effectiveness of home-based rehabilitation nursing program on

Loading...

EFFECTIVENESS OF HOME-BASED REHABILITATION NURSING PROGRAM ON FUNCTIONAL STATUS HEALTH PERCEPTIONS AND HEALTH-RELATED QUALITY OF LIFE AMONG ISCHEMIC STROKE SURVIVORS

BUNTAWAN HIRUNKHRO

A DISSERTATION SUBMITTED IN PARTIAL FULLFILLMENT OF THE REQUIREMENTS FOR THE DOCTORAL DEGREE OF PHILOSOPHY IN NURSING SCIENCE FACULTY OF NURSING BURAPHA UNIVERSITY AUGUST 2016 COPYRIGHT OF BURAPHA UNIVERSITY

iii

This dissertation received a partial research grant from Burapha University, second semester 2015, and from the Praboromarajchanok Institute, Ministry of Public Health, Thailand

iv

ACKNOWLEDGEMENT I would like to express my sincere gratitude and deep appreciation to many individuals who supported and encouraged me to complete this thesis. First, I would like to sincerely thank Assistant Professor Dr.Supaporn Duangpaeng, my major advisor, for her kindness, comprehensive suggestions, and invaluable support throughout the dissertation process. Second, I am very thankful to co-advisor, Assistant Professor Dr.Chantana Chantawong and Dr.Somsak Lila for their comments and suggestions without whose supervision and help this dissertation would not have been possible. Great appreciation is also due to Associate Professor Dr.Punyarat Lapvongwatana, and the dissertation examining committee, for their valuable suggestions. I gratefully acknowledge all teachers of the doctoral programs in both theFaculty of Nursing Burapha University, and my colleagues for their valuable guidance and ideas to which have enabled me to complete my dissertation. All have dedicated their personal time as consultants to doctoral students. Special thanks are expressed to the municipal authorities of the sub-districts of Pakprag district, the team from Paholpolpayahasana Hospital, and the team of workers at all Kaopurang Tambon Health Promoting Hospitals, as well as all participants and research assistants for their support and collaboration during all phases of data collection. Very special thanks to the Director of Chakriraj College of Nursing, Dr.Sukjai Charoensuk, and my colleagues who provided support, attention, and help during my study. I also would like to thank the director, the head nurse of the outpatient department, and all staff at Paholpolpayuhasena Hospital, Kanchanaburi Province who gave me permission to conduct research there. I am deeply indebted to all stroke survivors and their families who participated in this study. Special thanks to Burapha University and Praboromrchanok Institute who provided financial support for this study. Finally, I have received so much love and support from my family. Unforgettable, special thanks to all my friends and everyone who provided me help, support, and a spirit of togetherness.

Buntawan Hirunkhro

v 53810199:

MAJOR: NURSING SCIENCE; Ph.D. (NURSING SCIENCE)

KEYWORDS: HOME-BASED/ REHABILITATION NURSING/ FUNCTIONAL STATUS/ HEALTH PERCEPTIONS/ HEALTH-RELATED QUALITY OF LIFE/ ISCHEMIC STROKE SURVIVORS BUNTAWAN HIRUNKHRO: EFFECTIVENESS OF HOME-BASED REHABILITATION NURSING PROGRAM ON FUNCTIONAL STATUS HEALTH PERCEPTIONS AND HEALTH-RELATED QUALITY OF LIFE AMONG ISCHEMIC STROKE SURVIVORS. ADVISORY COMMITTEE: SUPAPORN DUANGPAENG, D.N.S., CHANTANA CHANTAWONG, Dr.PH. 199 P. 2016.

Stroke causes deterioration of functional status and a decrease of health-related quality of life [HRQoL] among the stroke survivors. The purpose of this quasi-experimental, two group pretest-posttest research design study was to examine the effects of a home-based rehabilitation nursing program [HRNP] on functional status, health perceptions, and HRQoL of ischemic stroke survivors. This study was conducted at Paholpolpayuhasena Hospital. Stroke survivors (n = 48) who met the inclusion criteria were selected by simple random sampling then divided into two groups either the intervention or HRNP group (n = 24) and control group (n = 24). The HRNP group participated in the program for three phases: Phase 1) the comprehensive individual need assessment and planning, Phase 2) individualized home-based rehabilitation, and Phase 3) continuity of comprehensive care. The control group received routine care only. The instruments included the Barthel index [BI], the Thai general health questionnaire [Thai GHQ-12], and the SF-36. Experimental design included data analysis by descriptive statistics and repeated measure MANOVA at three points in time at weeks 4, 8, and 12. Results after 12 weeks revealed that participants had significant overall health outcomes (functional status, health perceptions, and HRQoL) between HRNP and control groups group were significantly different at the .05 level (V = .56, F(3.44) = 18.84, p < .001). There was also a significant multivariate main effect over time at the .05 level (V = .96, F(9.38) = 1.082, p < .001). Between group changes over time showed improved health outcomes for the HRNP group at the .05 level (V = .83, F(9, 38) = 20.54, p < .001) as compared to the control group receiving usual care. Results indicate the benefits and appropriateness of the HRNP intervention for ischemic stroke survivors after discharge. It is therefore recommended that the HRNP intervention be implemented in Thai adults following ischemic stroke. Further, home-based care for ischemic stroke survivors should be considered in the research and development of nursing practice guidelines for ischemic stroke survivors.

vi

CONTENTS Page ABSTRACT ...............................................................................................................

v

CONTENTS ............................................................................................................... vi LIST OF TABLES ..................................................................................................... viii LIST OF FIGURES ................................................................................................... ix CHAPTER 1

INTRODUCTION ............................................................................................

1

Statements and significance of the problems ...........................................

