Spousal experiences of coping with and adapting to caregiving for a partner who has a stroke: a meta-synthesis of qualitative research

Supporting Individuals With an Acquired Brain Injury: An Interpretative Phenomenological Study Exploring the Everyday Lives of Caregivers

Acquired brain injury (ABI) is one of the most common causes of disability and death globally. Support from informal caregivers is critical to the well-being and quality of life of people with ABI and supports the sustainability of global health and social care systems. This study presents an in-depth qualitative analysis of the experiences of eight British informal caregivers supporting someone with ABI. Semi-structured interviews were conducted with narratives transcribed verbatim and analysed using interpretative phenomenological analysis (IPA). Three superordinate themes were generated: making sense of brain injury; being consumed by caregiving; and, the changing self. These data highlight the impact of caregiving on the caregiver's illness perceptions and sense of self. By identifying negative and positive changes in the caregiver's sense of self, and dilemmas regarding the care recipient's behaviour, we address less understood aspects of caregiver experiences. Caregiving can pose both challenges to the caregiver's sense of identity and an opportunity for self-growth. Some caregivers exhibit resilience throughout their journey, with post-traumatic growth more apparent in the later stages of caregiving. Illness perceptions shape caregiver well-being and family dynamics and indicate the need to address stigmatisation and discrimination faced by ABI survivors and caregivers. Although some caregivers acquired positive meaning and enrichment from their caregiving, previously described challenges of ABI caregiving are supported. Overall, our findings support the need for timely psychological/mental health support for caregivers, caregiver education, and the provision of short breaks from caregiving.

The impact of caregiving on the roles and valued activities of stroke carers: A systematic review of qualitative studies

OBJECTIVE

To understand the experiences of informal carers and the impact of role and activity changes on their health and wellbeing.

METHODS

A systematic search of CINHAL, MEDLINE, Embase, APA PsycInfo, and Web of Science was conducted. Studies were eligible if they included informal stroke carers (≥18 years), used a qualitative methodology, explored the roles and valued activities of stroke carers, and were published in English. The 10-item Critical Appraisal Skills Programme checklist for qualitative studies was used to assess methodological quality. The results of the included studies were thematically synthesised.

RESULTS

A total of 36 qualitative studies were included and four overarching themes were identified: (1) Life adjustment; (2) Changing role and identity; (3) Changing activities: From meaningful to purposeful; and (4) Understanding and supporting carers.

CONCLUSION

The sudden nature of stroke requires major readjustment in the carers life that has implications on their relationships, roles, and activities, subsequently impacting on their health and wellbeing. Health professionals and researchers should collaborate with stroke carers to identify their valued activities and implement realistic strategies to maintain these activities. Future interventions designed for carers should implement education about the importance of participating in valued activities and strategies to maintain these activities.

Thematic Analysis of Psychosocial Stressors and Adaptive Coping Strategies Among Informal Caregivers of Patients Surviving ICU Admission for Coma

BACKGROUND

Family caregivers of patients with severe acute brain injury (SABI) admitted to intensive care units (ICUs) with coma experience heightened emotional distress stemming from simultaneous stressors. Stress and coping frameworks can inform psychosocial intervention development by elucidating common challenges and ways of navigating such experiences but have yet to be employed with this population. The present study therefore sought to use a stress and coping framework to characterize the stressors and coping behaviors of family caregivers of patients with SABI hospitalized in ICUs and recovering after coma.

METHODS

Our qualitative study recruited a convenience sample from 14 US neuroscience ICUs. Participants were family caregivers of patients who were admitted with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, or hypoxic-ischemic encephalopathy; had experienced a comatose state for > 24 h; and completed or were scheduled for tracheostomy and/or gastrostomy tube placement. Participants were recruited < 7 days after transfer out of the neuroscience ICU. We conducted live online video interviews from May 2021 to January 2022. One semistructured interview per participant was recorded and subsequently transcribed. Recruitment was stopped when thematic saturation was reached. We deductively derived two domains using a stress and coping framework to guide thematic analysis. Within each domain, we inductively derived themes to comprehensively characterize caregivers' experiences.

RESULTS

We interviewed 30 caregivers. We identified 18 themes within the two theory-driven domains, including ten themes describing practical, social, and emotional stressors experienced by caregivers and eight themes describing the psychological and behavioral coping strategies that caregivers attempted to enact. Nearly all caregivers described using avoidance or distraction as an initial coping strategy to manage overwhelming emotions. Caregivers also expressed awareness of more adaptive strategies (e.g., cultivation of positive emotions, acceptance, self-education, and soliciting social and medical support) but had challenges employing them because of their heightened emotional distress.

CONCLUSIONS

In response to substantial stressors, family caregivers of patients with SABI attempted to enact various psychological and behavioral coping strategies. They described avoidance and distraction as less helpful than other coping strategies but had difficulty engaging in alternative strategies because of their emotional distress. These findings can directly inform the development of additional resources to mitigate the long-term impact of acute psychological distress among this caregiver population.

Predictors of Burden for First-Ever Stroke Survivor's Long-Term Caregivers: A Study of KOSCO

Long-term changes in caregiver burden should be clarified considering that extended post-stroke disability can increase caregiver stress. We assessed long-term changes in caregiver burden severity and its predictors. This study was a retrospective analysis of the Korean Stroke Cohort for Functioning and Rehabilitation. Patients with an acute first-ever stroke were enrolled from August 2012 to May 2015. Data were collected at 6 months and 6 years after stroke onset. The caregiver burden was measured with a subjective caregiver burden questionnaire based on the Korean version of the Caregiver Burden Inventory. The caregivers' characteristics and patients' clinical and functional status were also examined at each follow-up. A high caregiver burden, which suggests a risk of burnout, was reported by 37.9% and 51.7% of caregivers at 6 months and 6 years post-stroke, respectively. Both the caregiver burden total score and proportion of caregivers at risk of burnout did not decrease between 6 months and 6 years. The patients' disability (OR = 11.60; 95% CI 1.58-85.08; p = 0.016), caregivers' self-rated stress (OR = 0.03; 95% CI 0.00-0.47; p = 0.013), and caregivers' quality of life (OR = 0.76; 95% CI 0.59-0.99; p = 0.042) were burden predictors at 6 months. At 6 years, only the patients' disability (OR = 5.88; 95% CI 2.19-15.82; p < 0.001) and caregivers' psychosocial stress (OR = 1.26; 95% CI 1.10-1.44; p = 0.001) showed significance. Nearly half of the caregivers were at risk of burnout, which lasted for 6 years after stroke onset. The patients' disability and caregivers' stress were burden predictors in both subacute and chronic phases of stroke. The findings suggest that consistent interventions, such as emotional support or counseling on stress relief strategies for caregivers of stroke survivors, may reduce caregiver burden. Further research is needed to establish specific strategies appropriate for Korean caregivers to alleviate their burden in caring for stroke patients.

Development of a Dyad-Focused Intervention for Stroke Survivors and Their Family Caregivers: A Feasibility Study

IMPORTANCE

Transitioning from the hospital to the community poses significant challenges for stroke survivors and their caregivers.

OBJECTIVE

To examine the feasibility and preliminary effects of a dyad-focused strategy training intervention.

DESIGN

Single-arm trial with data collection at baseline, postintervention, and 3-mo follow-up.

SETTING

Rehabilitation settings in Taiwan.

PARTICIPANTS

Sixteen stroke survivor-caregiver dyads.

INTERVENTIONS

Dyad-focused strategy training was provided to stroke survivor-caregiver dyads twice a week over 6 wk. The training included shared decision-making, goal setting, performance evaluation, strategy development and implementation, and therapeutic guided discovery.

OUTCOMES AND MEASURES

Feasibility indicators were Goal Attainment Scaling, Dyadic Relationship Scale, Participation Measure-3 Domains, 4 Dimensions, Activity Measure for Post-Acute Care, Montreal Cognitive Assessment, Trail Making Test, Stroop Color and Word Test, Preparedness for Caregiving Scale, and Zarit Burden Interview.

RESULTS

In total, 15 dyads completed all intervention sessions with full attendance. Both stroke survivors and their caregivers demonstrated high engagement and comprehension and reported moderate to high satisfaction with the intervention. From baseline to postintervention, the effects on goal attainment, frequency and perceived difficulty of community participation, executive function, mobility function, and caregiver preparedness were significant and positive.

