process data were collected after the last data collection point of the RCT. Descriptive statistical analyses were conducted to describe the sample, the intervention trajectories, and the adherence measures. A scoring system to clarify quantitative measurement of the levels of implementation was constructed. The qualitative data sources were analyzed separately with a theory-driven content analysis using categories of adherence and potential moderating factors identified in the conceptual framework of implementation fidelity. The quantitative adherence results were extended with the results from the qualitative analysis to assess which potential moderators may have influenced implementation fidelity and in what way.

RESULTS

The results show that the core components of the intervention were delivered although the intervention trajectories were individualized. Based on the composite score of adherence, results show that 80.1% of the interventions in the RCT were implemented with high fidelity. Although it is challenging to assess the importance of each of the moderating factors in relation to the other factors and to their influence on the adherence measures, participant responsiveness, comprehensiveness of policy description, context, and recruitment appeared to be the most prominent moderating factors of implementation fidelity in this study.

CONCLUSIONS

This evaluation of implementation fidelity and the discussion of what constitutes high fidelity implementation of this intervention are crucial in understanding the factors influencing the trial outcome. The study also highlights important methodological considerations for researchers planning process evaluations and studies of implementation fidelity.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT02338869; registered 10/04/2014.

The development and feasibility of an online aphasia group intervention and networking program - TeleGAIN

PURPOSE

Aphasia group therapy offers many benefits, however people with aphasia report difficulty accessing groups and speech-language pathologists are faced with many challenges in providing aphasia group therapy. Telerehabilitation may offer an alternative service delivery option. An online aphasia group therapy program - Telerehabilitation Group Aphasia Intervention and Networking (TeleGAIN) - has been developed according to the guidelines of the Medical Research Council (MRC) framework for complex interventions. The purpose of this paper is to describe the development of TeleGAIN and the results of a pilot trial to determine feasibility and acceptability.

METHOD

The development of TeleGAIN was informed through literature reviews in relevant topic areas, consideration of expert opinion and application of the social cognitive theory. TeleGAIN was then modelled through a feasibility pilot trial with four people with aphasia.

RESULT

TeleGAIN appeared to be feasible and acceptable to participants and able to be implemented as planned. Participant satisfaction with treatment was high and results suggested some potential for improvements in language functioning and communication-related quality of life.

CONCLUSION

TeleGAIN appeared to be feasible and acceptable, however the study highlighted issues related to technology, clinical implementation and participant-specific factors that should be addressed prior to a larger trial.

Emotional and social characteristics of stroke patients with low verbal memory

BACKGROUND

Cognitive deficits, especially problems with memory observed after stroke often coexist with patients' experience of difficulties in everyday life situations.

AIMS

The purposes of the study were to explore the relationships between verbal memory, emotional functioning and social competence in stroke patients, and to examine the emotional and social condition of stroke patients with low verbal memory.

METHODS

Ninety-five participants were assessed with the Rey Auditory Verbal Learning Test, the Neuropsychology Behavior and Affect Profile, and the Social Competency Questionnaire. The participants' relatives (N = 95) also took part in the study evaluating patients' emotional and social functioning.

RESULTS

Stroke patients with low verbal memory had higher scores in depression, indifference, and inappropriateness than the patients with normal memory. They also obtained higher scores in the self-reported intimacy and lower scores in objectively assessed social exposition than controls.

DISCUSSION

It is worth considering patients' relationships with relatives that evolve after stroke, especially when the patients experience cognitive difficulties in gaining new information. Collecting verbal information seems to be important for the feeling of effectiveness in some dimensions of elders' social functioning.

CONCLUSIONS

Because the social engagement may be treated as protective factor in the course of recovery we would recommend that during rehabilitation more attention should be paid to emotional and social functioning of stroke patients with low verbal memory.

Promoting psychosocial well-being following stroke: study protocol for a randomized, controlled trial

Background

Stroke is a major public health threat globally. Psychosocial well-being may be affected following stroke. Depressive symptoms, anxiety, general psychological distress and social isolation are prevalent. Approximately one third report depressive symptoms and 20% report anxiety during the first months or years after the stroke. Psychosocial difficulties may impact significantly on long-term functioning and quality of life, reduce the effects of rehabilitation services and lead to higher mortality rates. The aim of the study is to evaluate the effect of a previously developed and feasibility tested dialogue-based psychosocial intervention aimed at promoting psychosocial well-being and coping following stroke among stroke survivors with and without aphasia.

