Informal Caregiving

Exploring the lived experiences of family caregivers of patients with stroke in Africa: a scoping review of qualitative evidence

OBJECTIVE

The burden of stroke is immense in African countries, with post-stroke care usually becoming the responsibility of family. This review sought to determine the current breadth and depth of qualitative evidence regarding the lived experiences of family caregivers of patients with stroke in Africa.

METHODS

Informed by Joanna Briggs Institute (JBI) methodology for scoping reviews, six databases were searched. Included articles were appraised for quality using the JBI checklist. A priori themes developed using the study objectives were used to synthesize study findings.

RESULTS

The review included 22 articles, which outlined key patterns in stroke outcomes with most articles focused on rehabilitation and the experiences, outcomes, burdens, and coping mechanisms of caregiving. The intersectionality of socio-economic status, socio-political structures, and religious or traditional beliefs, attitudes, and practices characterized etiology beliefs, treatment trajectories of stroke, and caregiving role assignment. Whereas burdens were driven by limited resources, adopted coping strategies involved spiritual or religious beliefs, optimism, resilience, and social support networks.

CONCLUSIONS

Family caregivers' values must be acknowledged, supported, and integrated into the traditional healthcare system to provide comprehensive stroke care. Caregivers' health and well-being should be given more attention given their necessary contribution to stroke survivorship in Africa.

Healthcare professionals' perspectives of the provision of, and challenges for, eating, drinking and psychological support post stroke: findings from semistructured interviews across India

AIM

This qualitative study explores with health professionals the provision of, and challenges for, postdischarge stroke care, focussing on eating, drinking and psychological support across India.

DESIGN

Qualitative semistructured interviews.

SETTING

Seven geographically diverse hospitals taking part in a Global Health Research Programme on Improving Stroke Care in India.

PARTICIPANTS

A purposive sample of healthcare professionals with current experience of working with patients who had a stroke.

RESULTS

Interviews with 66 healthcare professionals (23 nurses (14 staff nurses; 7 senior nurse officers; 1 intensive care unit nurse; 1 palliative care nurse)); 16 doctors (10 neurologists; 6 physicians); 10 physiotherapists; 5 speech and language therapists; 4 occupational therapists; 4 dieticians; 2 psychiatrists; and 2 social workers resulted in three main themes: integrated inpatient discharge care planning processes; postdischarge patient and caregiver role and challenges; patient and caregiver engagement post discharge.

CONCLUSIONS

Discharge planning was integrated and customised, although resources were limited in some sites. Task shifting compensated for a lack of specialists but was limited by staff education and training. Caregivers faced challenges in accessing and providing postdischarge care. Postdischarge care was mainly hospital based, supported by teleservices, especially for rural populations. Further research is needed to understand postdischarge care provision and the needs of stroke survivors and their caregivers.

Stroke systems of care in South-East Asia Region (SEAR): commonalities and diversities

The Southeast Asia Region (SEAR) accounts for nearly 50% of the developing world's stroke burden. With various commonalities across its countries concerning health services, user awareness, and healthcare-seeking behavior, SEAR still presents profound diversities in stroke-related services across the continuum of care. This review highlights the numerous systems and challenges in access to stroke care, acute stroke care services, and health care systems, including rehabilitation. The paper has also attempted to compile information on the availability of stroke specialized centers, Intravenous thrombolysis (IVT) ready centers, Endovascular therapy (EVT) ready centers, rehabilitation centers, and workforce against a backdrop of each country's population. Lastly, the efforts of WHO (SEARO)-CMCL (World Health Organization-South East Asia region, Christian Medical College & Hospital Ludhiana) collaboration towards improving stroke services and capacity among the SEAR have been described.

Development and validation of the caregiver needs and resources assessment

Introduction

Existing caregiver assessment tools were long criticized for focusing on the needs and burden while neglecting the importance of the resources. The current study aimed to develop a multidimensional and time-effective assessment tool that measures both needs and resources of non-paid family caregivers of older adults for screening and service-matching purposes.

Methods

Items of the Caregiver Needs and Resources Assessment (CNRA) were developed from extensive literature reviews and focus group interviews of family caregivers and social workers in the field. In addition, we collected 317 valid responses from family caregivers of older adults from local non-government organizations in examining the psychometric properties of the CNRA.

