Perceived Needs of Stroke Survivors from Non-English-Speaking Backgrounds and Their Family Carers

The purpose of this article is to discuss current findings in the research literature on the experiences and needs of stroke survivors and their family carers and to provide suggestions for future research. Based on this critical review, knowledge gaps and issues in stroke management in the community indicate that the needs of people surviving a stroke, particularly people from non-English speaking backgrounds, are not being adequately met by community-based health services. There is a critical need for changes in practices to meet the needs of this specific population.

Lay and health care professional understandings of self-management: A systematic review and narrative synthesis

Objectives:

Self-management is widely promoted but evidence of effectiveness is limited. Policy encourages health care professionals to support people with long-term conditions to learn self-management skills, yet little is known about the extent to which both parties share a common understanding of self-management. Thus, we compared health care professional and lay understandings of self-management of long-term conditions.

Methods:

Systematic review and narrative synthesis of qualitative studies identified from relevant electronic databases, hand-searching of references lists, citation tracking and recommendations by experts.

Results:

In total, 55 studies were included and quality was assessed using a brief quality assessment tool. Three conceptual themes, each with two subthemes were generated: traditional and shifting models of the professional–patient relationship (self-management as a tool to promote compliance; different expectations of responsibility); quality of relationship between health care professional and lay person (self-management as a collaborative partnership; self-management as tailored support) and putting self-management into everyday practice (the lived experience of self-management; self-management as a social practice).

Conclusion:

Self-management was conceptualised by health care professionals as incorporating both a biomedical model of compliance and individual responsibility. Lay people understood self-management in wider terms, reflecting biomedical, psychological and social domains and different expectations of responsibility. In different ways, both deviated from the dominant model of self-management underpinned by the concept of self-efficacy. Different understandings help to explain how self-management is practised and may help to account for limited evidence of effectiveness of self-management interventions.

The Experience of Engaging in Occupation following Stroke: A Qualitative Meta-Synthesis

Introduction:

A meta-synthesis is a means of extracting data from multiple qualitative studies about the same topic, re-analysing the findings and bringing them together as a collective whole. Data from six qualitative studies that investigated the experience of engaging in occupation following a stroke were extracted and reanalysed with the purpose of gaining a greater understanding of the subjective experience to inform occupational therapy practice.

Methods:

Six databases were systematically searched for literature published in English during 1990–2011. Seven studies were appraised using the Critical Appraisal Skills Programme tool; six of these were included in the meta-synthesis.

Findings:

Five conceptual themes regarding occupational engagement emerged from the review: an emotional response, impact on identity, role of significant others, community access and the process of occupational adaptation.

Conclusion:

Engagement in occupation following a stroke is linked to self-identity and an emotional response; both of these, in turn, have an impact on capacity for occupational adaptation. Individuals are situated within a context of significant others and community. These findings give occupational therapists greater insight into the experience of older people following stroke in community settings.

The first 3-months post-stroke: what facilitates successfully living with aphasia?

This study used a qualitative approach to describe the experience of the first 3 months post-stroke in order to identify factors which facilitate successfully living with aphasia. Fifteen participants completed semi-structured interviews and self-perceived ratings of how successfully he or she was living with aphasia. A number of themes were identified from the interviews, including: a need to do things in order to be actively engaged in rehabilitation; increase independence and have a purpose in life; the importance of social support; the value of rehabilitation; a need to adapt and make adjustments; and having a positive outlook. These results suggest that a range of service delivery models need to be considered during the early stages post-stroke in order to address individual needs and so that long-term outcomes of people with aphasia may be improved.

Factor Structure Investigation of the Care-Receiver Efficacy Scale–Short-Form

The present study investigated the factor structure invariance of the Care-Receiver Efficacy Scale–Short Form (CRES) using confirmatory factor analysis. Response data were collected from 177 participants across three time points. The analyses of the five-subscale, 25-item CRES at the individual time points indicated that the first-order and second-order models were acceptable. However, Perceptions of Dependence was not a reliable indicator for the higher order factor defined as Overall Care-Receiver Efficacy. The revised 20-item CRES without Perceptions of Dependence had adequate model fit. A series of progressively more constrained models revealed the higher order 20-item CRES can be used as a stable measure of health care self-efficacy for older care-receivers.

Strategies to enhance chronic disease self-management: How can we apply this to stroke?

PURPOSE

Social Cognition Theory and the cognitive construct of self-efficacy often form the theoretical basis for many chronic disease self-management programmes. Self-efficacy can be influenced through these programmes and has been shown to be predictive of greater levels of functioning and psychological well-being. Stroke is regarded as a complex chronic disability, and individuals may share many of the same concerns as those living with other chronic diseases such as arthritis and chronic pulmonary disease. However there has been minimal reported research on the utility of self-management programmes following stroke.