CONCLUSIONS AND RELEVANCE

Our study supports the feasibility and preliminary efficacy of dyad-focused strategy training for stroke survivor-caregiver dyads transitioning from the hospital to the community in Taiwan. Our preliminary evidence indicates that dyads who receive strategy training exhibit advancement toward their goals and experience considerable enhancements in their individual outcomes. Plain-Language Summary: This study addresses the scarcity of interventions catering to both stroke survivors and their caregivers. By demonstrating the feasibility of our dyad-focused intervention, the research offers preliminary evidence that supports the potential advantages of involving both stroke survivors and their caregivers in the intervention process.

Exploring challenges affecting resilience in carers of stroke survivors: a qualitative descriptive study

PURPOSE

To develop an intervention to build resilience in carers of stroke survivors this study aimed to understand these carers' (1) Challenges that adversely affect their resilience, and (2) suggestions for a relevant intervention to build resilience.

METHODS

Individual semi-structured interviews were used. Participants included carers of stroke survivors (stroke duration > six months). Transcripts were analysed using the General Inductive Approach. This study followed guidelines of Consolidated criteria for Reporting Qualitative research (COREQ).

RESULTS

Four themes were identified that affected resilience: (1) carer psychosocial outcomes, (2) stroke's sudden and unexpected impact, (3) financial stressors, and (4) carer exclusion in care planning. Carers suggested an intervention comprising information sharing and training in coping skills, positive communication, problem-solving, and connection with "people who have gone through this" to improve resilience. Most supported a group, monthly delivery of the intervention.

CONCLUSION

These findings provide direction for a suitable intervention. Further, they suggest that stroke rehabilitation could be improved by adopting a family-centered model of care so that carers can be included as active partners in care process. Protecting carers from the negative impact of caring role on their resilience may sustain their ability to provide long-term care for the stroke survivor.IMPLICATIONS FOR REHABILITATIONThe provision of informal care to stroke survivors can be associated with significant emotional consequences, withdrawal from social activities, and poor quality of life for the carers.The abruptness of stroke presentation along with its long-term nature can negatively affect the resilience of informal carers.Exploration of challenges affecting carer resilience is important to develop interventions to build resilience in carers of stroke survivors.Integrating interventions focusing on carers' resilience as part of the stroke rehabilitation process is imperative to ensure well-being of carers and sustainability of the care provided to the stroke survivor.

Disagreement about perceptions of patient disability between the stroke patient and caregiver: a cross sectional study exploring the association to patient and caregiver quality of life

OBJECTIVES

This study explored the association of disagreement in the perception of patient disability between patients and family caregivers with physical and psychological quality of life (QOL) in both parties.

METHODS

A cross-sectional analysis of data collected from male stroke patients and family caregivers was conducted. Physical and psychological QOL in patients and caregivers were measured using the WHOQOL BREF. Perceptions of patient disability were measured using the 12-item WHO Disability Assessment Schedule 2.0 (DAS). Using DAS scores reported independently by patients and caregivers, dyads were categorized into one of four groups representing agreement or disagreement about patient disability. Generalized estimating equations were used to examine the associations between WHOQOL scores in patients and caregivers and these four groups.

RESULTS

Among 56 dyads enrolled, approximately 52% were categorized into 'agreement' groups and 48% were categorized into 'disagreement' groups. The disagreement in perception about patient disability were significantly associated with poor patient physical QOL. However, the disagreement in perception were not significantly associated with caregiver QOL.

CONCLUSION

Findings suggest the association of disagreement with QOL differs between patients and caregivers. Further research is needed to carefully appraise the relationship and interaction between patient and caregiver.

Train-your-brain program to reduce depression, anxiety, and stress in stroke survivors: a pilot community-based cognitive intervention study

Introduction

Stroke is a major cause of death and disability worldwide, and it often results in depression, anxiety, stress, and cognitive impairment in survivors. There is a lack of community-based cognitive interventions for stroke survivors. This pilot single trial aimed to assess the feasibility, acceptability, and perceived effectiveness of a community-based cognitive intervention program called Train-Your-Brain (TYB) for stroke survivors and caregivers. The study focused on improvements in emotional and psychological well-being, as well as cognitive functioning.

Methods

A quasi-experimental design was used in this study. A total of 48 participants were recruited and assessed using Depression, Anxiety, Stress Scale - 21 items (DASS-21), Montreal Cognitive Assessment (MoCA) and Symbol Digits Modality Test (SDMT) before and after the intervention. The TYB program consisted of nine sessions and was conducted via the Zoom software application. Participants provided feedback on the program, highlighting areas for improvement.

Results

Twenty-seven stroke survivors and 21 caregivers completed the program. Participants expressed high satisfaction with the TYB program but recommended avoiding assessments in December and customizing the program for stroke survivors and caregivers. Stroke survivors showed significant improvements in depression and stress scores, while caregivers experienced no significant improvements after the program. While there was a slight improvement in stroke survivors' cognitive scores after the program, it was not statistically significant. Caregivers, however, experienced a significant decline in cognitive scores.

Discussion

The TYB program provided group support and validation, resulting in improved mood and reduced stress among stroke survivors. Cultural collectivism played a significant role in fostering group cohesion. However, the program's limited focus on caregivers and timing of assessments during the December holidays may have affected the outcomes. The TYB program demonstrated feasibility and potential effectiveness in alleviating psychological distress and enhancing cognitive function among stroke survivors. Future research should explore long-term effects, larger sample sizes, and non-English-speaking populations to enhance generalizability. Tailored interventions for caregivers are necessary.

Effect of a telephone and web-based problem-solving intervention for stroke caregivers on stroke patient activities of daily living: A randomized controlled trial

OBJECTIVE

To test for effects of a problem-solving intervention for stroke caregivers on stroke survivor activities of daily living.

DESIGN

Two-arm parallel randomized clinical trial with repeated measures at 11 weeks and 19 weeks.

SETTING

Medical centers for US military Veterans.

SUBJECTS

Caregivers of stroke survivors.

INTERVENTION

A registered nurse guided caregivers in using problem-solving strategies emphasizing creative thinking, optimism, planning, and expert information to address challenges associated with caregiving. Caregivers in the intervention completed one telephone orientation session followed by eight online, asynchronous messaging center sessions. The messaging center sessions involved (a) education on the Resources and Education for Stroke Caregivers' Understanding and Empowerment website (https://www.stroke.cindrr.research.va.gov/en/), (b) supportive communication between the nurse and caregiver, (c) nurse and caregiver interactions to improve problem-solving, and (d) maintain adherence to discharge planning instructions.

MAIN OUTCOME

The Barthel Index was used to measure activities of daily living.

RESULTS

174 participants (standard care n = 88, intervention n = 86) were enrolled at baseline. There were no significant differences between groups at baseline. Change scores in activities of daily living between baseline and 11 weeks were significantly higher in the intervention group than the standard care group (group difference = 6.43, 95% confidence interval: 1.28, 11.58). Group differences in change scores between baseline and 19 weeks were not statistically significant (group difference = 3.89, 95% confidence interval: -3.58, 11.36).

CONCLUSIONS

This web-based caregiver intervention improved stroke survivor activities of daily living by 11 weeks, but intervention effects were undetectable after 19 weeks.

Qualitative study exploring heterogeneity in caregiving experiences post-stroke in Singapore

OBJECTIVE

Stroke, a common illness in older adults, accounts for up to 4% of direct medical costs in developed nations. Informal caregiving contributing a significant proportion of economic burden post-stroke warrants a deeper understanding of the caregiving context to sustain caregiving arrangement. While literature exists describing differences in motivation and preferences of caregivers, limited literature explores differences in caregiving experiences of different types of caregivers (ie, spouse, adult-child, sibling or others). Addressing this gap, our study aimed to explore the caregiving experience of stroke survivors and their family caregivers across different caregiver identities in an Asian setting.

DESIGN

Qualitative descriptive study.

SETTING

Community setting.

PARTICIPANTS

We conducted semi-structured interviews with 26 stroke survivors and 35 caregivers purposively sampled from an outpatient rehabilitation setting, an outpatient clinic and a support organisation. Data were analysed using thematic analysis.

OUTCOME MEASURES

Themes including caregiving experience of stroke survivors and their family caregivers across different caregiver identities.