1

Research objective ................................................................................... 10 Research hypotheses ................................................................................ 10 Research framework ................................................................................ 10 Scope of the study .................................................................................... 13 Definition of terms ................................................................................... 13 2

LITERATURE REVIEWS ............................................................................... 15 Overview of stroke disease ...................................................................... 15 Stroke management .................................................................................. 17 Impacts of strokes ..................................................................................... 21 Health-related quality of life [HRQOL] concept ........................................ 26 Rehabilitation in and rehabilitation nursing ................................................ 38 Development of stroke care in Thailand ...................................................... 62 The home-based rehabilitation nursing program [HRNP] .......................... 68

3

RESEARCH METHODOLOGY ..................................................................... 75 Research design ....................................................................................... 75 Research setting ....................................................................................... 76 Population and sample ............................................................................. 77 Sample size .............................................................................................. 77 Research instruments ............................................................................... 79 Quality of instrument ............................................................................... 84 Protection of human subjects ................................................................... 85

vii

CONTENTS (continued) CHAPTER

Page

Experiment and data collection ................................................................ 86 Data collection ......................................................................................... 96 Data analysis ............................................................................................ 97 4

RESULTS ......................................................................................................... 98 Part 1 Characteristics of the participants .................................................. 98

Part 2 Change over time of mean score and standard deviation of the functional status, health perception and health related quality of life [HRQoL] .................................................................................................. 105 Part 3 Reported the effects of the home-based rehabilitation nursing Program on functional status, health perceptions, and HRQoL in Ischemic stroke survivors ........................................................................ 106 5

CONCLUSION AND DISCUSSION .............................................................. 115 Summary of the study .............................................................................. 115 Discussion of the research finding ........................................................... 117 Strengths and limitation of the study ....................................................... 124 Implications.............................................................................................. 126 Recommendations for future research ..................................................... 127

REFERENCES .......................................................................................................... 129 APPENDICES ........................................................................................................... 148 Appendix A ........................................................................................................ 149 Appendix B ........................................................................................................ 152 Appendix C ........................................................................................................ 161 Appendix D ........................................................................................................ 173 Appendix E ........................................................................................................ 176 Appendix F......................................................................................................... 185 Appendix G ........................................................................................................ 187 Appendix H ........................................................................................................ 189 Appendix I ......................................................................................................... 197 BIOGRAPY ............................................................................................................... 199

viii

LIST OF TABLES Tables 1

Page

The advantages and disadvantages of hospital-based, community-based, and home-based rehabilitation programs .......................................................... 44

2

The summary of impairment/ disability rates in acute (0-7 days), three week and six month .................................................................................................... 48

3

The prevalence rate and admission rate of stroke patients in the year 2010-2012 in Kanchanaburi province............................................................... 66

4 Development of HRQoL, the rehabilitation nursing concept, and EBP to the HRNP ...................................................................................................... 71 5

The summary of objectives and activities of the team in the HRNP ................ 95

6 Demographic characteristics of participants ..................................................... 99 7 Descriptive statistics related to the health condition of the participants ........... 102 8 Descriptive statistics related to the health condition of the participants ........... 104 9 Descriptive statistics of the blood pressure condition of the participants ......... 104 10 Mean score of the functional status, health perception and HRQoL ............... 105 11 Comparison measures of functional, general health perception and between groups and, within groups .................................................................. 107 12 The multivariate simple effects of functional status, health perception and HRQoL indicators of times within intervention and control groups.......... 108 13 Pairwise comparison between the mean difference of functional status in intervention and control group .......................................................................... 109 14 Pairwise comparison between the mean difference of health perception in intervention and control group .......................................................................... 111 15 Pairwise comparison between the mean difference of HRQoL in intervention and control group .............................................................................................. 113

ix

LIST OF FIGURES Figures

Page

1

Research framework of the home-based rehabilitation nursing program ......... 13

2

Wilson and Cleary model for health-related quality of life .............................. 28

3

The research design of this study...................................................................... 75

4

The intervention process .................................................................................. 89

5

Change in functional status between the HRNP and control group at baseline, week 4, week8, and week 12 ............................................................. 110

6

Change in health perception between the HRNP and control group at baseline, week 4, week 8, and week 12 ........................................................ 112

7

Change in HRQoL between the HRNP and control group at baseline, week 4, week 8, and week 12 ........................................................................... 114

CHAPTER 1 INTRODUCTION Statements and significance of the problems Stroke is a major public health concern, especially in the developed countries. It is a leading cause of illness and death throughout the world. The World Health Organization [WHO] (2015) states that 15 million people suffer from stroke worldwide each year. Of these, 5 million die and another 5 million are permanently disabled. The incidence of stroke increases every year. In the United States of America, the incidence of new or recurrent stroke is approximately 795,000 people per year. In England 900,000 people have survived a stroke and 300,000 are living with moderate to severe disability as a result (British Society of Gerodontology, 2010). In Asian countries such as India, the stroke prevalence is from 40 to 270 per 100,000 populations (Pandian, Padma, Vijaya, Sylaja, & Murthy, 2007). Thus, stroke is the leading cause of disability in many countries. Moreover, it is more prevalent among patients over 45 years old. Frequently, it is a common cause of adult-onset disability (Nation Institute of Neurological Disorders and Stroke [NINDS], 2011). In Thailand, stroke is the third leading cause of both death and disability (Bureau of Non Communicable Disease [NCD], 2010). The prevalence rate of new stroke patients in 2010 was 50.56 per 100,000 populations (Bureau of Epidemiology, 2013). In 2008, the Thai Stroke Society reported that management of stroke costs 29,571 Thai baht [THB] per person, or 2,973 million Thai baht [THB] per year (100 million USD). The estimated cost for management of stroke disease in Thailand based on around 0.5 million sufferers amounts to at least 20,632 million Thai baht [THB] per year (Thai Stroke Society, 2013). Even though the mortality rate from stroke has decreased because of advances in emergency medicine and acute stroke care, the incidence of stroke continues to increase. Stroke is still a major cause of serious longterm disability, often with devastating consequences for individuals and their families (NINDS, 2014). In addition, stroke rehabilitation health services continuing and extended beyond hospitals are important (WHO, 2012). Stroke is of concern in Thailand with a growing realization of the need for continuing care services.