Methods

The study will be conducted as a multicenter, randomized, single blind controlled trial with one intervention and one control arm. It will include a total of 330 stroke survivors randomly allocated into either an intervention group (dialogue-based intervention to promote psychosocial well-being) or a control group (usual care). Participants in the intervention group will receive eight individual sessions of supported dialogues in their homes during the first six months following an acute stroke. The primary outcome measure will be psychosocial well-being measured by the General Health Questionnaire (GHQ). Secondary outcome measures will be quality of life (SAQoL), sense of coherence (SOC), and depression (Yale). Process evaluation will be conducted in a longitudinal mixed methods study by individual qualitative interviews with 15–20 participants in the intervention and control groups, focus group interviews with the intervention personnel and data collectors, and a comprehensive analysis of implementation fidelity.

Discussion

The intervention described in this study protocol is based on thorough development and feasibility work, guided by the UK medical research council framework for developing and testing complex interventions. It combines classical effectiveness evaluation with a thorough process evaluation. The results from this study may inform the development of further trials aimed at promoting psychosocial well-being following stroke as well as inform the psychosocial follow up of stroke patients living at home.

Trial registration

NCT02338869; registered 10/04/2014 (On-going trial).

Improving transitions in acute stroke patients discharged to home: the Michigan stroke transitions trial (MISTT) protocol

Background

For some stroke patients and caregivers, navigating the transition between hospital discharge and returning home is associated with substantial psychosocial and health-related challenges. Currently, no evidence-based standard of care exists that addresses the concerns of stroke patients and caregivers during the transition period. Objectives of the Michigan Stroke Transitions Trial (MISTT) are to test the impact of a social worker home-based case management program, as well as an online information and support resource, on patient and caregiver outcomes after returning home.

Methods

The Michigan Stroke Transitions Trial is a randomized, pragmatic, open (un-blinded), 3-group parallel designed superiority trial conducted in 3 Michigan hospitals. Eligible participants are adult acute stroke patients discharged home directly or within 4 weeks of being discharged to a rehabilitation facility. The patient’s primary caregiver is also invited to participate. Patients are randomized on the day they return home using a randomized block design. Consented patients discharged to a rehabilitation facility who do not go home within 4 weeks are dropped from the study.

The 2 study interventions begin within a week of returning home and conclude 3 months later. The 3-group design compares usual care to either a home-based social worker stroke case management (SWSCM) program, or a combination of the SWSCM program plus access to an online information and support resource (MISTT website). Outcomes data are collected at 7-days and 90-days by trained telephone interviewers. Primary patient outcomes include the PROMIS global 10 score (a generic Quality of Life scale), and the Patient Activation Measure (PAM). Caregiver outcomes include the Bakas Caregiving Outcomes Scale. Final analysis will be based on 214 randomized acute stroke patients. To accommodate subjects excluded due to prolonged rehabilitation stays, as well as those lost-to-follow-up, up to 315 patients will be consented.

Discussion

The MISTT study will determine if a home-based case management program designed around the needs and preferences of stroke patients and caregivers, alone or in combination with a patient-centered online information and support resource can improve stroke survivor and caregiver outcomes 3 months after returning home.

Trial registration

ClinicalTrials.gov: NCT02653170 (Protocol ID: 135457). Registered April 9, 2015.

Shaping innovations in long-term care for stroke survivors with multimorbidity through stakeholder engagement

BACKGROUND

Stroke, like many long-term conditions, tends to be managed in isolation of its associated risk factors and multimorbidity. With increasing access to clinical and research data there is the potential to combine data from a variety of sources to inform interventions to improve healthcare. A 'Learning Health System' (LHS) is an innovative model of care which transforms integrated data into knowledge to improve healthcare. The objective of this study is to develop a process of engaging stakeholders in the use of clinical and research data to co-produce potential solutions, informed by a LHS, to improve long-term care for stroke survivors with multimorbidity.

METHODS

We used a stakeholder engagement study design informed by co-production principles to engage stakeholders, including service users, carers, general practitioners and other health and social care professionals, service managers, commissioners of services, policy makers, third sector representatives and researchers. Over a 10 month period we used a range of methods including stakeholder group meetings, focus groups, nominal group techniques (priority setting and consensus building) and interviews. Qualitative data were recorded, transcribed and analysed thematically.