RESULTS

Following five themes were reported: caregiver reserve, coping strategies, caregiver burden, competing commitments and role of foreign domestic worker (FDW) in family caregiving. Spouse caregivers were less willing to ask for help, commonly adopted faith-based, and spacing or recharging types of coping, reported emotional strain and shared limited accounts of FDWs. Adult-child caregivers were more willing to ask for help, engaged in alternative care arrangements involving FDWs, commonly adopted action-focussed coping and reported multidimensional caregiver burden.

CONCLUSION

Our findings illustrated the heterogeneity in factors affecting caregiving experience across spouse and adult-child caregivers. Practical implications include conducting a needs assessment for caregiver-stroke survivor dyads and providing tailored support, training and information to help caregivers cope better.

Living losses in stroke caregiving: A qualitative systematic review of systematic reviews on psycho-socio-emotional challenges and coping mechanisms

BACKGROUND

Stroke compromises the quality of life and wellbeing of stroke survivors and families as a whole. The unexpected caregiving responsibilities often cause psychological distress, overwhelming emotions, living losses and grief, and relational conflicts with stroke survivors. Despite the increasing research to better understand their needs, empirically sound and holistic psychosocial interventions for stroke caregivers are lacking.

AIMS

This study aims to consolidate psycho-socio-emotional needs and challenges in the existing systematic reviews and offer potential directions for psychosocial interventions to better support caregivers at a psycho-socio-emotional level.

METHODS

This systematic review adhered to the PRISMA guideline and employed the PICo (population, phenomena of interest, context) framework to screen for relevant systematic reviews for analysis. Six major databases were searched, including Academic Search Premier, CINAHL, Global Health, Medline, PsycArticles, and PsycInfo between 2010 and 2020. Ten systematic reviews were selected for full-text analysis using thematic synthesis.

SUMMARY OF REVIEW

Data synthesis revealed eight themes with sixteen sub-themes, all together organized into two main theme categories. The psycho-socio-emotional challenges included disruptions to (1) psychological homeostasis, (2) role equilibrium, (3) familial connection, and (4) caregiving empowerment. The psycho-socio-emotional coping mechanisms, which could be adopted to buffer against the identified challenges, involved (1) recalibration of normality and balance, (2) psychosocial support and caregiver relief, (3) relational reorientation and dyadic coping, and (4) institutional holistic care and support.

CONCLUSION

The findings accentuate the importance of addressing living losses and grief emerging from the caregiving journey, as well as facilitating meaning reconstruction to safeguard caregivers' wellbeing. Clinical implications and future research directions are discussed.

Care partner support

Palliative care focuses on improving the quality of life of people living with serious illness and their family carers. However despite policy, clinical, and research evidence underpinning the importance of a family approach to care, as well as justification for early palliative care integration, systemic inadequacies have impeded the quality of family support. This chapter provides an overview of common concepts in caregiving, a framework through which carer well-being can be understood, and an overview of disease specific considerations for care partners. There are several main needs that are relevant to care partners across disease settings include (1) information and guidance to prepare them for the role; (2) how to alleviate discomfort for the person with illness; (3) enhancing skills for the physical tasks of the role; (4) strategies for managing the psychological, and financial implications of the care partner role; and (5) assistance in advance care planning and on preparing for the care recipient's death. Care partner coping is a result of complex interactions between stressors and mediators as they navigate chronic illness, but palliative providers with an understanding of these factors are well-positioned to address carer risk factors and provide appropriate support.

Co-Design of an Educational Resource with Female Partners of Male Stroke Survivors to Support Physical Activity Participation

Many male stroke survivors find it challenging to meet the recommended physical activity (PA) guidelines for health benefits. The spouse/partner is an important source of self-management for stroke survivor PA participation; however, they feel unsupported by health professionals. This study aimed to co-design an educational resource prototype to guide and empower female partners in supporting male stroke survivors' participation in PA. We used a participatory action research (PAR) methodology. Thirteen support persons of male stroke survivors from Canterbury, New Zealand participated in four PAR cycles. The data were collected using individual interviews and focus groups and analyzed inductively using the general inductive approach. Three themes were reflected in the data and informed the prototype content: (1) managing an unwanted and challenging new life, (2) inconsistent access to meaningful information, and (3) considerations for successful stroke survivor PA participation. If partners are to be an essential source in supporting stroke survivors' self-management of PA, they require resources that are meaningful and credible to enhance their confidence and self-efficacy. Further research is needed to explore the acceptability and usability of the educational resource with a wider audience and evaluate the co-design process. An inclusive and collaborative approach where support persons were valued for their expertise was essential in co-designing a meaningful resource intended to support stroke survivors and support persons' self-management of their PA.

Factors impacting the access and use of formal health and social services by caregivers of stroke survivors: an interpretive description study

BACKGROUND

Evidence has shown that family and friend caregivers of stroke survivors are significantly and negatively impacted by caregiving. The negative effects of caregiving may persist over time suggesting that caregivers might benefit from ongoing engagement with supportive services. However, little is known about caregivers' use of formally funded health and social services, or the factors influencing their access to and use of these services. The aim of this study is to increase understanding of the factors that influence stroke caregivers' access and use of formal health and social services, from the perspective of stroke caregivers and healthcare providers.

METHODS

A qualitative study was conducted with stroke caregivers and health providers in Ontario, Canada using interpretive description. In-depth interviews were conducted with caregivers of survivors who experienced a stroke between six months to five years previous and healthcare providers who support caregivers and stroke survivors. All participants provided written informed consent. Interview data were analyzed using constant comparison to identify codes and develop key thematic constructs.

RESULTS

A total of 40 interviews were conducted with 22 stroke caregivers at an average 30-months post-stroke and 18 health providers. Factors that influenced stroke caregivers' access and use of services included: finances and transportation; challenges caregivers faced in caring for their health; trust that they could leave their family member and trust in health providers; limited information pertaining to services and a lack of suitable services; and the response of their social networks to their caregiving situation.

CONCLUSION

Stroke caregivers experience significant challenges in accessing and using formal health and social services. These challenges could be addressed by increasing availability of subsidized community-based supports such as respite and counselling tailored to meet the ongoing needs of caregivers. Systemic change is needed by the health system that readily includes and supports caregivers throughout the stroke recovery continuum, particularly in the community setting.

Prognostication in Poststroke Aphasia: Perspectives of Significant Others of People With Aphasia on Receiving Information About Recovery

PURPOSE

Knowing what to expect poststroke is important for many significant others of people with aphasia, yet an understanding of their perceptions and preferences in receiving prognostic information is limited. This knowledge is needed to inform the formulation and delivery of aphasia prognoses as conversations about prognosis can be harmful or helpful depending on their alignment with key stakeholder perspectives. Our preliminary study sought insight into the perspectives of significant others of people with aphasia on receiving prognostic information, with an aim toward informing evidence-based practice in aphasia prognostication.

METHOD

We interviewed seven significant others of people with aphasia, 3-12 months poststroke. The interviews were semistructured, conducted one-to-one, and analyzed qualitatively using reflexive thematic analysis.

RESULTS

Five themes were drawn from the interviews: (a) You don't know what you don't know. (b) Having them alive is the best you can ask for. (c) Recovery in the eye of the beholder. (d) Outcomes don't matter unless they help me help them. (e) It's my prognosis too if I'm living with aphasia.

CONCLUSIONS

A significant other's prognosis-related perceptions and preferences are products of their poststroke reality and may inadvertently shape that of the person with aphasia. In order to facilitate recovery, prognostication practices need to consider the needs of significant others both as providers of care and as requiring care themselves for their first-hand experiences of third-party disability.

At the Intersection of Race, Socioeconomics, and Chronic Illness: A Case and Frame Analysis of Two Survivor-Caregiver Dyads in the Aftermath of Stroke

Although the overall incidence of stroke in the United States has decreased in recent years, the incidence of stroke among Black Americans has not changed. This has resulted in a widening gap between White and Black stroke survivors and their families. A variety of factors contribute to this inequity including social determinants of health (e.g., adverse life events, discrimination, neighborhood deprivation, lack of access to health care). This article uses a "case and frame" approach, through the lens of ecological systems theory, to illustrate how social determinants of health express themselves in two stroke survivor-caregiver dyads living in a large Midwestern city. We draw out implications for practice and policy in social work and related disciplines that focus on recognizing the impact of social determinants of health, developing culturally-specific interventions that mitigate unique stressors but that also leverage unique strengths, and building capacity for cultural competence and cross-cultural health communication within organizations.