2 Stroke is a major public health problem in many countries (Chuenjairuang & Sritanyarat, 2012). Lack of rehabilitation services for people with disabilities and stroke survivors are a major public health problem in Thailand when compared with developed countries. Thailand is a developing country and moving rapidly towards. Several policies, plans and systems have been developed in response to various challenges relating to population and quality of life. However, the measures that have been initiated for preventing, assisting and recovering have not been adequate for Thai people (Prachuabmob et al., 2013). Many hospitals in Thailand are faced with a shortage of health professionals and other resources needed to provide long-term care. Stroke rehabilitation services are included in some medical school hospitals, tertiary level hospitals and private hospitals. However, they are rarely available in public secondary and primary level hospitals. Besides, in-patient rehabilitation units are also rarely available. Rehabilitation services in Thailand are still not included in the national target for inclusion at each level of care (Prasat Neurological Institute, 2007). Living with stroke is often a lengthy process. About 40 % of stroke survivors are left with moderate functional impairments, 15 % to 30 % have severe disabilities, and some have no deficits at all (American Heart Association [AHA], 2012; American Stroke Association [ASA], 2012; Ebrahim & Harwood, 1999). Therefore, nearly half of stroke survivors have residual deficits. Stroke has a major impact on survivors, producing both physiological and psychological problems, and impacting healthrelated quality of life [HRQoL] (Abubakar & Isezuo, 2012). Furthermore, stroke may have societal and economic impacts (AHA, 2012; ASA, 2012; Clarke, Marshell, Black, & Colantonio, 2002; Mericer, Audet, Herbert, Rochette, & Dubois, 2001). The effects of a stroke depend primarily on the location of the obstruction and the extent of brain tissue affected (Governor & Arnold, 2011). However, the major impacts of stroke are physiological, limiting basic activities of daily living and other self-care functions (Worldwide Stroke Organization [WSO], 2010 a). Moreover, stroke survivors may encounter troublesome symptoms from comorbidities and complications after stroke. In Thailand, the most common type of stroke is ischemic stroke, accounts for 75-80 % of strokes, haemorrhagic stroke accounts for about 20-25 % of strokes (Prasat Neurological Institute, 2012). Two-thirds of sufferers survive but are left with

3 weakness on one side of the body, hemiparesis, and functional impairments (Medical News Today [MNT], 2009; Miller et al., 2010). Depression in stroke survivors has been reported at 11 % to 61 % (WSO, 2010 b). However, the impact of stroke can be considered from several perspectives which are often overlapping: from the perspective of patients, their family and caregivers, primary care, acute hospital care, purchasers of healthcare and policy makers (Wolfe, 2000). Psychological impacts which are often undetected usually occur after severe illnesses and reduce the patient’s capacity to function and their quality of life [QoL]. The HRQoL originates from WHO’s definition, “Health is a state of physical, mental, and social well-being and not merely the absence of disease or infirmity”, that offers a narrow scope to the definition of quality of life (Farquhar, 1995). HRQoL is a multidimensional concept. The dimensions of HRQoL may vary from study to study. Previous studies used Wilson and Cleary’s HRQoL model to guide their studies including those by Kring and Crane (2009), Frank, Auslander, and Weissgarten (2003), Pholtana, Duangpaeng, and Kangchai (2014). Wilson and Cleary (1995) also suggested that their conceptual model of HRQoL can be used as an outcome of medical interventions. However, many factors were examined in their direct and indirect effects on HRQoL. According to the model, Wilson and Cleary’s HRQoL non-medical factors such as age, gender, education, and income can influence HRQoL through other concepts not directly related through functional status and general health perception. Therefore, Wilson and Cleary’s HRQoL model (1995) will be used in this study as the research framework. Stroke survivors are often left with devastating physical, psychosocial, and cognitive impairments that affect the stroke survivors’ HRQoL. Moreover, there are many significant factors related to HRQoL in stroke survivors such as individual and environmental characteristics, functional status, and general health perception that have also been found to affect HRQoL (Wolfe, 2000). Functional status has been viewed in different ways. The concept of functional status has been defined in various ways both within the discipline of nursing and by other various perspectives health-care disciplines. The term functional status is frequently used interchangeably with function, functioning, functional ability, and health (Prompuk & Moongtui, 2013). According to Wilson and Cleary (1995),

4 functional status refers to a patient’s ability to perform several aspects of tasks or functions, such as physical, social, emotional, role, and cognitive functions. Wilson and Cleary have shown functional status to be associated with health perceptions. Health perception ratings differ from many of the widely used component-specific measures of health status. For example, individuals’ perceptions regarding health may result in their saying they are healthy, even though they have physical impairments. Some would consider limited functional status as an illness (Iqbal, 2014). Hence, in this study we use the model of Wilson and Cleary (1995) to guide the outcome variables and intervention design for rehabilitation. WHO recommends continuing rehabilitative care for stroke survivors as a major strategy for them to stay healthy and prevent complications; rehabilitation is a major part of stroke care (Langhorne, Bernhardt, & Kwakkel, 2011). Rehabilitation has been defined in a number of ways. Rehabilitation should be provided as a unique, comprehensive, holistic process (Mauk, 2011). Rehabilitation is a treatment which is designed to facilitate the process of recovery from injury, illness, or disease to as normal a condition as possible (Rehabilitation definition, 2013). According to the Royal College of Nursing [RCN] (2007), state rehabilitation is a person-centered, active and creative process that involves adaptation to changes in life circumstances. It is an interaction between the person, people close to them, and multi-professional teams who recognize the contribution of all concerned. Furthermore, the goal of stroke rehabilitation is to restore the client to the greatest level of independence as possible by improving physical, mental and emotional functions (National Stroke Association [NSA], 2014). The Association of Rehabilitation Nurses [ARN] (2014) states that the roles of home care rehabilitation nurses are not limited. Rehabilitation nurses act as “multisystem” co-coordinators performing comprehensive assessments, managing complex responses of individuals, families, groups and communities to actual or potential health problems stemming from altered functional ability and altered lifestyle (resulting from physical disability or chronic illness). They also synthesize complex data to formulate decisions and plans that integrate health, education, research, and consultation into their clinical practice, collaborating with nursing peers and interdisciplinary teams to provide support for patients and caregivers and to coordinate and collaborate with other professionals and disciplines (ARN, 2014). The specialty