Results

The results revealed a 12-factor structure that fitted nicely into the conceptual frame of needs and resources domains. Need factors were positively associated with mental health symptoms, while resource factors were positively associated with peace in mind, meaning-making, and personal gain measures. The 36-item CNRA revealed good internal reliability and convergent validity.

Discussion

The CNRA has the potential to be used as a compact yet balanced assessment tool for understanding both the needs and resources of caregivers for human service professionals.

A stroke rehabilitation training program for community-based primary health care, South Africa

Background

With an increasing burden of stroke and a lack of access to rehabilitation services in rural South African settings, stroke survivors rely on untrained family caregivers for support and care. Community health workers (CHWs) support these families but have no stroke-specific training.

Objectives

To describe the development of a contextually appropriate stroke training program for CHWs in the Cape Winelands District, South Africa.

Method

Twenty-six health professionals and CHWs from the local primary healthcare services participated in action research over a 15-month period from September 2014 to December 2015. The groups participated in two parallel cooperative inquiry (CI) groups. The inquiry followed the cyclical steps of planning, action, observation and reflection. In this article, the planning step and how the CI groups used the first three steps of the analyse, design, develop, implement, evaluate (ADDIE) instructional design model are described.

Results

The CHWs' scope of practice, learning needs, competencies and characteristics, as well as the needs of the caregivers and stroke survivors, were identified in the analysis step. The program design consisted of 16 sessions to be delivered over 20 h. Program resources were developed with appropriate technology, language and instructional methodology.

Conclusion

The program aims to equip CHWs to support family caregivers and stroke survivors in their homes as part of their generalist scope of practice. The implementation and initial evaluation will be described in a future article.

Contribution

The study developed a unique training program for CHWs to support caregivers and stroke survivors in a resource-constrained, rural, middle-income country setting.

Feasibility of a meditation intervention for stroke survivors and informal caregivers: a randomized controlled trial

BACKGROUND

Depressive symptoms are a significant psychological complication of stroke, impacting both survivors and informal caregivers of survivors. Randomized controlled trials are needed to determine optimal non-pharmacological strategies to prevent or ameliorate depressive symptoms in stroke survivors and their informal caregivers.

METHODS

A prospective, randomized, parallel-group, single-center, feasibility study. Participants were assigned to a 4-week meditation intervention or expressive writing control group. The intervention comprised four facilitator-led group meditation sessions, one session per week and building upon prior session(s). Descriptive statistics were used to examine the proportion of eligible individuals who enrolled, retention and adherence rates, and the proportion of questionnaires completed. Data were collected at baseline, immediately after the 4-week intervention period, and 4 and 8 weeks after the intervention period. Secondary analysis tested for changes in symptoms of depression (Center for Epidemiologic Studies-Depression [CES-D]), anxiety [State-Trait Anxiety Inventory for Adults (STAI)], and pain (Brief Pain Inventory-Short Form) in the intervention group via paired t tests. Linear mixed models were used to compare longitudinal changes in the measures between the groups. Intervention and trial design acceptability were preliminary explored.

RESULTS

Seventy-one (77%) individuals enrolled and 26 (37%) completed the study (baseline and 8-week post-intervention visits completed). Forty-two (66%) participants completed baseline and immediate post-intervention visits. Mean questionnaire completion rate was 95%. The median meditation group session attendance rate for the intervention group was 75.0%, and the mean attendance rate was 55%. Non-significant reductions in CES-D scores were found. Paired t tests for stroke survivors indicated a significant reduction from baseline through week 8 in BPI-sf severity scores (p = 0.0270). Repeated measures analysis with linear mixed models for informal caregivers indicated a significant reduction in in STAI-Trait scores (F [3,16.2] = 3.28, p = 0.0479) and paired t test showed a significant reduction from baseline to week 4 in STAI-Trait scores (mean = - 9.1250, 95% CI [- 16.8060 to 1.4440], p = 0.0262). No between-group differences were found.

CONCLUSIONS

Future trials will require strategies to optimize retention and adherence before definitive efficacy testing of the meditation intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03239132. Registration date: 03/08/2017.