RESULTS

37 participants took part in the study. The concept of how data might drive intervention development was difficult to convey and understand. The engagement process led to four priority areas for needs for data and information being identified by stakeholders: 1) improving continuity of care; 2) improving management of mental health consequences; 3) better access to health and social care; and 4) targeting multiple risk factors. These priorities informed preliminary design interventions. The final choice of intervention was agreed by consensus, informed by consideration of the gap in evidence and local service provision, and availability of robust data. This shaped a co-produced decision support tool to improve secondary prevention after stroke for further development.

CONCLUSIONS

Stakeholder engagement to identify data-driven solutions is feasible but requires resources. While a number of potential interventions were identified, the final choice rested not just on stakeholder priorities but also on data availability. Further work is required to evaluate the impact and implementation of data-driven interventions for long-term stroke survivors.

The Aphasia Action, Success, and Knowledge Programme: Results from an Australian Phase I Trial of a Speech-Pathology-Led Intervention for People with Aphasia Early Post Stroke

Background: Speech pathologists work to optimise communication and reduce the emotional and social impact of communication disability in patients with aphasia but need evidence-based interventions to effectively do so.

Objective: This phase 1 study aims to evaluate an Australian speech-pathology-led intervention called the Aphasia Action, Success, and Knowledge (Aphasia ASK) programme for patients with aphasia early post stroke.

Methods: A convergent parallel mixed-methods design was utilised. The intervention included up to six individual face-to-face sessions with seven participants with aphasia and their nominated family member(s). Quantitative outcomes assessing mood, quality of life, and communication confidence were conducted for the participants with aphasia. Follow-up interviews were conducted with both participants with aphasia and family members to determine their perceptions of the programme.

Results: Significant improvements were found in communication confidence and mood after treatment and the gains were maintained at 3-month follow-up. Participants with aphasia and their family members reported a good level of satisfaction with the programme.

Conclusions: Findings suggest the Aphasia ASK programme is a suitable intervention with positive initial outcomes for people with aphasia. A larger scale evaluation with a greater variety of participants is now required. An Australian cluster randomised control trial is planned.

The Stroke and Carer Optimal Health Program (SCOHP) to enhance psychosocial health: study protocol for a randomized controlled trial

BACKGROUND

Stroke is a leading cause of disability and distress, and often profoundly affects the quality of life of stroke survivors and their carers. With the support of carers, many stroke survivors are returning to live in the community despite the presence of disability and ongoing challenges. The sudden and catastrophic changes caused by stroke affects the mental, emotional and social health of both stroke survivors and carers. The aim of this study is to evaluate a Stroke and Carer Optimal Health Program (SCOHP) that adopts a person-centred approach and engages collaborative therapy to educate, support and improve the psychosocial health of stroke survivors and their carers.

METHODS

This study is a prospective randomised controlled trial. It will include a total of 168 stroke survivors and carers randomly allocated into an intervention group (SCOHP) or a control group (usual care). Participants randomised to the intervention group will receive nine (8 + 1 booster) sessions guided by a structured workbook. The primary outcome measures for stroke survivors and carers will be health-related quality of life (AQoL-6D and EQ-5D) and self-efficacy (GSE). Secondary outcome measures will include: anxiety and depression (HADS); coping (Brief COPE); work and social adjustment (WSAS); carer strain (MCSI); carer satisfaction (CASI); and treatment evaluation (TEI-SF and CEQ). Process evaluation and a health economic cost analysis will also be conducted.

DISCUSSION

We believe that this is an innovative intervention that engages the stroke survivor and carer and will be significant in improving the psychosocial health, increasing independence and reducing treatment-related costs in this vulnerable patient-carer dyad. In addition, we expect that the intervention will assist carers and stroke survivors to negotiate the complexity of health services across the trajectory of care and provide practical skills to improve self-management.

TRIAL REGISTRATION

ACTRN12615001046594 . Registered on 7 October 2015.