5 roles of nursing rehabilitation affect clients’ positive outcomes, maximizing selfdetermination, restoring function, and optimizing client lifestyle choices (ARN, 2008). There are 3 main phases of rehabilitation in stroke patients including acute stroke rehabilitation, post-acute stroke rehabilitation, and the community phase of rehabilitation (Chueluecha, 2012). Moreover, rehabilitation can be separated into three major categories or settings: hospital-based and right after being discharged from hospital, community-based, and home-based (Anderson et al., 2000; WHO, 2004). First, stroke patients may receive a continuous rehabilitation program, which is from a hospital-based setting. Second, a community-based setting is conducted at the patient’s home and individually tailored (Anderson et al., 2000; Chen et al., 2010). Third, home-based rehabilitation is based on partnership and local context, linking formal and non-formal caregivers, empowering individuals, and providing a bridge between the individual, family, community, and the health care system. Therefore, ongoing support for home-based rehabilitation may take a form of appropriate care for stroke survivors, plans that are more effective, convenient, comfortable, and provide more privacy for patients, decreases distraction, and increases relevance for patients as well as being more economical (Hui-Chan, Ng, & Mak, 2005; Ng, Chu, Wu, & Cheung, 2005; Studenski et al., 2005). Previous studies of intervention done individually and/ or in a group show that rehabilitative programs can be effective in a home-based setting, including studies by Chaiyawat (2009), Hui-Chan eta. (2005), Ng et al. (2005), and Studenski et al. (2005). Review shows that the existing healthcare system for stroke management in Thailand has focused on hospital-based acute care. Most stroke survivors are admitted for emergency treatment. After the critical period, they are expected to be discharged home. Furthermore, stroke rehabilitation has focused on managing the acute stage and evaluating short-term treatment (Chalermwannapong, Panuthai, Srisupan, Panya, & Ostwald, 2010). Hence, in this study nursing rehabilitation is proposed to be strengthene to improve HRQoL among stroke survivors. Nowadays, there are many guidelines for the rehabilitation of stroke patients such as clinical guidelines for stroke rehabilitation from the AHA/ NINDS/ NSA/ National Stroke Foundation, and in the Canadian best practice recommendations for

6 stroke care. In Thailand there are the clinical nursing practice guideline for stroke by Prasat Neurological Institute (2007) and the clinical practice guideline for stroke rehabilitation by Prasat Neurological Institute (2007). However, improvement may be difficult to achieve in Thailand because the service care is not supported by law and there is a need for mutual agreement or consensus of policies and protocols (Pumcharoen, 2007). Paholpolpayuhasena hospital, a general hospital with 440 beds, both surgical and medical treatments for neurological diseases are provided. The Current Practical Guide for Stroke Management (2012) is used to care for stroke patients. The Hospital has a stroke clinic and physical therapy outpatient department. However, Paholpolpayuhasena hospital does not have specific care for stroke patients or a rehabilitation ward. Hence, stroke survivors and caregiver may lack fitting rehabilitation knowledge and skill training. Especially for continuing care for stroke survivors after discharge, the working connection in the hospital is not smooth now. There is a home visit team from the home health care department but they provide visits for general care and continuing rehabilitation service after discharge for stroke is not sufficient (Paholpolpayuhasena hospital record, 2014). Part of the role of community nurses is to service primary care units [PCU]; nurses in PCU provide routine home visits, but these are not specific for stroke patients. Therefore, their home visit and continuing care for stroke survivors may be incomplete care. Healthcare services also lack a specific service systems, that is, long-term and chronic care for stroke survivors (Kositamongkol, 2015). There is also inadequate preparation and ineffective coordination among staff from the hospital and PCU. Paholpolpayuhasena hospital has also seen a high occurrence of rehospitalization in stroke patients with 887/ 927, 892/ 932, and 1082/ 1121 persons/ hospitalizations in 2012, 2013, and 2014 respectively (Paholpolpayuhasena hospital record, 2014). Several studies have shown that many stroke survivors experience a decline in their HRQoL and require support, both psychological and physical care, so as to maintain their independence and the best possible quality of life for as long as possible (Norach, 2010). Therefore, the demand for continuing care services and facilities will also increase.

7 Several studies have been conducted involving stroke survivor populations (Chaiyawat, 2009; Hui-Chan et al., 2005; Ng et al., 2005; Studenski et al., 2005). Research also demonstrates good outcomes for interventions that attempt to improve functional status, QoL, and HRQoL (Chanruengvanich, 2005; Srisoparb, 2007; Chaiyawat, 2009). Moreover, a study in Thailand also found that home-based services provide significantly better physical and functional abilities for patients who obtained routine care (Chaiyawat, 2009; Khampolsiri, 2005). However, based on previous research studies, some results were not significant and remained unchanged in treating depression of stroke survivors (Khampolsiri, 2005; Chanruengvanich, 2005). Previous study showed that at 1 and 3 months after hospitalization, post-stroke patients are often dissatisfied with their QoL (Rachpukdee, 2007). Some previous studies showed poorer HRQoL at post-stroke of 3 to 9 months (Nicholes-Larsen, Clark, Zeringue, Greenspan, & Blanton, 2005). Post stroke depression [PSD] is common after stroke for 30-50 % of patients with slower progression in rehabilitation and poorer function outcomes. Approximately one-third of stroke survivors are not depressed in the immediate post-stroke period but become depressed after 4 months or more. PSD may become an obstacle to rehabilitation. Moreover, a study in Thailand by Nidhinadana et al. (2010) showed that the prevalence of PSD was 46.53 %. Additionally, stroke survivors who were depressed, suffered from fatigue, or were unemployed tended to have poor HRQoL (Abubakar & Isezuo, 2012). Therefore, existing programs may not be strong enough to sustain and decrease psychological impacts. Many studies used individual education and skill training programs as an intervention (Chanruengvanich, 2005, Chalermwannapong, 2008; Khampolsiri, 2005). However, rehabilitation education and training alone is not sufficient to overcome depression of stroke survivors (ARN, 2014; Khampolsiri, 2005). These studies often have weak methodologies, for example, with single group designs, non-random assignment, beginning late, short-term evaluation, and with lack of collaborative work with other health care professionals in the community concerned with the maintenance of psychological health. According to the NSA (2014) the benefits of stroke rehabilitation programs should begin as early as they can and involve the family and the stroke rehabilitation team. Several general principles suggest rehabilitation should begin as soon as possible after stroke (Langhorne et al.,

