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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Information needs of people who have suffered a stroke or TIA and their preferred approaches of receiving health information: A scoping review

PURPOSE

We aimed to synthesize the information needs of people with stroke (PwS) in recurrent stroke prevention.

METHODS

In this scoping review we searched Medline (via PubMed), CINAHL, and PsycINFO from inception to June 5, 2023, to identify all studies describing the information needs of people 18 years and older who have suffered a stroke or transient ischemic attack within the past 5 years. We included qualitative and quantitative studies from developed countries published in German or English. Data analysis was performed following Arksey and O'Malley's methodological framework for scoping reviews.

FINDINGS

We screened 5822 records for eligibility and included 36 articles published between 1993 and 2023. None of the included studies used a comprehensive framework or defined information needs. Based on statements from PwS and their caregivers, PwS needed information on treatment, etiology, effects of stroke, prognosis, rehabilitation, discharge, life changes, care role, support options, information sources, and hospital procedures. The most frequently expressed needs were information on the treatment (77.8%) and stroke etiology (63.9%). The primary information source was healthcare professionals (85.7%), followed by written information (71.4%), family and friends (42.6%), and the internet (35.7%), with information provided directly by healthcare professionals being preferred. The timing of information transfer is often described as too early.

CONCLUSION

PwS are primarily interested in clinical information about stroke, for example, treatment and etiology, and less often in information about daily life, for example, rehabilitation, the role of care, or lifestyle changes. PwS prefer to receive information directly from healthcare professionals. Developing a shared understanding of PwS's information needs is crucial to implement suitable strategies and programs for dealing with these needs in clinical practice.

Readability of patient education material in stroke: a systematic literature review

BACKGROUND

Stroke education materials are crucial for the recovery of stroke patients, but their effectiveness depends on their readability. The American Medical Association (AMA) recommends patient education materials be written at a sixth-grade level. Studies show existing paper and online materials exceed patients' reading levels and undermine their health literacy. Low health literacy among stroke patients is associated with worse health outcomes and decreased efficacy of stroke rehabilitation.

OBJECTIVE

We reviewed the readability of paper (i.e brochures, factsheets, posters) and online (i.e American Stroke Association, Google, Yahoo!) stroke patient education materials, reading level of stroke patients, accessibility of online health information, patients' perceptions on gaps in stroke information, and provided recommendations for improving readability.

METHOD

A PRISMA-guided systematic literature review was conducted using PUBMED, Google Scholar, and EbscoHost databases and "stroke", "readability of stroke patient education", and "stroke readability" search terms to discover English-language articles. A total of 12 articles were reviewed.

RESULTS

SMOG scores for paper and online material ranged from 11.0 - 12.0 grade level and 7.8 - 13.95 grade level respectively. Reading level of stroke patients ranged from 3rd grade to 9th grade level or above. Accessibility of online stroke information was high. Structured patient interviews illustrated gaps in patient education materials and difficulty with comprehension.

CONCLUSION

Paper and online patient education materials exceed the reading level of stroke patients and the AMA recommended 6th grade level. Due to limitations in readability, stroke patients are not being adequately educated about their condition.

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.

[Understanding of the parents' perception of a hospitalised infant about their skills]

The hospitalisation of a child involves the whole family. The parents' perception is therefore a suitable indicator to help improve family-centered helpgiving practices. A study was carried out in 2014 in a paediatric unit in Switzerland, in order to guide the cultural adaptation of a tool for measuring the practices in place to support the parents of hospitalised children. The purpose is also that they know better their abilities.

Written Education Materials for Stroke Patients and Their Carers: Perspectives and Practices of Health Professionals

Inadequacies in the provision of written education materials to stroke patients and their carers have been reported. In this study, 20 stroke team health professionals were surveyed regarding their use of and perspectives on written education materials. Seventy percent of participants provided materials to 25% or fewer stroke patients and 90% believed that patients and carers are only occasionally or rarely provided with sufficient written information. Health professionals were uncertain which team members provided written information and identified the need to improve the quality of materials used. Stroke teams should implement a system that facilitates the routine provision of quality written materials to patients and carers, communication among team members, and documentation and verbal reinforcement of the information provided.

A Qualitative Study into Stroke Caregivers' Educational Needs — Perspectives of Caregivers and Healthcare Professionals

Background:

Healthcare professionals (HCPs) often provide information based on what they thought caregivers would need and like to know, rather than on the latter's perceived or actual needs. The current descriptive study was undertaken to find out more about HCP's and caregivers' perceptions of educational needs while the stroke survivor is still being cared for in an acute hospital.