SEARCH STRATEGY

To comprehend the composition of chronic disease self-management programmes which could be applied to stroke, this paper examined the theoretical basis of self-management and particularly the evidence relating to interventions which have utilized self-efficacy enhancing strategies. Selected papers were retrieved from an extensive search of literature using Medline, Cinahl, PsychInfo and Web of Science databases and the Cochrane Collaboration. The search request focused on literature that specifically related to chronic disease, self-management and self-efficacy that had been published since 1995. However, seminal literature on self-efficacy produced prior to this date was also included.

DISCUSSION AND CONCLUSIONS

There is strong evidence to support the use of self-management programmes and their effect on self-efficacy and associated health outcomes. While there are differences in the nature of each chronic condition, there are similarities in the core skills required for self-management. Many effective strategies could be incorporated into current stroke rehabilitation programmes or used to develop targeted self-management interventions. Future research which informs stroke rehabilitation should utilize the evidence relating to other chronic conditions. This could be used to develop the most effective methods of equipping individuals following stroke to cope confidently with the transition from being discharged from therapy towards effective self-management in the longer term.

Changing self-efficacy in individuals following a first time stroke: preliminary study of a novel self-management intervention

Objective: To examine the effects of a self-management workbook intervention designed for use with individuals disabled after first time stroke.

Design: Multiple-participant two-phase (baseline followed by treatment) single subject design. The intervention was introduced at a randomly generated time-point.

Setting: Community.

Subjects: Seven men and three women, with a mean age of 61.5 years (SD 8.15), on average 24.2 weeks (SD 18.29) following first stroke, all with residual restriction of activity and participation.

Intervention: An individualized self-management workbook based on self-efficacy principles, incorporating sections to increase mastery, vicarious experience and feedback.

Main measures: Stroke Self-Efficacy Questionnaire, General Self-Efficacy Scale, Recovery Locus of Control Scale, Rivermead Mobility Index, Rivermead Activities of Daily Living Scale, Subjective Index of Physical and Social Outcome and the Hospital Anxiety and Depression Scale. Individual data were analysed with weighted mean trend test and two standard deviation band test. Group data were analysed with a randomization test.

Results: Visual inspection of the data over the 14-week period showed steady improvement for all of the 10 participants on the majority of variables. A randomization test indicated a statistically significant change in Stroke Self-Efficacy Questionnaire scores and Recovery Locus of Control Scale scores which followed introduction of the intervention. Measures of activity, participation and mood scores did not show a statistically significant change.

Conclusion: There is preliminary evidence that the use of an individualized stroke self-management intervention is acceptable and can lead to a change in self-efficacy in this small sample.

Reasons for recovery after stroke: a perspective based on personal experience

PURPOSE

The purpose of this study was to learn more about individual beliefs and personal strategies used to support the period of recovery after stroke. It sought to identify the factors that were perceived to be enablers as well as challenges to recovery. Personal actions or experiences, which were perceived to be effective in influencing progress, would be identified.

METHOD

Qualitative in-depth interviews were carried out with 10 participants (mean age 61.8 years). Time following stroke onset ranged between 6 weeks and 13 months. All participants had some residual activity limitation and three participants had varying degrees of aphasia. The interviews were approximately 60 - 90 minutes and all data was subjected to content analysis.

RESULTS

Analyses of interview data identified two main themes which were perceived to have influenced progress after stroke. The first related to internal factors such as personal control over progress, optimism and fears of dependency and the second included more external factors, such as the influence of therapeutic interactions and success with a specified marker of independence such as dressing, washing and walking.

CONCLUSION

An important finding of this study was that individuals all identified a number of specific factors which had supported or hindered their own recovery. There were a diversity of both internal/personal and external factors which may not be surprising, given the complexity of stroke, but all participants stressed the importance of both factors. The findings from this study are preliminary and relate only to this particular group of participants, as such they cannot be generalizable to the stroke population as a whole. However, the interaction between the two themes identified requires further exploration, especially in relation to therapy which could have both a positive and negative influence on personal control. There is a clear need to understand how professionals can, in the first place, take time to identify each individual's preferences and personal goals and secondly, make sure that these are fully addressed in a planned treatment programme. This will ensure that progress in individuals after stroke is supported by professionals with a more eclectic, individualized approach.

Coping with late-life challenges: Development and validation of the care-receiver efficacy scale

PURPOSE

Measures are lacking that address the challenges that people think they face in their roles as elderly care receivers. However, the development of a sense of efficacy in this role by mentally competent care receivers is critical to successful partnerships between caregivers and care receivers. The purpose of this article is to report the development and psychometric analysis of the Care-Receiver Efficacy Scale (CRES).