The Burden and Quality of life of Caregivers of Stroke Survivors with Cognitive Impairment in Selected Healthcare Facilities in Anambra State, Nigeria

Objective:

To determine the burden and quality of life of caregivers of stroke survivors with cognitive impairment in selected healthcare facilities in Anambra State, Nigeria.

Methods:

This was a cross-sectional survey using the World Health Organization QOL-BREF and Caregiver Strain Index (CSI) as instruments. Descriptive statistics of frequency, percentage counts, mean and standard deviation were used to summarize the socio-demographics. Spearman’s ranked order correlation; Mann–Whitney U test assessed the correlation and gender and age difference in QoL and caregiver’s burden. Alpha level was set at 0.05.

Results:

Physical health domain of QOL was slightly moderate (53.29 ± 15.19), psychological health was low (46.33 ± 16.96), social relationship was slightly moderate (51.16 ± 0.31), environmental health was slightly moderate (51.22 ± 15.88), the burden of caregivers was high (6.35 ± 1.29).

Conclusion:

The quality of life of the caregivers of stroke survivors with cognitive impairment was moderate, and the caregivers’ stress was high in the sample of the population studied.

Support system diversity among family caregivers of stroke survivors: a qualitative study exploring Asian perspectives

BACKGROUND

Caregiving is a global phenomenon which is bound to increase in tandem with the aging population worldwide. Stroke is a condition common in older people that requires complex caregiving necessitating provision of adequate support to the caregivers. Past literature consists of limited accounts of types and organization of support arrangements needed by different caregivers. We aimed to describe the support system of caregivers of stroke survivors in Singapore, highlighting differences across the different caregiver identities (i.e. spouse, adult-child, etc.).

METHODS

We conducted a qualitative descriptive study in the community setting involving 61 purposively sampled and recruited stroke survivors and caregivers. Semi-structured interviews were conducted, and transcripts were analysed using thematic analysis.

RESULTS

Our findings were summarized across the following 4 themes: 1) cultural influence and caregiving; 2) caregiver support system with the following sub-themes: 2.1) dyadic caregiver support type, 2.2) extended caregiver support type, 2.3.) distributed caregiver support type and 2.4) empowering caregiver support type; 3) breaks in care of stroke survivor and 4) complex relationship dynamics. We operationalized the caregiver support system as comprising of type, people and activities that enable the caregiver to participate in caregiving activities sustainably. While spouse caregivers preferred dyadic and extended support systems positioning themselves in a more central caregiving role, adult-child caregivers preferred distributed support system involving family members with paid caregivers playing a more central role.

CONCLUSIONS

Our findings highlight caregiver identity as a surrogate for the differences in the caregiver support systems. Practical implications include imparting relationship-building skills to the stroke survivor-caregiver dyads to sustain dyadic support system and educating clinicians to include differences in caregiving arrangements of stroke survivors in practising family-centred care.

Relationship and Social Network Change in People With Impaired Social Cognition Post Right Hemisphere Stroke

Purpose This article investigated relationship and social network change in the presence of a social cognition impairment post right hemisphere (RH) stroke. Impaired emotion perception and inferential reasoning are sources of interpersonal difficulty in people with social cognition impairment after traumatic brain injury. People with an RH stroke have also been identified as vulnerable to interpersonal relationship change. However, the influence of impairments in particular domains of communication or cognition on relationship and social network maintenance is yet to be explored. Method A multiple-case study methodology allowed for testing of theoretically developed propositions by exploring social networks and relationships within and between seven participant-proxy dyads. Purposeful recruitment was based on first-onset RH stroke and impaired social cognition, as determined by The Awareness of Social Inference Test. Results Social network size reduction (71.4%, n = 5) and interpersonal relationship change (85.7%, n = 6) were attributed to altered communication style, impairments in social cognition, and reduced insight and/or motivation. The spouse emerged as a facilitator of social engagement. Conclusion This study contributes to our understanding of the challenges experienced by people with impaired social cognition post RH stroke in maintaining relationships and their social networks.

Marital Stability and Quality of Couple Relationships after Acquired Brain Injury: A Two-Year Follow-Up Clinical Study

Couple relationships after acquired brain injury (ABI) could be vulnerable to emotional distress. Previous evidence has demonstrated significant marital dissatisfaction in the first period after a traumatic event, while long-term evaluations are lacking. In this study, we evaluated the impact of a series of demographic and clinical factors on marital stability after two years from the injury. Thirty-five patients (29% female) with mild/moderate ABI (57% vascular, 43% traumatic) and their partners were enrolled. The couples completed a series of psychological questionnaires assessing marital adjustment (Dyadic Adjustment Scale, DAS) and family functioning (Family Relationship Index, FRI) at discharge from the intensive rehabilitation unit and after 2 years. Demographics (i.e., educational level, job employment and religion commitment) and clinical variables (i.e., the Barthel index, aetiology and brain lesion localization) were considered as predictive factors. Regression analyses revealed that the DAS and FRI values are differently influenced by demographic and clinical factors in patients and caregivers. Indeed, the highest educational level corresponds to better DAS and FRI values for patients. In the spouses, the variability of the DAS values was explained by aetiology (the spouses of traumatic ABI patients had worse DAS values), whereas the variability in the FRI values was explained by religious commitment (spending much time on religious activities was associated with better FRI values). Our data suggest that some clinical and demographic variables might be important for protecting against marital dissatisfaction after an ABI.

Qualitative Study of Chinese Stroke Caregivers' Caregiving Experience During the COVID-19 Pandemic

BACKGROUND AND PURPOSE

The coronavirus disease 2019 (COVID-19) outbreak has led to disruptions in health care service delivery worldwide, inevitably affecting stroke survivors requiring ongoing rehabilitation and chronic illness management. To date, no published research has been found on stroke caregiving during the COVID-19 pandemic. This study aimed to explore Hong Kong stroke caregivers' caregiving experiences in the midst of this difficult time.

METHODS

Individual semistructured interviews were conducted with 25 Chinese adult primary stroke caregivers from May to June 2020 via telephone. Interviews were transcribed verbatim and analyzed using an interpretive description approach and constant comparison strategy.

RESULTS

Five themes of the stroke caregiving experience during the COVID-19 pandemic emerged: care service adversities, additional caregiving workload and strain, threatened relationship between caregiver and stroke survivors, threats to caregivers' physical and psychological well-being, and needs for continuing caregiving roles. Our findings suggested that caregivers have worsened physical and psychological well-being because of increases in care burden with simultaneously reduced formal and informal support. The relationship between caregiver and stroke survivor was subsequently affected, placing some survivors at heightened risk of abuse.

CONCLUSIONS

Our study provides valuable findings about stroke caregiving experiences and needs during the pandemic. Delivery of psychological support, telemedicine, and household hygiene resources would be useful to mitigate caregivers' psychological distress during the COVID-19 pandemic.

Challenges implementing a carer support intervention within a national stroke organisation: findings from the process evaluation of the OSCARSS trial

OBJECTIVES

To examine the implementation of an intervention to support informal caregivers and to help understand findings from the Organising Support for Carers of Stroke Survivors (OSCARSS) cluster randomised controlled trial (cRCT).

DESIGN

Longitudinal process evaluation using mixed methods. Normalisation process theory informed data collection and provided a sensitising framework for analysis.

SETTING

Specialist stroke support services delivered primarily in the homes of informal carers of stroke survivors.

PARTICIPANTS

OSCARSS cRCT participants including carers, staff, managers and senior leaders.

INTERVENTION

The Carer Support Needs Assessment Tool for Stroke (CSNAT-Stroke) intervention is a staff-facilitated, carer-led approach to help identify, prioritise and address support needs.

RESULTS

We conducted qualitative interviews with: OSCARSS cRCT carer participants (11 intervention, 10 control), staff (12 intervention, 8 control) and managers and senior leaders (11); and obtained 140 responses to an online staff survey over three separate time points. Both individual (carer/staff) and organisational factors impacted implementation of the CSNAT-Stroke intervention and how it was received by carers. We identified four themes: staff understanding, carer participation, implementation, and learning and support. Staff valued the idea of a structured approach to supporting carers, but key elements of the intervention were not routinely delivered. Carers did not necessarily identify as 'carers', which made it difficult for staff to engage them in the intervention. Despite organisational enthusiasm for OSCARSS, staff in the intervention arm perceived support and training for implementation of CSNAT-Stroke as delivered primarily by the research team, with few opportunities for shared learning across the organisation.