Preparedness for caregiving moderates the association between burden and health-related quality of life among family caregivers of stroke patients in Nigeria

Studies on improving the health-related quality of life of stroke patients are abundant, but less attention has been given to the factors influencing the wellbeing of their family caregivers, especially in low- to middle-income countries such as Nigeria where the burden of stroke is expected to increase. In this study, we examined the moderating role of preparedness for caregiving in the connection between the burden of caregiving and health-related quality of life of family caregivers of stroke patients in Nigeria. Family caregivers of stroke patients (140 females and 60 males; aged between 18 and 57 years) were purposively sampled from a Federal Medical Center in Southeastern Nigeria. Participants completed measures of caregiver’s strain (burden), health-related quality of life, and preparedness to give care. Results showed that burden negatively predicted physical health (β = –.61, CI: [–.89, –.34]) and mental health (β = –.76, CI: [−1.07, –.45]) dimensions of the health-related quality of life, respectively. Results also showed that preparedness moderated the relationship between burden and physical health (β = .21, CI: [.11, .32]), as well as mental health (β = .24, CI: [.12, .35]) dimensions. Ensuring that caregivers of stroke patients are adequately prepared to give care could ameliorate the negative impacts of caregiving on health of family caregivers of stroke patients.

Educating Caregivers to Reduce Complications and Improve Outcomes of Stroke Patients (ECCOS) - A Cluster-Randomized Trial

OBJECTIVES

Stroke constitutes a significant public health problem in developing countries. Caregivers provide an important support system for patient care but usually lack knowledge and skill to attend their stroke patients. We assessed whether a caregiver-directed educational intervention would reduce hospital-acquired complications and improve stroke patients' outcomes.

MATERIALS AND METHODS

We randomly assigned two Neurology inpatient wards to receive either standard care or an educational intervention. The coprimary outcomes included incidence of hospital-acquired complications and in-hospital mortality. Secondary outcomes included the modified Rankin Scale and mortality at three months.

RESULTS

Among 164 patients recruited, 82 received intervention, and standard care each. The mean (Standard deviation) Glasgow coma scale of patients was 11.01 (3.4), and National Institute of Health Stroke Scale was 19.17 (8.54). The incidence of complications (72 in the intervention versus 81 in the control group; p=0.56) was not different. Ten patients (12.2%) in the intervention group and 16 (19.5%) in the control group (p=0.20) died in-hospital. Twenty patients (27.8%) in the intervention and twelve (18.2%) in the control group attained modified Rankin Scale 0-2 at three months (p=0.12). The mortality at three months (20 [24.4%] in the intervention versus 25 [30.5%] in the control group) was not different (p=0.38). The intervention group had fewer complications (42 versus 68 in the control group; p=0.01) during the initial ten days of hospital stay, but adjusted analysis revealed no difference.

CONCLUSION

A structured educational intervention did not reduce the incidence of hospital-acquired complications, mortality, or morbidity. However, there was a trend towards fewer complications in the initial days of hospital stay. Extended hospital stay, caregiver fatigue, and dilution of the intervention over time might be reasons for the apparent lack of effect. CLINICAL TRIAL REGISTRATION-URL: http://www.ctri.nic.in. Unique identifier: CTRI/2018/11/016312.

Figuring it out by yourself: Perceptions of home-based care of stroke survivors, family caregivers and community health workers in a low-resourced setting, South Africa

BACKGROUND

In less resourced settings, formal rehabilitation services for stroke survivors were often absent. Stroke survivors were referred to community health workers (CHWs) who were untrained in rehabilitation.

AIM

To describe the experience and perceived needs of stroke survivors, their caregivers and CHWs in a context with limited access to and support from formal rehabilitation services.

SETTING

The Breede Valley subdistrict, Western Cape, South Africa, a rural, less resourced setting.

METHODS

A descriptive exploratory qualitative study. Four focus group interviews were held with purposively selected stroke survivors and caregivers and four with CHWs. A thematic approach and the framework method were used to analyse the transcripts.

FINDINGS

A total of 41 CHWs, 21 caregivers and 26 stroke survivors participated. Four main themes and 11 sub-themes were identified. Because of the lack of knowledge, training and rehabilitation services, the main theme for all groups was having to 'figure things out' independently, with incontinence management being particularly challenging. Secondly was the need for emotional support for stroke survivors and caregivers. Thirdly, contextual factors such as architectural barriers and lack of assistive products negatively impacted care and function. Lastly, the organisation of health and rehabilitation services negatively impacted home-based services and professional support.

