Do empowered stroke patients perform better at self-management and functional recovery after a stroke? A randomized controlled trial

Figures & data

Table 1 HEISS empowerment sessions for stroke self-management

Sessions	Topics	Objectives
Small group sessiona
1 (week 3)	Sharing the stroke journey	– Ice-breaking session to initiate a patient–nurse partnership
		– Identify personal strengths and limitations poststroke
		– Identify a support person for practicing self-management (rehabilitation buddy)
2 (week 4)	Becoming stroke-safe for life	– Recognize stroke-warning signs and treatment-seeking action
		– Partner with the nurse facilitator to identify lifestyle changes and self-BP monitoring for secondary stroke prevention
		– Set mutually agreed behavioral goals and action plan for home-based self-management practice
3 (week 5)	Becoming active after stroke	– Explore physical abilities and limitations in self-care or recreational activities selection
		– Partner with the nurse facilitator to develop realistic home-based self-care/activities plan by incorporating participant’s choice and preferences and accident precaution
4 (week 6)	Chronic symptoms recognition and management	– Explore patterns of poststroke physical and emotional symptoms
		– Partner with a nurse facilitator to develop chronic symptom monitoring and management plan by incorporating participant’s choice and preferences
5 (week 7)	Roads to stroke recovery	– Share experiences for facilitating factors/barriers and discuss problem-solving strategies
		– Partner with the nurse facilitator to compile a personal stroke self-management workbook with mutually agreed goals and action plan
6 (week 8)	Consolidation, sharing, and feedback	– Report on and share home-based self-management experience
		– Acknowledge goal attainments by positive reinforcement
		– Discuss problem-solving and required change/fine tuning of action plan in the workbook relevant to identified barriers
		– Consolidate mid-term goal setting and action plan for home-based implementation
Telephone follow-up
Biweekly individual telephone session (week 9 to week 13)	Individual feedback for home-based implementation	– Assess consistency of or deviation from personal rehabilitation goals and action plan
		– Provide reinforcement on positive changes
		– Explore problem-solving/alternatives to overcome perceived/actual barriers

Note:

a The HEISS commenced in week 3 because all stroke patients (both CG and IG) had to attend two health talk sessions in week 1 and week 2 (usual care in the ambulatory rehabilitation schedule).

Abbreviations: BP, blood pressure; CG, control group; HEISS, Health Empowerment Intervention for Stroke Self-management; IG, intervention group.

Figure 1 Flow diagram of participant recruitment.

Abbreviations: CG, control group; IG, intervention group.

Table 2 Baseline sociodemographic characteristics and clinical profile of participants (N=210)

Characteristics	Control (n=105)	Intervention (n=105)	Statistic value	P-value
Age (years)a	70.7 (13.9)	67.8 (14.2)	1.543	0.124b
Sex
Male	55 (52.4)	55 (52.4)	0.000	0.999
Female	50 (47.6)	50 (47.6)
Marital status
Single	10 (9.6)	10 (9.5)	3.289	0.193
Married	80 (76.2)	71 (67.6)
Divorced/separated/widowed	15 (14.2)	24 (22.9)
Educational level
No formal education	22 (20.9)	21 (20.0)	1.842	0.606
Primary school	27 (25.7)	24 (22.9)
Secondary school	47 (44.7)	46 (43.8)
Tertiary or above	9 (8.7)	14 (13.3)
Employment status
Full/part-time work	34 (32.4)	33 (31.4)	0.893	0.827
Housewife	15 (14.3)	20 (19.0)
Retired	48 (45.7)	45 (42.9)
Unemployed	8 (7.6)	7 (6.7)
Carer
Relatives	17 (16.2)	24 (22.9)	6.503	0.090
Paid full-time domestic helper	10 (9.6)	16 (15.2)
Paid part-time domestic helper	60 (57.1)	57 (54.3)
Aged care staff	18 (17.1)	8 (7.6)
Religion
No	62 (59.1)	61 (58.1)	0.007	0.935
Yes	43 (40.9)	44 (41.9)
Smoking habits
Never smoke	68 (64.8)	68 (64.8)	0.288	0.999^c
Ex-smoker	34 (32.3)	35 (33.3)
Smoker	3 (2.9)	2 (1.9)
Stroke type
Hemorrhagic	27 (25.7)	29 (27.6)	0.667	0.754
Ischemic	78 (74.3)	76 (72.4)
Affected brain region
Left	49 (46.7)	41 (40.2)	1.086	0.579^c
Right	52 (49.5)	57 (55.9)
Both	4 (3.8)	4 (3.9)
Mobility
Hemiplegia	6 (5.7)	4 (3.8)	1.467	0.854^c
Hemiparesis	90 (85.7)	92 (88.5)
Both	8 (7.6)	7 (6.7)
Not obvious	1 (1.0)	1 (1.0)
Affected body part
Left side	49 (46.6)	50 (47.6)	0.442	0.961
Right side	41 (39.1)	41 (39.0)
Both	9 (8.6)	9 (8.6)
Others (visual/speech)	6 (5.7)	5 (4.8)
Sensory influence
Intact	35 (33.3)	35 (33.3)	0.181	0.996^c
Impaired	65 (61.9)	66 (62.9)
Absent	5 (4.8)	4 (3.8)
Chronic illnesses	96 (91.4)	93 (90.3)	0.476	0.490
Hypertension	74 (70.5)	73 (70.9)	0.023	0.880
Diabetes mellitus	38 (36.2)	36 (35.0)	0.083	0.773
Hyperlipidemia	47 (44.8)	50 (48.5)	0.172	0.678
Heart disease	11 (10.5)	24 (23.3)	5.794	0.016
Complications	7 (7.0)	13 (12.7)	1.989	0.158

Notes: Data are presented as frequencies (%) unless stated otherwise.

a Data are presented as mean (standard deviation);

b between-group comparison was performed by Student’s t-test. Categorical variables were compared between the two groups using Pearson’s chi-square test, those marked ^‘c’ were compared using Fisher’s exact test.