CONCLUSIONS

We identified challenges across carer, staff and organisation levels that help explain the OSCARSS cRCT outcome. Ensuring training is translated into practice and ongoing organisational support would be required for full implementation of this type of intervention, with emphasis on the carer-led aspects, including supporting carer self-identification.

TRIAL REGISTRATION NUMBER

ISRCTN58414120.

The role of the social network during inpatient rehabilitation: A qualitative study exploring the views of older stroke survivors and their informal caregivers

BACKGROUND

After discharge, stroke survivors and their informal caregivers need support from their social networks to resume their most valued activities. Rehabilitation professionals could help them establish a strong support system.

OBJECTIVE

Explore how older stroke survivors and their primary informal caregivers expect to resume their valued activities after discharge, and discover their ideas about involving, informing and educating their family members, friends and important others during inpatient rehabilitation so that, once home, they will have adequate support.

METHODS

We conducted semi-structured interviews with stroke survivors from three geriatric rehabilitation centres and their primary informal caregivers, used the pictures of daily activities to elicit their perspectives, and applied a descriptive and interpretive design to data analysis.

RESULTS

Many participants had no concrete idea about how to resume their activities after discharge but nevertheless were optimistic they would. They expected help to be available and saw no need for professionals to involve their network during inpatient rehabilitation. However, once they had insight into the challenges to expect after discharge, they often appreciated the idea of professionals contacting their network. To better understand the challenges after discharge, it was helpful if professionals provided concrete, honest information about the stroke's consequences for daily life. Actually doing daily activities also helped gain better insights.

CONCLUSIONS

To enhance insight in the need of social support after discharge, we suggest that rehabilitation professionals are honest about what to expect and let stroke survivors explore their valued activities in a realistic context more often.

"It's like a lifeboat": stakeholder perspectives of an intensive comprehensive aphasia program (ICAP)"

Background

Intensive comprehensive aphasia programs (ICAPs) have gained popularity in recent years. Outcomes from ICAPs have demonstrated measurable improvements for most who take part, but how do people with aphasia and their family members experience an ICAP?

Aim

The aim of this paper was to explore, through qualitative interviews, the experiences of persons with aphasia and their family members who took part in an ICAP.

Methods & Procedures

Twelve interviews were conducted with persons with aphasia and family members regarding their experiences with the ICAP that they had just completed. Nine persons with aphasia were interviewed with their family members and three chose to take part in the interview alone. The Framework Analysis method was used to identify themes from the transcribed interviews.

Outcomes & Results

The interviewees discussed four themes related to treatment, psychosocial environments, physical environments, and outcomes. The interviewees remarked on the challenges that were provided by the treatment and how the treatment was different from previous treatment. Comments were made related to the relationships the participants and families developed within the context of the program. The physical environment allowed for relationships to develop. The interviewees discussed the physical and social environment as important additional factors that contribute to the overall therapeutic effect of the ICAP. Positive outcomes were noted in language skills and psychosocial contexts.

Conclusions

Based on interviewees' descriptions of this one ICAP, the concept of a therapeutic milieu was developed to describe how the intersection of the treatment, psychosocial interactions, and physical setting related to outcomes. Interviewees described how the therapeutic milieu of the ICAP was interwoven with the intensive therapy to create a "package" of therapy that led to improved outcomes. Implications for non-ICAP clinical practice is that participants linked more intensive therapy and greater social interactions with better outcomes.

Factors affecting in-hospital cost and mortality of patients with stroke: Evidence from a case study in a tertiary hospital in China

OBJECTIVE

The study aims to investigate the factors causing the difference of stroke patients' in-hospital cost and study these factors on health outcome in terms of mortality.

METHODS

Eight hundred and sixty-two in-patients with stroke in a tertiary hospital in China from 2017 to 2019 were included in the database. Descriptive statistics indexes were used to describe patients' in-hospital cost and mortality. Based on Elixhauser coding algorithms, multiple linear regression and logistic regressions (LRs) were used to evaluate the impact of factors identified from univariate analysis on in-hospital cost and mortality, respectively. In addition to LRs, a comparison study was then carried out with random forest, gradient boosting decision tree and artificial neural network.

RESULTS

Factors affecting both cost and mortality are age, discharged day-of-week, length of stay, stroke subtype, other neurological disorders, renal failure, fluid and electrolyte disorders and total number of comorbidities.

CONCLUSION

With the increase of age, the mortality rate of in-patients (except for the juvenile) with stroke increases and the cost of hospitalization decreases. Intracerebral haemorrhage is the most devastating stroke for its highest mortality in short length of stay. Medical services should focus on these specific comorbidities.

Burden on caregivers of patients with sequelae of cerebrovascular accident

OBJECTIVES

to evaluate the burden and its relationship with the sociodemographic characteristics of caregivers of people with sequelae of stroke.

METHODS

a cross-sectional, exploratory, and quantitative study was conducted with 151 caregivers of people with sequelae of stroke, through home interviews between September and December 2017.

RESULTS

there was a general mean of low burden. The items that indicated the worst changes were: "My time for social activities with friends," "My time for family activities," "My ability to cope with stress," and "My physical functioning." There was an association of burden with the female sex and with caregivers who have been assisting for longer.

CONCLUSIONS

the results allow us to reflect on the need to create a policy aimed at family caregivers to reduce the impact of care delivery.

The Unmet Needs of Stroke Survivors and Stroke Caregivers: A Systematic Narrative Review

INTRODUCTION

Facilitating stroke survivors and their caregivers to lead a fulfilling life after stroke requires service providers to think about their different needs. Poor post stroke care may lead to unmet needs in stroke survivors and stroke caregivers. This may compromise them in leading their lives optimally after stroke.

OBJECTIVES & METHODOLOGY

This systematic narrative review examines articles published from 1990 to 2017, generated from Ovid, MEDLINE, CINAHL, and PubMed. The search was also supplemented by an examination of reference lists for related articles via Scopus. We included 105 articles.

FINDINGS

We found that the type of unmet needs in stroke survivors and the contributing factors were substantially different from their caregivers. The unmet needs in stroke survivors ranged from health-related needs to re-integration into the community; while the unmet needs in stroke caregivers ranged from information needs to support in caring for the stroke survivors and caring for themselves. Additionally, the unmet needs in both groups were associated with different factors.

CONCLUSION

More research is required to understand the unmet needs of stroke survivors and stroke caregivers to improve the overall post-stroke care services.

"Caregiving is a full-time job" impacting stroke caregivers' health and well-being: A qualitative meta-synthesis

Family caregivers contribute to the sustainability of healthcare systems. Stroke is a leading cause of adult disability and many people with stroke rely on caregiver support to return home and remain in the community. Research has demonstrated the importance of caregivers, but suggests that caregiving can have adverse consequences. Despite the body of qualitative stroke literature, there is little clarity about how to incorporate these findings into clinical practice. This review aimed to characterise stroke caregivers' experiences and the impact of these experiences on their health and well-being. We conducted a qualitative meta-synthesis. Four electronic databases were searched to identify original qualitative research examining stroke caregivers' experiences. In total, 4,481 citations were found, with 39 studies remaining after removing duplicates and applying inclusion and exclusions criteria. Articles were appraised for quality using the Critical Appraisal Skills Programme (CASP), coded using NVivo software, and analysed through thematic synthesis. One overarching theme, 'caregiving is a full-time job' was identified, encompassing four sub-themes: (a) restructured life, (b) altered relationships, (c) physical challenges, and (d) psychosocial challenges. Community and institution-based clinicians should be aware of the physical and psychosocial consequences of caregiving and provide appropriate supports, such as education and respite, to optimise caregiver health and well-being. Future research may build upon this study to identify caregivers in most need of support and the types of support needed across a broad range of health conditions.

Interpersonal relationship challenges among stroke survivors and family caregivers

A strong interpersonal relationship after stroke is important for the well-being of survivors and family caregivers. However, as many as 54% of families experience relationship problems after stroke and as many as 38% of couples experience overt conflict. The purpose of this study is to enhance understanding about relationship challenges among stroke dyads and to identify implications for direct practice in social work. Semi-structured interviews were conducted with N = 19 care dyads. Qualitative data were analyzed through an interpretive description lens. Seven themes about relationship challenges were identified. Findings highlight areas to consider in promoting strong relationships between survivors and family caregivers. Social workers may have the opportunity to assist dyads with disrupting negative communication cycles, strengthening empathy and collaboration, and achieving a balance so that each person's needs are met.