Methods:

Ten caregivers, five nurses, and two neurologists were interviewed about their perceptions of educational needs during the stroke survivors' stay in acute care. All interviews were audiotaped, transcribed verbatim, and then analysed to identify main patterns of responses. The Framework Approach, which involves the steps of familiarisation, identifying a thematic framework, indexing, charting, mapping, and interpretation was used to inform the analysis.

Results:

Caregivers and HCPs agreed on the need for information on disease progression, prevention of recurrence, practical and emotional care. However, HCPs felt caregivers should also know about medication, which was not mentioned by any of the caregivers. Caregivers preferred “hands-on experience” and “hearing” from HCP to print materials. While some caregivers felt that their active involvement in caregiving training was not required if a foreign domestic worker (FDW) was to be hired, HCPs interviewed felt strongly that next-of-kin should, nonetheless, be trained as well.

Conclusion:

The expressed needs on stroke education did not differ greatly between caregivers and HCPs. Perhaps unique to the Singapore context, is the availability of FDWs to take on the care-giving role. HCPs should be aware of differences in expectations in the level of involvement of family members in the presence of a FDW.

An assessment of the quality of information on stroke and speech and language difficulty web sites

Online healthcare information is used by patients, their carers and families (PCF) experiencing speech and language difficulties (SLD) after a stroke. This information may be of variable quality. Tools have been designed to assess the risk of poor information quality, evaluating both generic and specific concepts, yet none focuses on stroke. The readability of information is also an issue when communication disorders are under consideration. The study investigated the quality and readability of information on 51 web sites pertaining to SLD following a stroke. These were assessed using two generic evaluation tools (DISCERN and the HON Code), readability tests (Flesch Reading Ease and Flesch-Kincaid Grade Level) and a specifically designed Stroke Tool based on the reported information needs of stroke PCF experiencing SLD. The tools themselves were then evaluated for their feasibility, reliability and validity. In common with previous studies, the information quality of the selected web sites was found to be extremely variable with only 59% achieving a score of 50% or more using HON, only 37% using DISCERN, and 49% using the Stroke Tool. Readability is generally very poor with only 6% of web sites scoring below the recommended grade 7. The tools did not correlate well, suggesting that they measure different domains of quality. The Internet may be a valuable resource for stroke PCF; however, the variable quality of information means that cautious use is recommended. The readability of information is a more serious issue that needs addressing by web site developers.

Educational needs of patients with a stroke and their caregivers: a systematic review of the literature

OBJECTIVE

To systematically review the research on stroke patients' and caregivers' educational needs.

METHODS

A search of the literature prior to and including the year January 2009 was conducted using Medline, CINAHL, EMBASE, PsychINFO and the Cochrane Library, yielding 959 articles. Of these, 21 studies were included in the review.

RESULTS

Stroke patients and caregivers reported many and diverse educational needs, which often were not met. The educational needs of stroke patients and caregivers concerned knowledge about the clinical aspects of stroke, prevention, treatment and functional recovery. The most commonly reported needs of caregivers involved patients' moving and lifting, exercises, psychological changes and nutritional issues. Patients and caregivers wanted information that was tailored to their situation.

CONCLUSION

Patients and caregivers have many unmet educational needs. The findings call for improved education of patients and caregivers on various issues that are specific to the various recovery phases after stroke.

PRACTICE IMPLICATIONS

The findings of this review can be used to develop educational interventions for stroke patients and caregivers. Further research is needed to investigate the feasibility and effects of educational interventions and whether they meet the educational needs of patients and caregivers.

Information provision to clients with stroke and their carers: self-reported practices of occupational therapists

BACKGROUND

The literature promotes the use of a wide range of educational materials for teaching and training clients with chronic conditions such as stroke. Client education is a valuable tool used by occupational therapists to facilitate client and carer ability to manage the stroke-affected upper limb. The aim of this study was to identify what information was provided to clients and carers, how this information was delivered, when the information was delivered and the client factors that influenced the method of information provision.

METHODS

Convenience and snowball sampling was used to recruit occupational therapists working in stroke. Twenty-eight participants completed the study questionnaire anonymously and their responses were summarised descriptively.

RESULTS

There was a clinically important trend for carers to receive less information than clients. Written and/or verbal information was the favoured method for delivering information related to handling (57%), soft-tissue injury minimisation (46.4%) and oedema management (50%). Information was delivered with decreasing frequency from admission (86%) to discharge (64%). More than 90% of participants indicated that the client's cognitive ability, visual ability, level of communication, primary language and perceptual ability were considered prior to the delivery of information.

DISCUSSION

Participants regularly conveyed information to clients and carers with respect to management of the stroke-affected upper limb. However, an increased emphasis on the development of practical self-management skills, awareness of the impact of personal factors and a timeline for information provision may prove useful.