8 2011). Moreover, findings in a large case series show that functional recovery from stroke reaches a maximum level by 3-6 months after onset (Gilman, 2006). From these findings, it is obvious that an effective home-based rehabilitation nursing program for stroke survivors must consider timing of services to document a change in incidents and the benefit of results. Hence, in order to achieve the health of stroke survivors, nursing programs must be designed to address home-based rehabilitation which is needed in ongoing support after discharge especially within the first 6 months. Therefore, existing programs may not be strong enough to sustain and decrease psychological impacts. Many studies used individual education and skill training programs as an intervention (Chanruengvanich, 2005, Chalermwannapong, 2008; Khampolsiri, 2005). However, rehabilitation education and training alone is not sufficient to overcome depression of stroke survivors (ARN, 2014; Khampolsiri, 2005). These studies often have weak methodologies, for example, with single group designs, non-random assignment, beginning late, short-term evaluation, and with lack of collaborative work with other health care professionals in the community concerned with the maintenance of psychological health. According to the NSA (2014) the benefits of stroke rehabilitation programs should begin as early as they can and involve the family and the stroke rehabilitation team. Several general principles suggest rehabilitation should begin as soon as possible after stroke (Langhorne et al., 2011). Moreover, findings in a large case series show that functional recovery from stroke reaches a maximum level by 3-6 months after onset (Gilman, 2006). From these findings, it is obvious that an effective home-based rehabilitation nursing program for stroke survivors must consider timing of services to document a change in incidents and the benefit of results. Hence, in order to achieve the health of stroke survivors, nursing programs must be designed to address home-based rehabilitation which is needed in ongoing support after discharge especially within the first 6 months. Using better efforts at promoting rehabilitation involves the family, social support networks, the health care provider in the hospital/ community, and adequate preparation of caregivers may not only produce improved functional status, but also satisfy health perception, and improve HRQoL. Hence, coordinating and collaborating

9 with other professionals or disciplines, and continuing support will result in increasing rehabilitation duration, and HRQoL (Wilson & Cleary, 1995). Therefore, the model of HRQoL by Wilson and Cleary (1995) and the concept of rehabilitation nursing by the ARN (2014) was selected as the conceptual framework of this study and integrated with evidence from previous studies. This program is expected to be effective to improve and maximize stroke survivors’ functional status, health perceptions, and HRQoL. The ARN provides guidelines to adapt the role played by home-care nurses in developing an intervention for stroke survivors. Importantly, previous studies were used for establishing their suggestions designed to produce outcomes. The strategies used in those studies were education, behavior modification and physical exercise, psychological support, home visits, telephone visits, and providing some materials such as a booklet, CD, or a pamphlet in their intervention. This study uses a quasi-experimental design to achieve the study’s purpose and beneficial results. This design fills the gap of knowledge by improving quality process implement at Paholpolpayuhasena hospital and Kaopurang tumbon health promoting hospital by efforts at promoting ischemic stroke rehabilitation beyond the individual level and to the family and community level. It does so by involving family, social support networks, the health care providers of the hospital/ community in rehabilitation of stroke survivors after discharge and ongoing even to the stroke survivor’s home for 12-weeks. A team was established through collaboration with selected health professionals from Paholpolpayuhasena hospital, health care teams in the community, and family caregivers. The program was tailored to Thai adult stroke survivors and their family context. Stroke survivors may be able to perform activities of daily living independently with great satisfaction after a stroke. The program is designed to help them minimize the impact of any psychosocial impairment. Stroke survivors should have improved functional status, health perceptions, and HRQoL. This 12 week intervention is developed through knowledge which emerges in three phases. Phase 1 is a comprehensive individual needs assessment and planning, phase 2 is individualized home-based rehabilitation, and phase 3 is continuing comprehensive care. The repeated measure multivariate analysis of variance (RM-MANOVA) was used to test the within-subject variables, with analysis at several points in time to give a clear indication of the effect. The continuing rehabilitative services using a

10 collaborative team strategy after post-hospital discharge was important environmental support to help survivors. Continuing rehabilitation was also intended to improve the functional status of stroke survivors. Improving independence in performing activities of daily living was expected to increase stroke survivors’ health perceptions, and HRQoL.

Research objective To test the effectiveness of the home-based rehabilitation nursing program [HRNP] and to compare the differences in functional status, health perceptions, and HRQoL in ischemic stroke survivors receiving the HRNP and those receiving usual care at baseline, with comparison at weeks 4, 8, and 12 after baseline.

Research hypotheses 1. Participants who receive the HRNP will have significant higher combination mean scores of functional status, health perceptions, and HRQoL than the control group who receives usual care. 2. There will be significant differences in mean scores of functional status, health perceptions, and HRQoL between the intervention and the control groups and within the intervention and the control group across the four assessment points at baseline and at 4, 8, and 12 weeks. 3. There will be significant differences in mean scores of functional status, health perceptions, and HRQoL on interaction by time and group.