Reciprocity between older adults and their care-givers in emigrant households of Kerala, India

The felt obligation to return a benefit, termed reciprocity, has been identified as motivating care exchanges between older adults and their younger family members. Within the context of large-scale emigration of young adults from the Indian state of Kerala, this study examines how left-behind older adults and their family care-givers recognise, interpret and give meaning to reciprocal exchanges, expectations and obligations in their care relationship. Employing a social exchange perspective, we qualitatively explore the norm of reciprocity through in-depth interviews of 48 participants (older adults and their care-givers) from emigrant households. Older adults and their care-givers identified reciprocal notions in their care exchange relationship that provided an interpretive framework for describing expectations, motivations, obligations and experiences across care-giving relationships. Spousal care-givers derived reciprocal motives and mutual care obligations through the institution of marriage. Adult children recognised filial duties and responsibilities and were in principle prepared to provide care to their parents. Reciprocating the support received and the likelihood of intergenerational transfers motivated care exchanges from adult children to their older parents. Daughters-in-law executed transferred filial roles from their emigrant husbands and bore a larger burden of care. Primary adult care-givers relied on the ‘demonstration effect’, hoping that children observe the care-giving process and emulate it later. Imbalances and non-reciprocity in the care exchange led to frustrations and threatened the care relationships.

Development and validation of a quality of relationship intervention for stroke survivor-family caregiver dyads

Background: The relationship between stroke survivors and family caregivers is critical for the well-being of both dyad members. Currently, there are few interventions targeted at dyads and focused on strengthening the relationship between survivors and family caregivers.Objectives: This study reports on the development of a customizable, strengths-based, relationship-focused intervention driven by the real-world experience and advice of stroke dyads. It also describes the "tips" that survivors and family caregivers offered for dealing with relationship challenges after stroke.Methods: Content of the intervention, including relationship tips, was derived from semi-structured interviews with N= 19 stroke dyads. A modified Delphi process with a national panel of 10 subject matter experts was used to evaluate and refine the content of the intervention and the associated screening tool.Results: Seventeen domains of relationship challenges and tips were identified. Consensus was reached among experts that the intervention content was relevant to the goal of helping survivors and family caregivers maintain a strong relationship after stroke; (2) clear from the perspective of stroke survivors and family caregivers who would be using it; (3) accurate with respect to the advice being offered, and; (4) useful for helping stroke survivors and family caregivers improve the quality of their relationship.Conclusions: This study extends the limited body of research about dyadic interventions after stroke. The next steps in this line of research include feasibility testing the intervention and evaluating its efficacy in a larger trial.

Nurses striving to provide caregiver with excellent support and care at a distance: a qualitative study

Background

In Norway, changes in life expectancy have led to increased attention to older people who are ageing at home, by means of home care services, adapted technology and informal caregivers. The caring situation has become difficult for many caregivers. The use of telecare has now offered them the possibility to receive support at home. The purpose of this study was to explore how nurses provide support and care at a distance, using a web camera and a web forum in a closed telecare network for caregivers to persons suffering from stroke and dementia.

Methods

The study had an explorative design with a qualitative approach. The data sources consisted of interviews with nurses and excerpts from posts in a closed telecare network. Content analysis was used to analyse the text from the interviews and the text from the web forum.

Results

The main theme, “Balancing asymmetric and symmetric relationships” described nurses’ relationship with caregiver. Two categories, “Balancing personal and professional qualities” and “Balancing caregivers’ dependence versus independence” were identified. The first describing the tension in their dialogue, the second describing how nurses provided the caregivers with a sense of security as well as strengthening them to master their daily lives.

Conclusions

The nurses provided long distance support and care for the caregivers, by using computer-meditated communication. This communication was characterized by closeness as well as empathy. To strengthen the caregivers’ competence and independence, the nurses were easy accessible and provided virtual supervision and support. This study increases the knowledge about online dialogues and relationship between nurses and caregivers. It contributes to knowledge about balancing in the relationship, as well as knowledge about bridging the gap between technologies and nursing care as potential conflicting dimensions. Maintenance of ethical principles are therefore critical to be aware of.

Supporting carers of stroke survivors to reduce carer burden: development of the Preparing is Caring intervention using Intervention Mapping

Background

Burden is well documented among carers of stroke survivors, yet current evidence is insufficient to determine if any strategies reduce this negative outcome. Existing interventions for carers of stroke survivors typically involve supporting carers according to their individual needs through face-to-face interactions and provision of information including workbooks or educational guides. To date, no interventions have been developed using a method which systematically incorporates evidence, behaviour change theories, and stakeholder involvement to change the behaviours of carers and relevant individuals who support carers. This study aimed to develop a programme plan for a theory and evidence-based intervention to reduce burden in carers of stroke survivors.

Methods

Informed by evidence from two systematic reviews and 33 qualitative interviews, the first four stages of Intervention Mapping were used to guide the intervention development process: 1) needs assessment; 2) identifying outcomes and objectives; 3) selecting theoretical methods and practical applications; and 4) creating a programme plan. Structured and facilitated involvement from stakeholders, including carers, researchers, and professionals from health and community services was integral to the intervention development process. Stakeholders helped to prioritise the focus of the intervention, develop the goals, outcomes and objectives for the programme, and generate and refine intervention ideas.

Results

Stakeholders prioritised the need for carers to feel prepared before and during the transition from hospital to home as key to reducing burden. The proposed intervention ‘Preparing is Caring’ targets this need and involves providing and signposting carers to relevant information and support for practical and emotional needs. This is to be delivered before, during, and immediately after the stroke survivor’s transition from hospital to home by a person taking on a single point of contact role. It is comprised of multiple theory-based components including: training packages for information and support providers working with carers and wider staff teams, plus elements to support carers to feel prepared.

Conclusions

We have developed a comprehensive programme plan for a multiple-component, theory and evidence informed behaviour change intervention aimed at preparing carers before and during the transition from hospital to home. Future work is required to refine, implement and evaluate the Preparing is Caring intervention.

Interventions for Psychological Health of Stroke Caregivers: A Systematic Review

Background: The increasing number of stroke patients (SPs) requires informal caregivers to bear a high burden of responsibilities and heavy (di)stress. Moreover, these issues could lead to the development of serious psychological problems (e.g., depressive and/or anxious) that in turn could give rise to poor health-related quality of life outcomes. However, although the value of psychological interventions has been widely recognized for SPs, the scientific literature lacks an updated synthesis of interventions addressing the psychological health of their caregivers. Aim: The aim of this review is to summarize the interventions for the psychological health of stroke caregivers and provide a resume of literature-based evidence of their efficacy. Method: A literature review from 2005 to date was conducted in three online databases: PubMed, Scopus, and Google Scholar. Eligibility criteria for studies were (A) English language, (B) caregivers and patients aged 18 years or above, (C) SP's caregiver beneficiating of a specific intervention, and (D) outcome measures addressing depressive and/or anxiety symptomology, quality of life, well-being, or burden. Results: Across the selected 45 studies, substantial differences are observable in three main categories: (a) type of intervention (b) techniques, and (c) operators. Interventions' advantages and results are discussed. Overall, studies using psychological techniques, such as cognitive-behavioral therapy, coping skill-training, and problem-solving therapy, showed their usefulness and efficacy in reducing the caregivers' depressive and anxious symptoms, and burden. Interventions led by psychologists and tailored to meet caregivers' specific needs showed more positive outcomes. Conclusion: This review underlines the usefulness of psychological interventions aimed at reducing the psychological burden, such as anxious and depressive symptomatology, of SPs' informal caregivers. Hence, psychological interventions for caregivers should be integrated as part of the stroke rehabilitation process to improve informal caregivers' and patients' quality of life and well-being.

Key informants' perspectives on implementing caregiver programs in an organized system of stroke care

PURPOSE

Family caregivers provide essential support to individuals recovering after experiencing a stroke. Although clinical guidelines recommend the provision of caregiver education and support, these guidelines have not been implemented into standard clinical practice. The objective of this study was to gain insight from key informants-affiliates of a regional stroke system-to identify organization and system level barriers and facilitators associated with implementing stroke caregiver programs.