Measuring outcomes in people who have had a stroke and their carers: can the telephone be used?

PURPOSE

Telephone interviews may be a cost-effective alternative to administering stroke outcome measures for people who are living in the community following a stroke, but there is a lack of research that has compared the different modes of administering outcome measures. The aim of this study was to determine whether telephone administration of selected stroke outcome measures resulted in significantly different results to face-to-face administration of the same outcome measures.

METHOD

Nineteen participants who were taking part in a randomised controlled trial (RCT) evaluating the effectiveness of a postdischarge education and support package for stroke patients and their carers were recruited for this study. Participants had the RCT follow-up outcome measures, at 3 months post discharge, administered by both telephone and face-to-face. Participants were randomised to receive either the telephone or face-to-face administration first and a period of 2 weeks separated the two administrations. Outcome measures were the Knowledge of Stroke Questionnaire, a stroke self-efficacy questionnaire, Hospital Anxiety and Depression Scale, Stroke and Aphasia Quality of Life Scale, and the Caregiver Strain Index.

RESULTS

There were no significant differences between scores obtained on any of the outcome measures that were administered by telephone and face-to-face (P > .05).

CONCLUSION

The telephone can be used to administer the outcome measures that were evaluated in this study to stroke patients and carers. These findings may be of benefit to stroke researchers and clinicians who wish to incorporate the use of telephone measures into the follow-up care of stroke patients and their carers.

Provision of rehabilitation services in Québec following stroke: a comparative survey conducted by postal questionnaire

We conducted a survey to document the rehabilitation services available to clients aged 65 years and older who had suffered a stroke. In all, respondents - gleaned from 295 resources located in three health regions in the province of Québec - completed a postal questionnaire describing the services that they offer, in terms of type of intervention (related to nine capabilities and seven areas of social participation) and type of services (evaluation, rehabilitation, and support). The results show that most rehabilitation services offered to older people with stroke address motor skills and mobility. Somewhat unexpectedly, for four capability-related interventions and two social-participation-related interventions, there appear to be more active rehabilitation services offered in regions with rural areas than in metropolitan regions.

What education do stroke patients receive in Australian hospitals?

OBJECTIVE

This study evaluated the educational practices of staff working in acute stroke wards in Australian hospitals, including the coordination and methods of patient education provision, post-discharge education and support services available, and the education and support services that health professionals would like to provide.

METHODS

Health professionals who worked in acute stroke wards in Australian hospitals were surveyed about the stroke education practices of staff in their ward. Thirty-four hospitals returned a completed questionnaire via email or fax.

RESULTS

Verbal communication and written materials were the most frequently used methods of information provision. Twenty-three (67.6%) wards developed their own written education materials, five (14.7%) offered group education programs, and 19 (55.9%) offered education or support after discharge. Fourteen (41.2%) wards had a particular staff member responsible for coordinating the provision of education to patients and one (2.9%) ward had a written policy on stroke education. The majority (70.6%) of participants would like to be able to provide more education/support services.

CONCLUSION

The educational practices of the Australian hospitals surveyed were variable, with improvements needed in the coordination and documentation of patient education and the available follow-up services.

PRACTICE IMPLICATIONS

Health professionals need to be aware of the importance of education in the care of patients following stroke. Patients' informational needs, while in hospital and after discharge, may be better met if staff in acute stroke wards had improved communication and coordination practices and ensured that stroke education was appropriately documented and supported by policy.

Rehabilitation needs for older adults with stroke living at home: perceptions of four populations

BACKGROUND

Many people who have suffered a stroke require rehabilitation to help them resume their previous activities and roles in their own environment, but only some of them receive inpatient or even outpatient rehabilitation services. Partial and unmet rehabilitation needs may ultimately lead to a loss of functional autonomy, which increases utilization of health services, number of hospitalizations and early institutionalization, leading to a significant psychological and financial burden on the patients, their families and the health care system. The aim of this study was to explore partially met and unmet rehabilitation needs of older adults who had suffered a stroke and who live in the community. The emphasis was put on needs that act as obstacles to social participation in terms of personal factors, environmental factors and life habits, from the point of view of four target populations.

METHODS

Using the focus group technique, we met four types of experts living in three geographic areas of the province of Québec (Canada): older people with stroke, caregivers, health professionals and health care managers, for a total of 12 groups and 72 participants. The audio recordings of the meetings were transcribed and NVivo software was used to manage the data. The process of reducing, categorizing and analyzing the data was conducted using themes from the Disability Creation Process model.