Trialling of an optimal health programme (OHP) across chronic disease

Population ageing is a worldwide phenomenon, most advanced in developed countries and expected to continue over the next few decades. As people are surviving longer with age-associated disease and disability, there is an imperative to identify innovative solutions for an already overburdened health care system. Such innovations need to be focused on disease management, taking into consideration the strong associations that have been established between psychosocial factors and pathophysiological mechanisms associated with chronic disease. Aside from personal and community costs, chronic diseases produce a significant economic burden due to the culmination of health care costs and lost productivity. This commentary reports on a programme of research, Translating Research, Integrated Public Health Outcomes and Delivery, which will evaluate an optimal health programme that adopts a person-centred approach and engages collaborative therapy to educate, support and improve the psychosocial health of those with chronic disease. The effectiveness of the optimal health programme will be evaluated across three of the most significant contributors to disease burden: diabetes mellitus, chronic kidney disease and stroke. Cost-effectiveness will also be evaluated. The findings derived from this series of randomised controlled trials will also provide evidence attesting to the potential applicability of the optimal health programme in other chronic conditions.

Bringing research into a closed and protected place: development and implementation of a complex clinical intervention project in an ICU

This article reports a Swedish research project designed to study the impact of a cyclic light system, sound absorbents, and selected interior design changes in rooms within an intensive care unit. The authors describe the limitations of many previously reported intensive care unit (ICU) design research projects, and believe that much more knowledge is needed, which reflects a multidisciplinary perspective. It is complicated to carry out intervention research in ICUs because of the condition of patients, family presence, staffing, and other issues. A combination of methodological approaches, close contact with the clinical field, secure funding, and clear communication within the multidisciplinary research team are of vital importance. The results from the authors' initial evaluation process are reported including patient interviews and data from medical records. The Medical Research Council's guideline for design and evaluation of complex interventions directed the actual project and forms the structure for this article.

Optimisation of complex health interventions prior to a randomised controlled trial: a scoping review of strategies used

BACKGROUND

Many complex intervention trials fail to show an intervention effect. Although this may be due to genuine ineffectiveness, it may also be the result of sub-optimal intervention design, implementation failure or a combination of these. Given current financial constraints and the pressure to reduce waste and increase value in health services research, pre-trial strategies are needed to reduce the likelihood of design or implementation failure and to maximise the intervention's potential for effectiveness. In this scoping review, we aimed to identify and synthesise the available evidence relating to the strategies and methods used to 'optimise' complex interventions at the pre-trial stage.

METHODS

We searched MEDLINE, CINAHL, AMED, PsycINFO and ProQuest Nursing & Allied Health Source for papers published between January 2000 and March 2015. We included intervention development and optimisation studies that explored potential intervention weaknesses and limitations before moving to a definitive randomised controlled trial (RCT). Two reviewers independently applied selection criteria and systematically extracted information relating to the following: study characteristics; intervention under development; framework used to guide the development process; areas of focus of the optimisation process, methods used and outcomes of the optimisation process. Data were tabulated and summarised in a narrative format.

RESULTS

We screened 3968 titles and 231 abstracts for eligibility. Eighty-nine full-text papers were retrieved; 27 studies met our selection criteria. Optimisation strategies were used for a range of reasons: to explore the feasibility and acceptability of the intervention to patients and healthcare professionals; to estimate the effectiveness and cost-effectiveness of different combinations of intervention components; and to identify potential barriers to implementation. Methods varied widely across studies, from interviews and focus groups to economic modelling and probability analysis.

CONCLUSIONS

The review identifies a range of optimisation strategies currently used. Although a preliminary classification of these strategies can be proposed, a series of questions remain as to which methods to use for different interventions and how to determine when the intervention is ready or 'optimised enough' to be tested in a RCT. Future research should explore potential answers to the questions raised, to guide researchers in the development and evaluation of more effective interventions.

Effects of a 4-week transitional care programme for discharged stroke survivors in Hong Kong: a randomised controlled trial

