Opportunities and challenges in secondary stroke prevention: a mixed methods study

Understanding the factors that influence stroke survivors to begin or resume exercise: a qualitative exploration

BACKGROUND

Exercise after stroke has the potential to increase survivors' physical function and decrease disability. However, despite health professional reporting they recommend exercise to stroke survivors, the majority are physically inactive. Stroke survivors have previously expressed a lack of adequate knowledge and skills to engage in exercise.

OBJECTIVES

The aim of this study was to understand why active stroke survivors chose to (re)engage in exercise and how they went about doing so. A secondary aim was to understand if health professionals had a role in facilitating exercise engagement.

METHODS

Semi-structured interviews were conducted with stroke survivors who regularly engaged with exercise. Seven people aged between 60 and 71 years participated in the study. Time since stroke varied from 1 to 13 years. A reflexive thematic analysis approach was used to analyze interviews.

RESULTS

Exercise was spoken about in a positive light. For some, exercise had always been important, for others it became important after their stroke. The themes of Changing Support Over Time, Old and New Identity and Proactively Impacting the Future were developed. The participants felt that health professionals often facilitated engagement in exercise, although the type of support that was most valued differed at different points in the post-stroke journey.

CONCLUSIONS

Authoritative support from health professionals and family members helped participants to engage in exercise in the early stages after stroke. Collaboration and being part of a team was appreciated for ongoing exercise engagement. Exercise provided hope as participants developed their identity after stroke.

Factors associated with health behaviours among stroke survivors: A mixed-methods study using COM-B model

AIMS

To identify factors associated with health behaviours among stroke survivors, through a multi-centre study.

DESIGN

A sequential mixed methods design.

METHODS

In the quantitative research phase, a total of 350 participants were recruited through multi-stage sampling from December 2022 to June 2023. General information questionnaires, The Stroke Prevention Knowledge Questionnaire (SPKQ), Short Form Health Belief Model Scale (SF-HBMS), Health Promoting Lifestyle Profile (HPLPII), and the WHOQOL-BREF (World Health Organization Quality of Life Questionnaire, Brief Version) were distributed across five tertiary hospitals in Henan province, China. For the qualitative research component, semi-structured interviews were conducted to explore the barriers and facilitators of health behaviour. This study adheres to the GRAMMS guidelines.

RESULTS

A total of 315 participants (90.0%) completed the survey. Identified barriers to health behaviour included residing in rural areas, higher scores on the Charlson Comorbidity Index (CCI) and mRS, as well as lower scores on SPKQ, SF-HBMS and WHOQOL-BREF. Twenty-four individuals participated in qualitative interviews. Twenty-eight themes were identified and categorised by frequency, covering areas such as knowledge, skills, intentions, social influences, social/professional role and identity, environmental context and resources, beliefs about capabilities, beliefs about consequences and behavioural regulation. Both quantitative and qualitative data suggested that health behaviour among stroke survivors is at a moderate level, and the identified barrier factors can be mapped into the COM-B model (Capability, Opportunity, Motivation and Behaviour).

CONCLUSION

The study indicates that key barriers to health behaviour among stroke survivors align with the COM-B model. These identified factors should be carefully considered in the planning of future systematic interventions aimed at improving health behaviours among stroke survivors.

PATIENT OR PUBLIC CONTRIBUTION

Patients were invited to completed questionnaires in the study and semi-structured interviews. The investigators provided explanation of this study' content, purpose and addressed issues during the data collection.

Utilising interactive technology for stroke patient education: a systematic review

PURPOSE

As a leading cause of death and disability worldwide, how to effectively manage and prevent stroke is a key consideration for health care systems. Throughout the world stroke management recommendations include education; however, not all patients receive this intervention. Advances in technology have provided health professionals with a range of innovative, effective, and modern tools that may be useful in delivering stroke education. This study aimed to systematically review the current evidence for the use of interactive technology in stroke patient education, and whether this was effective for increasing patients' stroke knowledge and behaviours that lower stroke risk.

METHODS AND MATERIALS

The protocol was registered with PROSPERO (#225223) and a literature search undertaken in Embase (including MEDLINE and PubMed), PsycInfo and CINAHL from inception until August 2022. The Mixed Methods Appraisal Tool was used to assess the methodological quality of the included articles.