RESULTS

Rehabilitation needs persist for nine capabilities (e.g. related to behaviour or motor activities), nine factors related to the environment (e.g. type of teaching, adaptation and rehabilitation) and 11 life habits (e.g. nutrition, interpersonal relationships). The caregivers and health professionals identified more unmet needs and insisted on an individualized rehabilitation. Older people with stroke and the health care managers had a more global view of rehabilitation needs and emphasized the availability of resources.

CONCLUSION

Better knowledge of partially met or unmet rehabilitation needs expressed by the different types of people involved should lead to increased attention being paid to education for caregivers, orientation of caregivers towards resources in the community, and follow-up of patients' needs in terms of adjustment and rehabilitation, whether for improving their skills or for carrying out their activities of daily living.

Patient, carer and staff experience of a hospital-based stroke service

OBJECTIVE

Here, the aim is to study the experiences of patients, carers and staff throughout a hospital stroke care pathway.

DESIGN

Focus groups of patients, carers and staff followed a semi-structured format to elucidate experiences. The groups were recorded, transcribed and subjected to thematic analysis. Analyses were verified by researchers and participants.

RESULTS

Patients and carers produced four overlapping themes: 'information', 'staff attitudes', 'availability of care/treatment' and 'considering the whole person in context'. The carers' group produced two additional themes: 'accommodation of patients' individual needs' and 'burden of care'. Their experiences were complex and multi-faceted; positive views of the whole service co-existed with negative views of some aspects. The staff groups produced six themes: 'specialist service', 'split service', 'availability of care', 'consistency of care', 'staff morale' and 'wish for change'. Positive views of the specialist service were tempered by problems with physical and professional separation, staff shortages and 'hierarchical practice' that reduced collective decision-making.

CONCLUSION

Some of the patients' and carers' perspectives have not been previously reported in the stroke literature, including a desire for individualized treatment, the consideration of wider, non-physical needs and the carers' sense of burden. In addition, the study revealed how staff, carers and patients viewed each other and the service and demonstrated the concordance of their perceptions. However, staff showed little insight into the users' need for information and negative experiences of care. In contrast with previous research, lack of emotional care, poor continuity of care and lack of staff knowledge and skills were not identified as problems.

Fear of recurrence and beliefs about preventing recurrence in persons who have suffered a stroke

OBJECTIVES

The aim of this study was to investigate fear of recurrent stroke and beliefs about its causes and prevention.

METHODS

Eighty-nine patients participated 1 month following stroke and 81 were followed up at 9 months. Interviews addressed fears and beliefs about stroke, causes, recurrence and prevention by using closed and open-ended questions. Responses were subject to quantitative and qualitative analysis, respectively.

RESULTS

Fear of recurrence was common. Profound disability was a particularly feared outcome. Participants were knowledgeable about causes. However, causal controllability ratings were low. Some reported concern about preventative strategies (e.g., difficulty stopping smoking). Many reported idiosyncratic beliefs (e.g., avoiding overexertion) or fatalistic ideas about strokes (e.g., 'nothing' can prevent them). Similar quantitative results were obtained at follow-up.

CONCLUSIONS

Many patients fear stroke recurrence. They lack a sense of control over causes and have fears associated with idiosyncratic and fatalistic beliefs. There is a need to elicit and address individuals' own fears and beliefs about stroke before providing evidence-based secondary prevention recommendations.

Analysis of stroke patients' and carers' reading ability and the content and design of written materials: recommendations for improving written stroke information

OBJECTIVE

This study (a) evaluated the reading ability of patients following stroke and their carers and the reading level and content and design characteristics of the written information provided to them, (b) explored the influence of sociodemographic and clinical characteristics on patients' reading ability, and (c) described an education package that provides well-designed information tailored to patients' and carers' informational needs.

METHODS

Fifty-seven patients and 12 carers were interviewed about their informational needs in an acute stroke unit. Their reading ability was assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM). The written information provided to them in the acute stroke unit was analysed using the SMOG readability formula and the Suitability Assessment of Materials (SAM).

RESULTS

Thirteen (22.8%) patients and 5 (41.7%) carers had received written stroke information. The mean reading level of materials analysed was 11th grade while patients read at a mean of 7-8th grade. Most materials (89%) scored as only adequate in content and design. Patients with combined aphasia read significantly lower (4-6th grade) than other patients (p=0.001).

CONCLUSION

Only a small proportion of patients and carers received written materials about stroke and the readability level and content and design characteristics of most materials required improvement.

PRACTICE IMPLICATIONS

When developing and distributing written materials about stroke, health professionals should consider the reading ability and informational needs of the recipients, and the reading level and content and design characteristics of the written materials. A computer system can be used to generate written materials tailored to the informational needs and literacy skills of patients and carers.