Stroke rehabilitation involves care issues concerning the physical, psychosocial and spiritual aspects. Hospital-based rehabilitation has its limitations because many of the care issues only emerge when patients return home. Transitional care models supporting patients after discharge from the hospital have proved to be effective among chronically ill patients, but limited studies were conducted among stroke survivors. This study was a randomised controlled trial conducted to test the effectiveness of a transitional care programme (TCP) which was a nurse-led 4-week programme designed based on the assessment-intervention-evaluation Omaha System framework. Between August 2010 and October 2011, 108 stroke patients who were discharged home, able to communicate, and had slight to moderate neurological deficits and disability were randomised into control (n = 54) and intervention groups (n = 54). Data on the patient-related and clinical outcomes were collected at baseline, 4 weeks when the TCP was completed and 8 weeks after discharge from hospital. Repeated measures analysis of variance with intention-to-treat strategy was used to examine the outcomes. There were significant between-group differences in quality of life, the primary outcome measure of this study, in both physical (F(1, 104) = 10.15, P = 0.002) and mental (F(1, 104) = 8.41, P = 0.005) domains, but only the physical domain achieved a significant time × intervention interaction effect (F(1, 103) = 7.73, P = 0.006). The intervention group had better spiritual-religion-personal measures, higher satisfaction, higher Modified Barthel Index scores and lower depression scores when compared with the control group. They also had lower hospital readmission and use of emergency room rates, but only the use of emergency room had significant difference when compared to control. This study is original in testing a transitional model among stroke patients discharged from hospital. The TCP shares common features that have been proved to be effective when applied to chronically ill patients, and the duration of 4 weeks seems to be adequate to bring about immediate effects.

Flexible guided self-determination intervention for younger adults with poorly controlled Type 1 diabetes, decreased HbA1c and psychosocial distress in women but not in men: a real-life RCT

AIM

To report results from an 18-month randomized controlled trial (RCT) testing the effectiveness of a flexible guided self-determination (GSD) intervention on glycaemic control and psychosocial distress in younger adults with poorly controlled Type 1 diabetes.

METHODS

Between January 2010 and February 2012, we randomly allocated two hundred 18-35-year-olds [mean age 25.7 (5.1) years, 50% men] with Type 1 diabetes for ≥ 1 year [mean duration 13.7 (6.8) years] and HbA1c  ≥ 64 mmol/mol (8.0%) to either an immediate GSD (intervention; n = 134) or 18-months delayed GSD group (control; n = 66). Group-based or individual GSD sessions were offered, drawing on reflection sheets and advanced professional communication. The primary outcome was HbA1c (measured at baseline and every three months thereafter) and among secondary outcomes was psychosocial distress (self-reported at baseline and after nine and 18 months). Intention-to-treat analyses included linear regression and repeated measurement analyses.

RESULTS

A borderline significant decrease in HbA1c in the intervention group compared with the control group ( - 4 vs - 1 mmol/mol or - 0.4% vs - 0.1%; P = 0.073) was driven by a significantly greater reduction in the GSD women ( - 5 vs + 1 mmol/mol or - 0.5% vs + 0.1%; P = 0.017); parallel decreases were observed in the GSD and control men ( - 3 mmol/mol or  - 0.3%; P = 0.955). Significantly greater reduction in the GSD group's psychosocial distress was again driven by differences between the GSD and the control women. The men's improvements were not connected with the intervention.

CONCLUSIONS

The flexible GSD intervention benefitted younger adult women by significantly improving glycaemic control and decreasing diabetes related distress. No effect was seen among men.

The psychosocial needs of gynaecological cancer survivors: A framework for the development of a complex intervention

PURPOSE

To develop and pilot test an intervention targeting the women's psychosocial needs during the follow-up period after surgical treatment for gynaecological cancer.

METHODS

The project consisted of four phases. Phase 1 involved development of an intervention on the basis of meetings with key healthcare professionals, a literature review and six semi-structured interviews with women who attended the existing follow-up program. The Guided Self-Determination (GSD) method developed in diabetes care was identified as an appropriate framework for the intervention. GSD consists of reflection sheets for patients and advanced professional communication skills. The GSD method was adapted to women in a follow-up program after gynaecologic cancer treatment (GSD-GYN-C). Phase 2 involved primary pilot testing of the intervention and the findings were used to modify the intervention in phase 3. This modification involved the development of additional reflection sheets and a fidelity assessment tool. A systematic training program was arranged for the GSD-GYN-C-nurses. Phase 4 involved secondary pilot testing where nurses and women confirmed the applicability of GSD-GYN-C and final adjustments were made. Selected measurements were tested for sensitivity during pilot testing. Data from phase 2 and 4 were also used to select the primary outcome and calculate power for a future randomized clinical trial (RCT).

RESULTS

Pilot testing supported our hypothesis that GSD-GYN-C may be transferable and useful to survivors of gynaecological cancer.

CONCLUSION

GSD-GYN-C was developed and validated and is now ready for evaluation in an RCT.