Research framework The research framework of the HRNP was developed by the researcher based on the concepts of health related quality of life [HRQoL] by Wilson and Cleary (1995), integrated with the concepts of rehabilitative nursing by ARN (2014), and evidence from previous studies. According to the model of Wilson and Cleary (1995), there is a correlation between total HRQoL and individual characteristics, environmental characteristics, and the direct impact of biological, symptom status, functional status, general health

11 perception on subjective rating perception about how happy of satisfied someone is with life as a whole through other concepts not directly related through functional status and general health perception. This model of HRQoL of Wilson and Cleary (1995) was selected as the conceptual framework to design useful outcomes of this nursing intervention. Wilson and Cleary (1995) define the HRQoL as the individual’s perspective regarding the effect of disease-specific impairment on quality of life and they indicate that HRQoL should include at least physical and emotional symptoms, and social status. The ARN (2008) defines rehabilitation nursing as the diagnosis and treatment of human responses of individuals and groups to actual or potential health problems stemming from altered functional ability and altered lifestyle. The ARN provides guidelines so home care nurses can adapt their role by developing an intervention for stroke survivors. Previous studies were used to establish suggestions which produce useful outcomes. The intervention program is expected to be effective to improve and maximize stroke survivors’ functional status, health perceptions, and HRQoL. An assumption underlying the Wilson and Cleary’s model is that if patients are to be successful in adapting to physical symptoms, the patients must be able to perform functional activities and be satisfied as reflected in health perceptions. Moreover, health perceptions have been shown to be related to biological and physical factors; stroke survivors may embrace healthy behaviors that help them to improve HRQoL outcomes. Rehabilitation is a dynamic process through which a person is assisted to achieve optimal physical, emotional, psychological, social, and vocational potential and to maintain dignity, self-respect, and a quality of life that is as selffulfilling and satisfying as possible (Hickey & Todd, 2009). For this study, the researcher developed a program that improves physical, psychological, and social function and ultimately improves functional status, health perception, and HRQoL among ischemic stroke survivors. Therefore, a HRNP intervention was developed based on the model HRQoL and a strategy to guide the intervention based on ARN guidelines and suggestions of previous studies that explain relationships among variables. The HRNP intervention is based on cooperation by all stakeholders, the HRNP combines rehabilitation nursing practice in a 12-week intervention and

12 highlights the significance of the individual and environmental characteristics and its benefits by collaborative support and promoting family help, the medical nurse from the hospital, community nurses from the patient’s community encouraging caring for the stroke survivor, and enhancing psychosocial support by home and telephone visits. The design of this quasi-experimental study will be tailored for ischemic stroke survivors. The initial stage was the preparing step before the start of the program. It consisted of assembling a team, major caregiver preparation, and enlisting others who can cooperate in the work of the HRNP in the stroke survivor’s home. The purpose of preparing a team is to understand and acknowledge the HRNP, in order to develop skills of support and exercise to help the stroke survivor. The HRNP includes 3 phases as follows: Phase 1: Comprehensive individual needs assessment and planning: The objective is to identifying needs and planning by assessing learning needs, influencing characteristics of the individual and environment, the functional status, health perception, HRQoL and to make a mutual plan by the stroke survivor, caregiver, and the researcher Phase 2: An individualized home-based rehabilitation: The objective is to gain more knowledge by providing education and skill training. The education activities are to provide basic knowledge about stroke, healthy eating, risk factors of disease, and to enhance skills to affect modifiable behavioral risk factors of disease. The skill training activities are for relearning skills in physical exercise and ADL. Phase 3: Continuing comprehensive care stage: The objective of this phase is to promote psychosocial care by continuing and enhancing supportive care with home and telephone visits by the team. All techniques from the HRNP may help stroke survivors deal with negative mood so the patient’s perceptions become more positive. The results aim to improve functional status, health perceptions, and HRQoL among stroke survivors. In addition, these strategies of rehabilitation nursing will increase both individual and environmental characteristic of stroke survivors for the continuation and support of individual rehabilitation. Stroke survivors will be enabled to do ADL and have reduced psychological impacts, with the expected outcome to improve functional status, health perceptions and HRQoL among stroke survivors.

13 The research framework in this study is shown in figure 1.

Home-based rehabilitation nursing program Functional status

Phase 1: Comprehensive individual needs assessment and planning

Health perceptions

Phase 2: Individualized home-based rehabilitation Phase 3: Continuing comprehensive care

Health-related quality of life

Figure 1 Research framework of the home-based rehabilitation nursing program

Scope of the study The aim of this study is to examine the effectiveness of a HRNP on functional status, health perceptions, and HRQoL among ischemic stroke survivors. This study was conducted among adult stroke survivors of ischemic stroke from Paholpolpayuhasena hospital that lived in Muang district, Kanchanaburi province, Thailand. The sample of this study consists of 48 ischemic stroke survivors. The sample was selected from a patient population who met inclusion criteria. The study was conducted from December 2015 to May 2016.

Definition of terms Stroke survivors refers to persons who are 30-65 years old, have been diagnosed with ischemic stroke by a neurologist or physician, are being treated at Paholpolpayuhasena hospital, and have a slight to moderate disability level. Home-based rehabilitation nursing program [HRNP] refers to a set of nursing rehabilitative activities developed by the researcher and based on the model of the HRQoL, rehabilitation nursing strategies, and recommendations from previous studies. The program comprises three phases: Phase 1, comprehensive individual needs assessment and planning. The objective is to identify needs and make rehabilitative plans; Phase 2, an individualized home-based rehabilitation. The objective is to gain more knowledge by providing education and skill training;

14 and Phase 3, the continuing comprehensive care stage. The objective of this phase is to promote psychosocial care. Home-based rehabilitation nursing program team refers to a group of select health care providers from Paholpolpayuhasena hospital including 1 physician, 2 nurses, 1 physical therapist, 1 pharmacologist, 1 nutritionist, and select health professiionals from Kaopurang tumbon health promoting hospital, including 3 nurses, and family caregivers of stroke survivors. Functional status refers to the level of stroke survivors’ ability to perform physical functions in activities of daily living, such as eating, grooming, dressing, toileting, mobility, and other activities. The Barthel index [BI] was used to measure functional status. Health perceptions refer to level of stroke survivor in aspects of stroke disease as a multidimensional domain that was measured by the Thai general health questionnaire [Thai GHQ-12]. Health-related quality of life refers to individual’s perspectives of stroke survival regarding the effect of disease-specific impairment on quality of life including physical functioning, role limitations due to physical problems, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems and mental health. This variable was measure by the SF-36 Thai version [SF-36]. Usual care refers to regular activities for stroke survivors who are given care by health professionals that work at Paholpolpayuhasena and Kaopurang tumbon health promoting hospitals. The activities consist of assessment of health problems, and individual education, 1-2 rehabilitation sessions, follow up, and other services. This was based upon Paholpolpayuhasena’s guidelines for treatment and care for stroke patients.