RESULTS

From an initial yield of 760 articles, 10 articles met the study inclusion criteria. The articles explored a range of interactive technologies, with none of them includes articles using the same technology. All of the articles reported at least one positive effect from the technology. Two articles reported on stroke incidence post-intervention. The methodological quality of the articles varied, but was largely medium to high.

CONCLUSION

The paucity of evidence highlights a need for future studies to provide insights into the benefits of quality interactive technology-based stroke education and to identify options for optimal delivery modes in stroke education.

Use of the Self- and Family Management Framework in quantitative studies

BACKGROUND

The Self- and Family Management Framework (SFMF) identifies factors and outcomes of patient and family management of chronic illness. In a previous citation analysis, we reported the frequency and nature of use of the SFMF.

PURPOSE

We conducted a sub-analysis of quantitative articles in the citation analysis to examine testing of relationships depicted in the SFMF.

METHODS

We analyzed study purposes, independent and dependent variables, study implications, and text that referred to the SFMF in 40 articles.

FINDINGS

The SFMF has been used largely to explore factors affecting SFM behaviors, focusing on patient versus family self-management. Independent variables included all categories of facilitators/barriers specified in the SFMF. Dependent variables included all SFMF components (Facilitators/Barriers, Processes, Proximal and Distal Outcomes). Racial/ethnic diversity was limited among study participants. Study implications pertained mostly to psychosocial outcomes. Most studies referred to the SFMF generally.

DISCUSSION

Findings will contribute to revision of the SFMF.

Inclusion of stroke patients in expanded cardiac rehabilitation services: a cross-national qualitative study with cardiac and stroke rehabilitation professionals

PURPOSE

This qualitative study explored healthcare professionals' views in relation to the potential expansion of cardiac rehabilitation services to include stroke patients, thereby becoming a cardiovascular rehabilitation model.

DESIGN AND METHODS

23 semi-structured interviews were completed with hospital and community-based stroke and cardiac rehabilitation professionals in Switzerland (n = 7) and Ireland (n = 19). The sample comprised physiotherapists, occupational therapists, speech and language therapists, stroke physicians, cardiologists, psychologists, dieticians and nurses. Interviews were audio-recorded and the transcripts were analysed in NVivo using inductive Thematic Analysis.

RESULTS

Barriers and facilitators to cardiovascular rehabilitation were captured under four broad themes; (i) Cardiac rehabilitation as "low-hanging fruit," (ii) Cognitive impairment ("the elephant in the room"), (iii) Adapted cardiac rehabilitation for mild stroke, and (iv) Resistance to change.

CONCLUSIONS

Hybrid cardiac rehabilitation programmes could be tailored to deliver stroke-specific education, exercises and multidisciplinary expertise. Post-stroke cognitive impairment was identified as a key barrier to participation in cardiac rehabilitation. A cognitive rehabilitation intervention could potentially be delivered as part of cardiac rehabilitation, to address the cognitive needs of stroke and cardiac patients.Implications for rehabilitationThe cardiac rehabilitation model has the potential to be expanded to include mild stroke patients given the commonality of secondary prevention needs.Up to half of stroke survivors are affected by post-stroke cognitive impairment, consequently mild stroke patients may not be such an "easy fit" for cardiac rehabilitation.A cardiovascular programme which includes common rehabilitation modules, in addition to stroke- and cardiac-specific content is recommended.A cognitive rehabilitation module could potentially be added as part of the cardiac rehabilitation programme to address the cognitive needs of stroke and cardiac patients.

[Use of smartphone apps in secondary stroke prevention]

Modifiable risk factors such as hypertension, obesity or smoking have been reported to explain up to 90% of risk for ischemic stroke. Treatment of these risk factors is known to decrease the risk of recurrent stroke events. We performed a computer-based literature research from June to August 2018 using the electronic database PubMed to investigate the effect of smartphone apps on risk factor control for secondary stroke prevention as well as feasibility and patient satisfaction with mobile health. Studies evaluating interventions by smartphone or tablet devices in stroke patients and reported results regarding risk factors, feasibility or patient satisfaction were considered (n = 10). Identified data showed significant improvement regarding the control of risk factors hypertension and diabetes as well as significant improvements of the lifestyle risk factors physical inactivity and obesity. Stroke patients perceive smartphone apps mostly as useful and are open-minded regarding mHealth, provided that these complement rather than replace personal medical care.