DESIGN AND METHODS

Content validity, internal consistency reliability, factor structure, and convergent validity were assessed through a pilot study, expert review, and field administration with 177 participants.

RESULTS

Results suggest that the CRES comprises five subscales, with strong reliability evidenced for three subscales but marginal reliability for the remaining two. Strong support was found for content validity from expert review and moderate support from the relationship between empirical and expert judgment of item location. Support for validity also was found from correlation with the Geriatric Depression Scale-Short Form and the Philadelphia Geriatric Center Morale Scale.

IMPLICATIONS

The CRES may be useful as an outcome measure for psycho-socio-behavioral interventions aimed at increasing the capacity of care receivers to direct and improve their own care. Future measure revision and validation are important to optimize its utility.

Conducting qualitative interview research with people with expressive language difficulties

Despite the increasing application of qualitative interviewing and analysis approaches, individuals with expressive language difficulties are still frequently excluded from such research. In this article, the authors seek to clarify the role for and importance of conducting qualitative interviews with respondents with impaired expressive language. They review current research with reference to studies conducted with individuals with intellectual disabilities or dementia, or those who have experienced stroke or traumatic brain injury, and identify deficits within existing research. They consider the challenges and difficulties that contribute to the limited inclusion of individuals with impaired expressive communication in qualitative interviews and discuss the way forward with suggestions of possible means of overcoming these obstacles. They argue that a willingness to adapt methods appropriately and to modify expectations is an important factor in ensuring that researchers hear the voice of respondents with expressive language deficits.

What do stroke patients and their carers want from community services?

BACKGROUND

Previous research has focused on the longer term needs of 'new' stroke patients at fixed time intervals after the event, but neglected those of stroke patients who may have had the event many years earlier.

OBJECTIVE

To identify the long-term support needs of patients with prevalent stroke, and their carers identified from practice stroke registers.

DESIGN OF STUDY

Patients and their carers were invited to attend focus groups at the university, a nursing home or in the community.

SETTING

Seven practices in South Birmingham. Adults (18+) with a validated record of stroke.

METHODS

Focus groups were audio-taped and data analysed using a constant comparison method.

RESULTS

Twenty-seven patients and six carers participated in the study. Three major themes emerged: emotional and psychological problems; lack of information available for patients and their families; the importance of Primary Care as the first point of contact for information or problems, even if these were non medical.

CONCLUSIONS

Better methods of providing information for long-term survivors of stroke, and for addressing their emotional and psychological needs are required. Primary care could be a key setting for helping to provide more inclusive services for both patient and carer.

Qualitative studies of stroke: a systematic review

BACKGROUND AND PURPOSE

Qualitative studies are increasingly used to investigate social processes and phenomena influencing health behaviors and service provision. We aimed to identify the scope of published qualitative studies of stroke, consider their relevance to development and delivery of services for people with stroke, and make recommendations for future work.

METHODS

Literature review of published articles was identified by systematically searching online literature databases using keywords from the start of each database until 2002. Articles were reviewed by 2 authors, using a standardized matrix for data extraction. The 2003 European Stroke Initiative recommendations for stroke management were used to categorize the literature for consideration of its contribution to stroke research.

RESULTS

We included 95 articles. Their empirical contribution includes an emphasis on recording the "human" experience of stroke; identification of needs as perceived by patients and their families, differences in priorities between patients and professionals, and barriers to best-quality care. We identified 12 papers that were specifically undertaken to develop or evaluate interventions.

CONCLUSIONS

Qualitative studies have addressed a wide range of issues related to the impact of stroke on individuals and caregivers, and to the organization and delivery of services. Significant problems remain in ensuring the delivery of best-quality stroke care, which such studies have the potential to address. Maximizing this potential requires greater collaboration between nonclinical and clinical scientists, service providers, and users to formulate research questions of interest as well as new research strategies, such as meta-analysis, to pool qualitative research findings and multisited investigations.

Families dealing with stroke desire information about self-care needs

As hospital lengths of stay have decreased, healthcare professionals have less opportunity to fully educate stroke patients and their families regarding self-care before the patient is discharged home. Consequently, families often need continuing education provided to them in outpatient settings. The purpose of this study was to identify the self-care needs about which people dealing with stroke most frequently want information. Twenty-four people responded to a survey that listed 48 self-care needs structured within Orem's universal self-care requisites (USCRs). The top five self-care needs about which information was desired were: preventing falls; maintaining adequate nutrition; staying active; managing stress; and dealing with emotional and mood changes. These needs correlated with several of Orem's USCRs. By keeping these needs in mind, healthcare professionals can develop better educational materials and provide more pertinent information to stroke patients and their families during homecare or office visits, support group meetings, or via the Internet.