15

CHAPTER 2 LITERATURE REVIEWS To study the effectiveness of the home-based rehabilitation nursing program on functional status, health perceptions, and HRQoL among ischemic stroke survivors. In this chapter, the literature reviewed organized around conceptual framework used in this study as the follows. 1. Overview of stroke disease 2. Stroke management 3. Impacts of strokes 4. Health-related quality of life [HRQoL] concept 5. Rehabilitation and rehabilitation nursing 6. Development of stroke care in Thailand 7. The home-based rehabilitation nursing program [HRNP]

Overview of stroke disease Stroke type and incidence of stroke Stroke or cerebrovascular accident [CVA] is defined by the WHO as “rapidly developed clinical signs of focal or global disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin. This includes subarachnoid hemorrhage but excludes transient ischemic attack [TIA], subdural hematoma, and hemorrhage or infarction caused by infection or tumor (WHO, 2015).” Types of stroke Strokes can be classified into two main categories: ischemic stroke and hemorrhagic strokes (ASA, 2012). 1. Ischemic stroke is also known as occlusion stroke. In ischemic stroke, the occlusion may affect large vessels (thrombosis or embolism), or small vessels (lacunar stroke). The most common cause of thrombolic stroke is atherosclerosis in the arteries of the brain. Most embolic strokes come from cardiac emboli. The primary causes of emboli from the heart are atrial fibrillation, damaged, infected, or prosthetic valves and

16 damage to dyskinetic myocardial segments (Kalra & Crome, 1993; MNT, 2009). About 5 % of ischemic strokes result from nonatherosclerotic vasculopathies, hypercoagulable states, hematologic disorders, arteritis, migraine/ vasospasm, and cocaine use (Hickey & Todd, 2009). 2. Hemorrhagic stroke occurs when a blood vessel that supplies the brain ruptures and bleeds. When an artery bleeds into the brain, brain cells and tissues do not receive oxygen and nutrients. In addition, pressure builds up in surrounding tissues and irritation and swelling occur. About 13 percent of strokes are caused by hemorrhage (10 % are intracerebral hemorrhage and 3 percent are subarachnoid hemorrhage strokes). Hemorrhagic strokes are divided into two main categories: intracerebral hemorrhage, bleeding from the blood vessels within the brain, and subarachnoid hemorrhage, bleeding is in the subarachnoid space (ASA, 2012). Those who survive intracranial hemorrhage often experience rapid neurological recovery during the first two or three months after the hemorrhage (MNT, 2009; Roth & Harvey, 1996). The consequences of stroke are classified by the WHO (1980), and define a relationship between impairments, disabilities, and handicaps in stroke patients. The WHO published an international classification of impairments, disabilities, and handicaps [ICIDH] in 1980. Impairments are signs and symptoms of the underlying pathology of stroke, disabilities include limitations in functional activities, and handicaps refer to a disadvantage for a given individual that limits or prevents him or her from fulfilling a role that is normal for that individual (Duncan et al., 2005; Duncan, Wallace, Studenski, Lai, & Johnson, 2001). In Thailand, hemorrhagic stroke was found about 20 % of the time. Hemorrhagic stroke is associated with a greater than average initial stroke severity, higher mortality, and poorer long term neurologic outcomes than ischemic stroke. The most common type of stroke is an ischemic stroke, found in about 75-80 % of all strokes (Prasat Neurological Institute, 2012). The incidence of stroke increases every year. Stroke is a disease that causes major health problems in many countries. It is a leading cause of disease and death throughout the world. Stroke is the leading cause of disability in many countries. According to the WHO (2012) about 15 million people suffer a stroke worldwide each year. Of these, 5 million die and another 5 million are permanently disabled. In

17 England 900,000 people have survived a stroke and 300,000 are living with moderate to severe disability as a result (British Society of Gerodontology, 2010). In Asian countries such as India, stroke is prevalent in 40 to 270 people per 100,000 (Pandian et al., 2007). In Thailand, the prevalence rate of new stroke patients in the year 2010 was 50.56 per 100,000 people (Bureau of Epidemiology, 2013). Stroke can be found in all ages and in both sexes. However, it is more prevalent among patients over 45 years of age. Frequently, it is a cause of disability in adults (Chemerinski, Robinson, & Kosier, 2001; NINDS, 2011).

Stroke management Stroke can be separate to emergency treatment phase and the secondary phase/ long term phase. Getting treated right away can save lives and reduce problems after a stroke. In the last few years, important new advances have been made in stroke treatment. However, these new treatments must be started within a few hours of the onset of symptoms in order to be effective. The medical management of stroke differs depending on the type of stroke and also treatment (The New York Times, 2013). Moreover, stroke can be separate to emergency treatment phase and the secondary phase/ long term phase is prevention of future strokes. The emergency treatments phase can be separate to three main treatments for stroke including recombinate tissue plasminogen activator [rt-PA], surgery, and nonsurgical procedures (Jedsadayanmata, 2013; The New York Times, 2013). 1.Rrecombinate tissue plasminogen activator [rt-PA] Thrombolytic drugs such as rt-PA are often called clot busters. The rt-PA is a drug that can stop a stroke caused by a blood clot by breaking up the clot. The rt-PA is short for tissue plasminogen activator and can only be given to patients who are having a stroke caused by a blood clot (ischemic stroke). It must be given within three hours of the onset of symptoms. Also, health Canada has approved rt-PA to be used within three hours from the time symptoms begin (Heart and Stroke Foundation, 2009). However, emerging science is now showing that rt-PA could be effective up to 4 ½ hours afterward. As a result, the Canadian stroke strategy has issued new Canadian best practices recommendations for stroke care, which have included this new treatment time. However, it will be up to the attending emergency doctors to