Table 3 Primary and secondary outcomes of control and intervention groups across time

Outcomes	T0 (the baseline)		T1 (1 week posttest)		T2 (3 months posttest)		T3 (6 months posttest)
	Control (n=105)	Intervention (n=105)	Control (n=92)	Intervention (n=97)	Control (n=88)	Intervention (n=96)	Control (n=82)	Intervention (n=93)
Self-efficacy
Self-efficacy in illness management	35.2 (15.0)	37.4 (12.9)	36.7 (15.0)	40.9 (13.4)	35.5 (15.1)	42.8 (13.5)	36.7 (14.8)	44.2 (12.3)
Self-management behavior
Cognitive symptom management	9.0 (5.9)	8.4 (4.8)	9.6 (5.8)	13.6 (6.5)	9.5 (5.9)	14.1 (6.5)	9.0 (5.7)	12.1 (6.5)
Communication with physician	3.4 (2.8)	3.4 (3.2)	4.9 (4.3)	8.4 (5.5)	5.2 (4.7)	7.7 (5.6)	5.7 (4.4)	7.0 (5.4)
Medication adherencea	75 (72.1)	76 (72.4)	69 (75.0)	74 (77.1)	65 (73.9)	75 (78.1)	68 (81.0)	66 (71.0)
Self-BP monitoring recorda	45 (42.9)	45 (42.9)	50 (54.9)	72 (75.0)	48 (54.5)	71 (75.5)	47 (58.8)	70 (77.8)
Functional ability
BI	75.8 (22.0)	72.6 (22.9)	84.5 (19.0)	86.6 (19.5)	83.2 (21.9)	88.3 (20.9)	82.2 (26.3)	86.3 (24.9)
Lawton IADL scale	7.7 (5.5)	7.0 (4.4)	9.1 (6.2)	11.1 (5.3)	8.4 (6.1)	11.6 (5.3)	9.5 (6.2)	11.8 (5.6)

Notes: Data are presented as mean (standard deviations) unless stated otherwise.

a Data are presented as frequencies (%).

Abbreviations: BI, Barthel index; BP, blood pressure; IADL, instrumental activities of daily living.

Table 4 GEE models for outcomes comparison across time between control and intervention groups

Outcomes	Regression coefficients of the GEE models
	Group B (95% CI)	T1 B (95% CI)	T2 B (95% CI)	T3 B (95% CI)	Group × T1 B (95% CI)	Group × T2 B (95% CI)	Group × T3 B (95% CI)
Self-efficacy
Self-efficacy in illness management	2.24 (−1.52, 6.01)	1.10 (−1.66, 3.85)	−0.47 (−3.57, 2.63)	0.42 (−2.96, 3.80)	2.11 (−1.77, 6.00)	5.44 (1.24, 9.64)*	5.59 (1.22, 9.95)*
Self-management behavior
Cognitive symptom management	−0.57 (−2.01, 0.87)	0.56 (−0.70, 1.82)	0.40 (−0.84, 1.65)	−0.21 (−1.65, 1.23)	4.49 (2.60, 6.37)***	5.18 (3.27, 7.09)***	3.61 (1.62, 5.61)***
Communication with physician	−0.03 (−0.84, 0.78)	1.44 (0.60, 2.28)***	1.78 (0.78, 2.77)***	2.23 (1.17, 3.29)***	3.53 (2.13, 4.94)***	2.44 (0.93, 3.95)**	1.36 (−0.23, 2.95)
Medication adherencea	1.01 (0.55, 1.86)	1.15 (0.69, 1.90)	1.04 (0.59, 1.82)	1.61 (0.87, 2.99)	1.10 (0.50, 2.42)	1.29 (0.57, 2.92)	0.57 (0.25, 1.32)
Self-BP monitoringa	1.00 (0.58, 1.73)	1.55 (1.04, 2.30)*	1.54 (0.98, 2.40)	1.83 (1.12, 2.98)*	2.49 (1.32, 4.68)**	2.56 (1.32, 4.96)**	2.31 (1.11, 4.81)*
Functional ability
BI	−3.24 (−9.28, 2.80)	8.46 (5.15, 11.77)***	6.98 (2.44, 11.53)**	5.48 (0.80, 10.16)*	5.20 (0.75, 9.64)*	8.04 (2.40, 13.68)**	7.97 (1.51, 14.43)*
Lawton IADL scale	−0.65 (−1.98, 0.69)	1.56 (0.67, 2.44)**	0.92 (−0.05, 1.89)	1.80 (0.66, 2.93)**	2.46 (1.29, 3.63)***	3.54 (2.27, 4.80)***	2.86 (1.39, 4.32)***

Notes: T1, 1-week posttest; T2, 3-month posttest; T3, 6-month posttest. Only the model estimates of regression coefficients of the dummy variables for the group (Group: 0= control [reference]; 1= intervention), time points (T1, T2, and T3 with the baseline [T0] as reference), and time points and group interaction terms (Group × T1, Group × T2, and Group × T3) are shown for the GEE models.

a The binary outcomes were entered into GEE models with the use of binary logistic link function, and the regression coefficients are presented as odds ratio.

* P<0.05;

** P<0.01;

*** P<0.001.

Abbreviations: BI, Barthel index; BP, blood pressure; CI, confidence interval; GEE, generalized estimating equation; IADL, instrumental activities of daily living.