CONCLUSIONS

With appropriate training, the CHWs can be pivotal in the training and support of family caregivers and stroke survivors. Care pathways and the role and scope of both CHWs and therapists in home-based stroke rehabilitation should be defined and restructured, including the links with formal services.

Stroke Survivors' Perspectives on Post-Acute Rehabilitation Options, Goals, Satisfaction, and Transition to Home

BACKGROUND AND PURPOSE

Patients and caregivers have not typically been involved in the selection of a post-acute care (PAC) provider. In 2015, the Centers for Medicare & Medicaid Services proposed the need to involve patients and their families during discharge planning. Engaging patients in rehabilitation decisions encourages shared decision making among patients and their clinicians. The purpose of this study was to examine stroke survivors' perspectives on their involvement in selecting a PAC provider and their goal setting and their satisfaction with the rehabilitation stay and their discharge advice for stroke survivors, prior to 2015.

METHODS

This qualitative study utilized semistructured interviews. Thematic content analysis was performed on interviews involving 18 stroke survivors (mean age = 68 years) related to their involvement in planning for their inpatient rehabilitation facility or skilled nursing facility stay, goal setting, and discharge needs.

RESULTS

More than half the participants were not involved in the selection of their PAC setting and believed that doctors made these decisions. Around two-fifths of stroke survivors reported that they were not involved in rehabilitation goal setting. Most patients were satisfied with their rehabilitation stay. When asked to recommend discharge topics for other stroke survivors, participants recommended additional information on health care services, interventions, and insurance coverage.

DISCUSSION AND CONCLUSION

Despite recommendations to include stroke patients in PAC selection and goal setting, many former inpatient rehabilitation facility and skilled nursing facility patients report not being involved in either aspect of care.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A273).

Is There a Role for Informal Caregivers in the Management of Diabetic Foot Ulcers? A Narrative Review

Successful management of diabetic foot ulceration (DFU) is crucial for preventing long-term morbidity and lowering risk of amputations. This can be achieved with a multifaceted approach involving a multidisciplinary team, with the patient at the centre. However, not all healthcare setups enable this, and the rate of lower limb amputations continues to rise. It is therefore time to consider new approaches to diabetic foot care, capitalising on engagement from patients in self-management while supported by their informal caregivers (ICGs) to help improve outcome. The role of ICGs in DFU care has the potential to make a significant difference in outcome, yet this resource remains, in most cases, underutilised. Limited research has been conducted in this area to reveal the true impact on patient outcomes and the caregivers themselves. This narrative review aims to explore how ICGs can benefit DFU management with applicability to different healthcare setups while benefiting from established experience in the care of other chronic health conditions.

Surviving a stroke in South Africa: outcomes of home-based care in a low-resource rural setting

Background: Little is known of stroke outcomes in low- and middle-income countries with limited formal stroke rehabilitation services and of homebased-stroke services delivered within the primary health care (PHC) context by community health workers (CHWs). Objectives: To describe and analyze the outcomes of patients with stroke from a rural PHC setting in the Western Cape, South Africa. Methods: In a longitudinal survey, 93 stroke patients, referred to home and community-based care services (HCBC) between June 2015 and December 2017, were assessed at baseline, one month and three months. Changes in function (Barthel Index (BI)), caregiver strain (Caregiver Strain Index (CSI)), impact of environmental factors and satisfaction with stroke care were measured. Results: HCBC was delayed, fragmented and brief (median session duration 20 minutes (IQR 15.0-30.0)). Although function improved significantly, dependence remained high: median BI score changed from 40.0 (IQR 15.0-70.0) to 62.5 (IQR 30.0-81.25) (p = .019). A third (33.0% (30/91)) of caregivers initially experienced strain and the median CSI score remained 3.0 (IQR 0.0-7.0) (p = .672). Overall, patient and caregiver satisfaction with HCBC was low with only 46.9% (31/66) of caregivers and 17.4% (12/69) of patients satisfied with all aspects of care. Only 47.6% of assistive product needs were met. Environmental factors negatively impacted on patient function and caregiving. Conclusions: Clinical practice pathways and referral guidelines should be developed for the HCBC platform. Specific training of CHWs, focusing on how to educate, support and train family caregivers, provide assistive devices and refer to health services is needed.