Fast tracking the design of theory-based KT interventions through a consensus process

BACKGROUND

Despite available evidence for optimal management of spinal pain, poor adherence to guidelines and wide variations in healthcare services persist. One of the objectives of the Canadian Chiropractic Guideline Initiative is to develop and evaluate targeted theory- and evidence-informed interventions to improve the management of non-specific neck pain by chiropractors. In order to systematically develop a knowledge translation (KT) intervention underpinned by the Theoretical Domains Framework (TDF), we explored the factors perceived to influence the use of multimodal care to manage non-specific neck pain, and mapped behaviour change techniques to key theoretical domains.

METHODS

Individual telephone interviews exploring beliefs about managing neck pain were conducted with a purposive sample of 13 chiropractors. The interview guide was based upon the TDF. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using thematic content analysis. A 15-member expert panel formally met to design a KT intervention.

RESULTS

Nine TDF domains were identified as likely relevant. Key beliefs (and relevant domains of the TDF) included the following: influence of formal training, colleagues and patients on clinicians (Social Influences); availability of educational material (Environmental Context and Resources); and better clinical outcomes reinforcing the use of multimodal care (Reinforcement). Facilitating factors considered important included better communication (Skills); audits of patients' treatment-related outcomes (Behavioural Regulation); awareness and agreement with guidelines (Knowledge); and tailoring of multimodal care (Memory, Attention and Decision Processes). Clinicians conveyed conflicting beliefs about perceived threats to professional autonomy (Social/Professional Role and Identity) and speed of recovery from either applying or ignoring the practice recommendations (Beliefs about Consequences). The expert panel mapped behaviour change techniques to key theoretical domains and identified relevant KT strategies and modes of delivery to increase the use of multimodal care among chiropractors.

CONCLUSIONS

A multifaceted KT educational intervention targeting chiropractors' management of neck pain was developed. The KT intervention consisted of an online education webinar series, clinical vignettes and a video underpinned by the Brief Action Planning model. The intervention was designed to reflect key theoretical domains, behaviour change techniques and intervention components. The effectiveness of the proposed intervention remains to be tested.

Acute phase factors associated with the course of depression during the first 18 months after first-ever stroke

PURPOSE

The aim of this study was to describe the course of post-stroke depression (PSD) during the first 18 months after first-ever stroke and to examine differences in the course of depressive symptoms in relation to patient demographic and clinical characteristics in the acute phase.

METHODS

As part of a longitudinal cohort study, data were collected from medical records and in face-to-face interviews using standardized questionnaires within 15 days after stroke and 6, 12 and 18 months later. The sample consisted of 94 patients with first-ever stroke. PSD was measured with the Beck Depression Inventory II. Repeated measures analysis of variance was used to evaluate the course of depressive symptoms over time and in relation to demographic and clinical variables.

RESULTS

Depression levels were stable during the 18 months after first-ever stroke. However, depression scores were significantly higher among patients who had lower physical functioning in the acute phase, were living alone or were not employed at the time of stroke.

CONCLUSIONS

Several demographic and acute phase factors were associated with a more severe PSD course following stroke. Psychosocial support that begins in the acute phase and continues throughout the rehabilitation process may be helpful in improving both physical and psychological outcomes following stroke.

IMPLICATIONS FOR REHABILITATION

Depression levels are stable during the first 18 months after first-ever stroke. The course of post-stroke depression is related to the level of physical functioning in the acute phase, whether the stroke survivors live alone and their employment status at the time of stroke. Psychological support that begins in the acute phase and continues throughout the rehabilitation process may be helpful in improving both physical and psychological outcomes following stroke.

Promoting psychosocial wellbeing following stroke using narratives and guided self-determination: a feasibility study

BACKGROUND

Extensive studies have documented the complex and comprehensive psychosocial consequences of stroke. Psychosocial difficulties significantly affect long-term functioning and quality of life. Many studies have explored psychosocial interventions to prevent or treat psychosocial problems, but most have found modest effects. This study evaluated, from the perspective of adult stroke survivors, (1) the content, structure and process and (2) experienced usefulness of a dialogue-based psychosocial nursing intervention in primary care aimed at promoting psychosocial health and wellbeing.