METHODS

Twelve key informants were interviewed. Informants discussed their experiences with and perceptions of caregiver programs. They also identified barriers and facilitators to implementing caregiver programs. Interview data were analyzed using inductive thematic analysis.

RESULTS

Three themes were generated: (1) lack of consensus on the need for caregiver education and support programs as part of the health care system; (2) a collaborative process is needed to engage stakeholders and identify champions (3) stakeholders need different types of evidence in support of implementation.

CONCLUSIONS

This study provides initial insight into the potential barriers and facilitators needed to develop and implement stroke caregiver programs. Further exploration of these topics can inform caregiver program development and their implementation into stroke systems of care.IMPLICATIONS FOR REHABILITATIONRehabilitation research needs to demonstrate that caregivers are a unique group in need of support from the health care system.Rehabilitation research needs to contribute to the evidence that caregiver programs can improve patient, caregiver, and health system outcomes.Researchers can enhance caregiver program implementation through collaboration between researchers, stakeholders, and system change champions starting with program development.

Unmet care needs of community-dwelling stroke survivors: a protocol for systematic review and theme analysis of quantitative and qualitative studies

INTRODUCTION

Stroke is a leading cause of disability worldwide. The average hospital length of stay ranges from 3 to 28 days, and after discharge home the stroke survivors will live with physical, cognitive, even psychological disorders for the rest of their lives. It is essential to review the unmet needs of stroke survivors.

METHODS AND ANALYSIS

A systematic review of previous quantitative and qualitative studies reporting the unmet needs of stroke survivors in their homes will be conducted. The following six databases will be searched from inception to December 2018 for relevant articles: PubMed, EMBASE, CINAHL, PsycINFO, SCOPUS and China Biology Medicine. We will include studies limited to human and published in English or Chinese, and the patients with stroke should discharge home rather than any other professional organisations including nursing homes or community rehabilitation units and so on. Data of quantitative research will be standardised for comparison, thematic analysis will be used for qualitative data and a narrative synthesis and pooled analysis of the main outcomes will be reported.

ETHICS AND DISSEMINATION

This review will be submitted to an international professional journal, and the detailed search strategies and analysis flowchart will be openly included as supplements. This study does not require ethical approval as no patient's identifiable data will be used. Our findings will give a new look at the aspect of stroke survivors' unmet needs in their long-term recovery stage, especially the trajectories of unmet needs at different timepoints. What is more, this review will demonstrate the long-term unmet needs of stroke survivors from different countries, will compare any variations between high-income and low-income regions, and the geographical differences of needs will be mapped if necessary. We will endeavour to provide as much information as possible to healthcare professionals and public health policy makers in order to promote further medical reform.

TRIAL REGISTRATION NUMBER

CRD42018112181.

Carer-related research and knowledge: Findings from a scoping review

The review discussed in this paper provides a unique synthesis of evidence and knowledge about carers. The authors adopted a scoping review methodology drawing on a wide range of material from many different sources published between 2000 and 2016. It offers key insights into what we know and how we know it; reinforces and expands evidence about carers' profile; shows knowledge is uneven, e.g. much is known about working carers, young carers and carers of people with dementia but far less is about older carers or caring for someone with multiple needs. A striking feature of much research is a focus on caring as a set of tasks, rather than a dimension of an, often dyadic, relationship. While there is substantive evidence about the negative impact of caring, the review suggests that links between caring and carer outcomes are neither linear nor inevitable and vary in depth and nature. A reliance on cross-sectional studies using standardised measures is a major weakness of existing research: this approach fails to capture the multidimensionality of the caring role, and the lived experience of the carer. Although research relating to formal support suggests that specific interventions for particular groups of carers may be effective, overall the evidence base is weak. There is a tension between cost-effectiveness and what is valued by carers. Developing robust evaluative models that accommodate this tension, and take account of the dyadic context of caring is a critical challenge. A fundamental deficit of carer-related research is its location in one of two, largely separate, paradigmatic frameworks: the "Gatherers and Evaluators" and the "Conceptualisers and Theorisers." The authors suggest that developing an integrated paradigm that draws on the strengths and methods of existing paradigms, has considerable potential to generate new knowledge and new evidence and extend understanding of care and caring.

Association between incongruence about survivor function and outcomes among stroke survivors and family caregivers

BACKGROUND

Stroke survivors and family caregivers often have incongruent appraisals of survivor cognitive, physical, and psychosocial function. Partner incongruence contributes to poor outcomes for survivors and caregivers.

OBJECTIVES

This study explored whether partner incongruence: (1) differs by function domain; (2) increases or decreases over time, and; (3) is associated with self-rated health, distress, stress, and depressive symptoms.

METHODS

Structured surveys were administered to 32 survivors and caregivers at approximately 3 (enrollment) and 7 months (follow-up) post-stroke. Paired t-tests were used to examine partners' ratings of survivor function at enrollment and follow-up, and changes in incongruence over time. Partial correlations were used to examine the association between incongruence at enrollment and outcomes at follow-up.

RESULTS

Survivors consistently rated their own memory and thinking as significantly better than caregivers rated their memory and thinking. At follow-up, survivors rated their own communication as significantly better than caregivers rated their communication. Incongruence about survivor memory and thinking was associated with survivor distress, as well as caregiver distress, stress, and depressive symptoms. Incongruence about survivor ADLs was associated with caregiver stress and depressive symptoms. Incongruence about survivor social participation was associated with caregiver distress.

CONCLUSIONS

Findings from this study suggest that survivors and caregivers often have incongruent appraisals of survivor function, that incongruence does not improve naturally over time, and that incongruence may be detrimental for survivor and caregiver outcomes. Further research should be directed at the mitigation of incongruence and strategies to improve outcomes for both survivors and family caregivers.

[Interventions for stroke survivor caregivers: a systematic reviewIntervenciones para los cuidadores de los sobrevivientes de un accidente cerebrovascular: revisión sistemática]

OBJECTIVE

To synthesize and critically review the literature on interventions aimed at decreasing the burden of stroke survivor caregivers and other associated factors.

METHOD

The literature search for the present systematic review was performed in PubMed, SciELO, Coordination for the Improvement of Higher Education Personnel (CAPES) website, and the Virtual Health Library using the following search terms: Stroke AND Caregivers AND Intervention; and Stroke AND Caregivers AND clinical trial. Eight randomized controlled clinical trials (RCT) published between 2008 and 2017 were selected.

RESULTS

The selected studies were performed in Sweden, Taiwan, Germany, China, India, and the United States. Psychoeducational, support, and skill acquisition interventions produced positive results for caregivers - in the psychological, physical, and social domains, in the quality of the care provided, and in the acquisition of knowledge by caregivers - and for stroke survivors - for example, decreased use of health care services and improved capacity for self-care. The critical evaluation of the studies showed that none met all the methodological requirements for RCTs. The main limitations were missing data and the heterogeneity of interventions.

CONCLUSION

The interventions had positive results for caregivers and survivors. However, future studies should consider long term assessments of the outcomes, with detailed description of the baseline needs that guided the study and the sharing of the support materials used to allow the intervention to be reproduced.

"I Don't Believe in Leading a Life of My Own, I Lead His Life": A Qualitative Investigation of Difficulties Experienced by Informal Caregivers of Stroke Survivors Experiencing Depressive and Anxious Symptoms

OBJECTIVES

Health and social care services are increasingly reliant on informal caregivers to provide long-term support to stroke survivors. However, caregiving is associated with elevated levels of depression and anxiety in the caregiver that may also negatively impact stroke survivor recovery. This qualitative study aims to understand the specific difficulties experienced by caregivers experiencing elevated symptoms of anxiety and depression.

METHODS

Nineteen semi-structured interviews were conducted with caregivers experiencing elevated levels of depression and anxiety, with a thematic analysis approach adopted for analysis.

RESULTS

Analysis revealed three main themes: Difficulties adapting to the caring role; Uncertainty; and Lack of support.

CONCLUSIONS

Caregivers experienced significant difficulties adapting to changes and losses associated with becoming a caregiver, such as giving up roles and goals of importance and value. Such difficulties persisted into the long-term and were coupled with feelings of hopelessness and worry. Difficulties were further exacerbated by social isolation, lack of information and poor long-term health and social care support.