METHODS

This was part of a feasibility study guided by the UK MRC complex interventions framework. It consisted of dialogue-based encounters with trained health professionals during approximately the first year poststroke. It was tested in two formats; individual or group encounters. Inclusion criteria were: Acute stroke, above 18 y.o., sufficient physical and cognitive functioning to participate. Data were collected immediately before, during and 14 days after the completion of the intervention. Pre- and post-data included medical and demographic data, quality of life, emotional wellbeing, life satisfaction, anxiety and depression. Qualitative interviews focusing on participant experiences were conducted two weeks following the intervention. Log notes taken by the health professionals conducting the intervention and work sheets filled in by participants also comprised data. Data analysis was case-oriented. The structured instruments were analysed regarding completeness of data and indication of changes in outcome variables. The qualitative interviews, log notes and work sheets were analysed using thematic content analysis.

RESULTS

Twenty-five stroke survivors (17 men, 8 women), median age 64 (range 33-89), participated. Physical limitations varied from mild to severe. Seven participants had moderate to severe expressive aphasia. The participants found the content and process of the intervention relevant. Both the individual and group formats were found useful. Patients with aphasia reported that there were too few encounters (eight encounters were originally planned). The participants underscored the benefits of being supported through a difficult time, having a chance to tell and (re)create their story and being supported in their attempts to cope with the situation.

CONCLUSIONS

This study provides initial support for the usefulness of the psychosocial intervention and highlights areas requiring further consideration and development.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01912014.

Living at home with eating difficulties following stroke: a phenomenological study of younger people's experiences

AIMS AND OBJECTIVES

To explore and describe the experience of eating and eating-related difficulties in stroke survivors living at home.

BACKGROUND

The ability to consume food and to take pleasure in eating is an essential part of life. For people with stroke, eating difficulties are frequent. A phenomenological perspective of stroke survivors' experience of eating difficulties exceeding the acute stroke event and in-hospital rehabilitation is missing.

DESIGN

A qualitative study founded on the Husslarian descriptive phenomenology.

METHODS

Colaizzi's seven phases of data analysis provided a systematic approach to explore 17 in-depth interviews from seven participants and how eating difficulties influenced their daily lives.

RESULTS

Eating difficulties revealed themselves in participants' relationship with the outer world in far-reaching disruptions of habits, capacities and actions. Four key themes illuminating the eating difficulties emerged: (1) preserving dignity by not conveying serious problems, (2) staying vigilant to bodily limitations, (3) stepping out of the security zone and (4) moving on without missing out. The findings exposed that eating difficulties might not only lead to serious consequences such as malnutrition but also, and equally importantly, lead to losses in the existential, social and cultural lifeworld.

CONCLUSIONS

The experience of eating difficulties entails an ongoing readjustment process, which is strongly influenced by interactions with other people. The findings suggest that individualised long-term support is needed to facilitated the use of helpful strategies to manage eating difficulties.

RELEVANCE TO CLINICAL PRACTICE

The long-term losses that people with eating difficulties experience are not reflected in conventional screening tools and interventions. To avoid haphazard identification presupposes professional knowledge of how eating difficulties are woven into daily life. This knowledge may inform innovative nursing strategies reaching beyond immediate rehabilitation. Partnership-based practice may provide an important framework to establish unique needs and to mobilise relevant actions and resources.

Work-aged stroke survivors' psychosocial challenges narrated during and after participating in a dialogue-based psychosocial intervention: a feasibility study

Background

Studies point to the lack of psychosocial support and rehabilitation services that are adjusted to the work-aged stroke survivors’ specific needs in order to promote psychosocial well-being. The aim of the study was to illuminate the psychosocial challenges work-aged participants (i.e. aged 18–67 years) thematised during and after participating a dialogue-based psychosocial intervention during the first year following a stroke.

Methods

The study was a feasibility study guided by the UK Medical Research Council Framework for developing and evaluating complex interventions. Qualitative data from in-depth interviews with fourteen stroke-survivors aged 33–66 years, researcher field notes and log notes written during the intervention were analysed applying a hermeneutic-phenomenological approach.

Results

The stroke and its consequences had a substantial impact on family and work life. Their experiences were summarised in the two themes The threat of becoming marginalised in family life and The threat of becoming marginalised in work life.

Conclusion

Life as a work-aged stroke survivor was experienced as challenging and created a threat of becoming marginalised in family and work life. The study highlights the need to understand the specific psychosocial challenges and needs facing work-aged stroke survivors’ in order to promote their psychosocial well-being. More research is needed concerning specific life-span challenges amongst work-aged stroke survivors in order to further develop appropriate interventions that helps address this issue.