CLINICAL IMPLICATIONS

A greater understanding of difficulties experienced by depressed and anxious caregivers may inform the development of psychological support targeting difficulties unique to the caring role. Improving caregiver mental health may also result in health benefits for stroke survivors themselves.

Critical points in the experience of spouse caregivers of patients who have suffered a stroke. A phenomenological interpretive study

AIMS

To explore and document the experiences and values of spouse caregivers of stroke survivors. To gain more in-depth knowledge of how the act of caring and the adaption process affects caregiving spouses.

MATERIALS AND METHODS

Phenomenological, qualitative study. This study included spouses of stroke survivors who also served as primary caregivers. Individual, semi-structured, in-depth interviews were conducted, transcribed, and analysed using a thematic content analysis as proposed by Giorgi. Data was analysed and managed using Atlas-ti (version 7.0). This study was approved by our institution´s Complejo Hospitalario de Caceres Ethics and Research Committee.

RESULTS

Spouse caregivers of stroke survivors undergo a process of disruption in their private lives and relationships, marked by their caregiving duties. The experiences of spouses caring for stroke survivors is condensed into topics and subtopics: "Caregiving and that´s all" summarizes the sense of having no life horizons and also caregiver impossibility of moving away from caring role. Otherwise, "Breaking the couple´s life together" enlightens the further consequences of stroke in couples shared live biography, which needs to be understood and rebuilt. Finally, "Going through the (non) loss alone" alludes to how spouses reinterpret meaning of loss, which is not appreciated by others and that refers to the balance between stroke survival and any acquired global disability.

CONCLUSIONS

A comprehensive approach to the couple (family), from a psycho-socio-emotional and relational perspective, is essential for ensuring adequate quality of life for people who suffered a stroke as well as their caregivers. Spouses-caregivers must be considered as individuals living a transition process due to their unexpected disrupting change, which nurses should address through a comprehensive and integrated approach focused on transition care. Care resources must be adapted to the interpretation that the spouses have of their caregiving role and their relationship with the different components of the caregiving process.

Effects of modified 8-week reminiscence therapy on the older spouse caregivers of stroke survivors in Chinese communities: A randomized controlled trial

OBJECTIVE

Our aim was to evaluate the effectiveness of a modified 8-week reminiscence therapy on the burden, positive experience, and life satisfaction of older spouse caregivers and the life satisfaction of stroke survivors.

METHODS

We conducted a randomized controlled trial by using 75 older stroke couples recruited from communities in Zhengzhou, China. We randomly assigned participants to 1 of 3 groups: Group 1 (G₁ , 25 couples, all attend intervention) and Group 2 (G₂ , 22 couples, only caregivers attend intervention), who participated in a modified 8-week reminiscence therapy, and a waiting list (control) group (G₃ , 28 couples). Interviewers blinded to treatment group assignment administered the life satisfaction to both stroke survivors and caregivers, caregiver burden, and positive experience for caregivers, at preintervention, immediately postintervention, and at 1 month and 3 months after cessation of the intervention.

RESULTS

We found a statistically significant interaction between treatment groups and assessment time points for the 4 outcome measures (P < .001). Although the effects were decreased after intervention at 1 month, the improvement in caregivers' positive experience, life satisfaction, burden, and life satisfaction of stroke survivors were still significant (P < .001).

CONCLUSIONS

The use of a modified 8-week reminiscence therapy in this study sample improved the life satisfaction of stroke survivors and their spouse caregivers, improved the positive experience of caregivers, and decreased the burden of caregivers.

Like an extended family: Relationships that emerge when older caregivers use written messages to communicate in an ICT-based healthcare service

OBJECTIVE

To explore the relationships that emerge amongst caregivers of persons with dementia and stroke when caregivers use written messages as their communication tool in a closed information and communication technology (ICT)-based support group.

METHODS

An explorative design with a qualitative approach was used that applied systematic text condensation (STC) to analyse 173 written messages extracted from a web forum.

RESULTS

Empathetic, empowering and familiar relationships emerged amongst peers of older caregivers when the caregivers used written messages as their communication tool. The empathetic relationship was characterised by sincerity and openness when the caregivers shared emotions related to caregiving. The empowering relationship reflected a fellowship based on solidarity influenced by a sense of optimism and a willingness to share knowledge to support one another in overcoming challenges. In the familiar relationship, the caregivers were thoughtful and good-humoured with one another and displayed an attitude of consideration towards one another, as in an extended family.

PRACTICE IMPLICATION

The use of computer-mediated communication in health care service will change the context of establishing and maintaining interpersonal relationships. Therefore, greater knowledge regarding how the peers of caregivers interact with one another is vital so nurses may better support and educate ICT-based support groups.

Staying married after stroke: a constructivist grounded theory qualitative study

BACKGROUND

Marriages are one of the most powerful predictors of health and longevity, yet research in stroke has focused separately on survivors' experience of impairments and how spouses deal with caregiving.

OBJECTIVES

The purpose of this constructivist grounded theory study was to understand the key themes related to reconstruction or breakdown of marriages after stroke.

METHODS

In semi-structured interviews, 18 couples in long-term marriages discussed how their marriages were reconstructed or broke down after one member of the couple returned home after being hospitalized for a stroke. Constant comparison methods were used to compare the experiences of 12 couples in which both partners indicated their relationship was going well with 6 couples who either separated or remained in parallel marriages.

RESULTS

Analysis revealed an overarching process of reconstructing compatible role-identities and three themes related to the reconstruction or breakdown of the marital identity: feeling overwhelmed, resolving conflict, and perceiving value in the marriage.

CONCLUSIONS

Our findings highlight that marriages are contexts in which survivors and spouses can recalibrate their role-identities. Marriage relationships are not peripheral to survivors' and spouses' outcomes after stroke; rather, marriage is fundamental to the management of impairments and to the well-being of the couple.

Reconciling Marriage and Care after Stroke

La plupart des recherches concernant les impacts des accidents vasculaires cérébraux (AVC) sur les couples ont été centrées sur la transition vers le rôle de soignant ou de bénéficiaire de soins. Même s’il est bien établi que la source principale du soutien dans les cas de maladies chroniques soit le mariage, il n’existe que peu de données sur les effets de ces soins, après un AVC, sur la relation maritale. Afin de combler cette lacune, nous avons réalisé une étude qualitative fondée sur une théorie à base empirique impliquant 18 couples dans lesquels l’un des époux avait subi un AVC. Les résultats ont mis en évidence deux thèmes étroitement liés en ce qui concerne la dynamique de couple : organiser les soins, un thème qui implique la découverte des problèmes dans la vie de tous les jours et leur prise en charge ; et repenser le mariage, un aspect qui nécessite la détermination du sens rattaché à la relation de couple dans un nouveau contexte caractérisé par des soins et des incapacités. Trois types du mariage se sont ressortis à partir de ces processus : la « reconfirmation » du mariage tel qu’il existait avant l’AVC ; la recalibration » du mariage autour des nouveaux soins ; et la « relation parallèle » — considérée comme « son mariage » à chacun des deux prtenaires. Ces résultats mettent en évidence la nécessité de considérer les dynamiques des relations, en plus des connaissances associées à l’AVC et aux soins.

Marriage after the transition to stroke: a systematic review

In health and chronic illness, satisfying marriages promote wellbeing and life satisfaction, yet stroke research has focused on either the stroke survivor as the patient or the spouse as a care-giver. Using Pope, Mays and Popay's framework for synthesising qualitative and quantitative methods, we conducted a systematic review and synthesis of 39 peer-reviewed studies to determine what happens to marital relationships after one partner has suffered a stroke. All the articles examined the impact of stroke. Three overarching themes characterise the evolution of marriage after stroke: chaos in the marriage, work to re-establish the marriage and evolution of the marriages. While both the stroke condition itself and the survivors’ need for care undermined the emotional qualities of the relationship for some couples, about two-thirds were able to retain or regain the relationship closeness. As in other chronic illnesses, the relationship closeness and a couple's ability to collaborate contributed to the survivor's recovery and to the satisfaction with life of the stroke survivor and the spouse. Our results underscore the need to consider the quality of, and the qualities of, the relationship between stroke survivors and their spouses. Future research could include a greater focus on qualitative or mixed-methods approaches to explore the interactions between stroke survivors and spouses that impact the wellbeing of both partners.