Between the lines: generating good qualitative data in studies involving persons with aphasia

High-quality data are essential for developing knowledge in qualitative inquiries. Language impairments affect the ability to meet the requirements that constitute good qualitative data. In this article, we focus on generating good qualitative data in persons with aphasia following stroke. We drew on experiences from a longitudinal nursing intervention to discuss how to maximize data generation in accordance with norms for data quality in this population. The longitudinal design, using a combination of research methods, and the iterative process of data generation and analysis over time constituted a continuity that enhanced communication, mutual understanding, and a trustful partnership.

Uncovering treatment burden as a key concept for stroke care: a systematic review of qualitative research

BACKGROUND

Patients with chronic disease may experience complicated management plans requiring significant personal investment. This has been termed 'treatment burden' and has been associated with unfavourable outcomes. The aim of this systematic review is to examine the qualitative literature on treatment burden in stroke from the patient perspective.

METHODS AND FINDINGS

The search strategy centred on: stroke, treatment burden, patient experience, and qualitative methods. We searched: Scopus, CINAHL, Embase, Medline, and PsycINFO. We tracked references, footnotes, and citations. Restrictions included: English language, date of publication January 2000 until February 2013. Two reviewers independently carried out the following: paper screening, data extraction, and data analysis. Data were analysed using framework synthesis, as informed by Normalization Process Theory. Sixty-nine papers were included. Treatment burden includes: (1) making sense of stroke management and planning care, (2) interacting with others, (3) enacting management strategies, and (4) reflecting on management. Health care is fragmented, with poor communication between patient and health care providers. Patients report inadequate information provision. Inpatient care is unsatisfactory, with a perceived lack of empathy from professionals and a shortage of stimulating activities on the ward. Discharge services are poorly coordinated, and accessing health and social care in the community is difficult. The study has potential limitations because it was restricted to studies published in English only and data from low-income countries were scarce.

CONCLUSIONS

Stroke management is extremely demanding for patients, and treatment burden is influenced by micro and macro organisation of health services. Knowledge deficits mean patients are ill equipped to organise their care and develop coping strategies, making adherence less likely. There is a need to transform the approach to care provision so that services are configured to prioritise patient needs rather than those of health care systems.

The aphasic storyteller: coconstructing stories to promote psychosocial well-being after stroke

Telling stories is essential to the continuous process of creating meaning and to self-understanding. Persons with aphasia are vulnerable to psychosocial problems by their limited ability to talk and interact with others. This single-case study illustrates how a young woman with aphasia and a trained nurse interacted to coconstruct stories within the context of a longitudinal clinical intervention aimed at promoting psychosocial well-being in the first year after a stroke. Data were collected through qualitative interviews and participant observation; they were then analyzed from a hermeneutic-phenomenological perspective. The experience of coconstructing stories made an important contribution to improving the participant's psychological well-being. The shared construction of the participant's story evolved as a cumulative process, and it was facilitated by the establishment of trust in the participant-nurse relationship, the systematic use of worksheets and supported conversations, and a specific focus on psychosocial topics and structural organization.

Psychosocial well-being in persons with aphasia participating in a nursing intervention after stroke

The psychosocial adjustment process after stroke is complicated and protracted. The language is the most important tool for making sense of experiences and for human interplay, making persons with aphasia especially prone to psychosocial problems. Persons with aphasia are systematically excluded from research projects due to methodological challenges. This study explored how seven persons with aphasia experienced participating in a complex nursing intervention aimed at supporting the psychosocial adjustment process and promoting psychosocial well-being. The intervention was organized as an individual, dialogue-based collaboration process based upon ideas from “Guided self-determination.” The content addressed psychosocial issues as mood, social relationships, meaningful activities, identity, and body changes. Principles from “Supported conversation for adults with aphasia” were used to facilitate the conversations. The data were obtained by participant observation during the intervention, qualitative interviews 2 weeks, 6 months, and 12 months after the intervention and by standardized clinical instruments prior to the intervention and at 2 weeks and 12 months after the intervention. Assistance in narrating about themselves and their experiences with illness, psychological support and motivation to move on during the difficult adjustment process, and exchange of knowledge and information were experienced as beneficial and important by the participants in this study.