18 determine when rt-PA may be administered or if it is appropriate to the situation. In some cases, rt-PA cannot be used and other drugs are required (The New York Times, 2013). 2. Surgery In some cases, surgery may be required to repair damage after a stroke or to prevent a stroke from occurring. Surgery may be performed to remove blood that has pooled in the brain after a hemorrhagic stroke, to repair broken blood vessels, or to remove plaque from inside the carotid artery. For strokes caused by a bleed within the brain (hemorrhagic stroke), or by an abnormal tangle of blood vessels, surgical treatment may be done to stop the bleeding. If the bleed caused by a ruptured aneurysm (swelling of the vessel that breaks), a metal clip may be placed surgically at the base of the aneurysm to secure it or bypass/ revascularization (Heart and Stroke Foundation, 2009) 3. Non-surgical procedures Some people may benefit from treatments that are performed through a thin, flexible tube called a catheter into the blood vessels or the brain. Many of these procedures are new and experimental and not all hospitals may be able to do them. Catheter-based procedures are being developed to remove plaque buildup from arteries and to treat aneurysms (weak spots in the wall of a blood vessel that can bulge outward and rupture) (The New York Times, 2013). For secondary/ long-term phase is prevention of future strokes. Prevention future strokes can reduces risk factor that cause of recurrent stroke. The treatable vascular risk factors and medication for prevent stroke are important to control disease that cause of stroke e.g. hypertension, diabetes, lipids, and medical manage Treatable vascular risk factors 1. Hypertension According to guideline source of AHA/ ASA state meta-analyses of randomized controlled trials have shown that lowering blood pressure can reduce the risk of stroke by 30 to 40 percent. Detection, evaluation, and treatment of high blood pressure recommend lifestyle modifications to manage hypertension. Lifestyle changes associated with a reduction in blood pressure include losing weight; restricting salt intake; consuming a diet high in fruits, vegetables, and low-fat dairy

19 products; participating in regular aerobic exercise; and limiting alcohol intake (American Family Physician, 2011). 2. Diabetes The prevalence of diabetes mellitus in patients with ischemic stroke is 15 to 33 %. It is estimated that diabetes causes approximately 9 % of recurrent strokes. Diet, exercise, oral hypoglycemic drugs, and insulin are recommended in patients with diabetes to control glycemic levels. Existing guidelines recommend glycemic control and blood pressure management in patients with diabetes who have had a stroke or TIA (American Family Physician, 2011). 3. Lipids Large epidemiologic studies have demonstrated a modest association between elevated total cholesterol or low-density lipoprotein levels and an increased risk of ischemic stroke. Other studies have found a link between high serum triglyceride levels and ischemic stroke and large-artery atherosclerotic stroke. Low levels of high-density lipoproteins have also been linked to ischemic stroke. Statin therapy is recommended in patients with ischemic stroke or TIA, even without known coronary heart disease, to reduce the risk of stroke and cardiovascular events. Lifestyle modifications include decreasing saturated fat and cholesterol intake, achieving ideal body weight, and increasing physical activity can manage dyslipidemia (American Family Physician, 2011). Medication for prevent stroke Nowadays, there are many guidelines for the prevention of stroke in patients with ischemic stroke. The treatable vascular risk factors that cause stroke e.g. hypertension, diabetes, lipids and medication for prevention of stroke such as aspirin, ticlopidine, clopidogrel (plavix), and a combination of aspirin and dipyridamole (aggrenox), and anticoagulants (American Family Physician, 2011; Sacco, 2006). In the treatment of stroke survivors are widely used as follows: 1. Antiplatelet agents Four antiplatelet medications have been approved by the U.S. Food and drug administration for preventing vascular events in patients with a stroke including: aspirin, ticlopidine, clopidogrel (plavix), and combination aspirin/ dipyridamole (aggrenox). On average, these agents have been shown to reduce the relative risk of

20 stroke, MI, or death by more than 20 %. Aspirin (acetylsalicylic acid [ASA]) aspirin therapy prevents stroke in patients who have had a recent stroke or TIA. Although the level of benefit is comparable for dosages between 50 and 1,500 mg orally per day, higher dosages are associated with an increased risk of gastrointestinal hemorrhage. The increased risk of hemorrhagic stroke in patients taking aspirin is smaller than the risk of ischemic stroke, which results in a net benefit of aspirin therapy (Antman, Selwyn, Braunwald, & Loscalzo, 2008; Sipmue, 2009). Ticlopidine: adverse effects associated with ticlopidine use include diarrhea and rash. Ticlopidine is also associated with thrombotic thrombocytopenic purpura. Rates of gastrointestinal bleeding are similar or lower in patients taking ticlopidine than in patients taking aspirin (Antman et al., 2008; Sipmue, 2009). Clopidogrel or Plavix: adverse effects of clopidogrel include diarrhea and rash, although gastrointestinal symptoms and hemorrhage are less common than in persons taking aspirin. Proton pump inhibitors have been shown to reduce the effectiveness of clopidogrel, and may also increase the risk of major cardiovascular events when taken with clopidogrel (Antman et al., 2008; Sipmue, 2009). Aspirin/ dipyridamole: according to the AHA/ ASA guidelines on prevention of recurrent stroke shown four large randomized trials have examined the effects of combination aspirin/ dipyridamole in patients with TIA or stroke. Results showed that combination therapy is at least as effective as aspirin alone for prevention of stroke; however, it is not tolerated as well by patients (American Family Physician, 2011). The way to selecting the oral antiplatelet therapy. Selecting between aspirin, ticlopidine, clopidogrel, and combination aspirin/ dipyridamole should be based on relative effectiveness, safety, cost, patient characteristics, and patient preference. Evidence shows that each therapy is effective for the prevention of secondary stroke. In persons who experience a stroke while on antiplatelet therapy. Three additional antiplatelet agents are being investigated for effectiveness in secondary stroke prevention: triflusal, cilostazol (pletal), and sarpogrelate.

21 2. Oral anticoagulants Oral anticoagulants have been evaluated for the prevention of recurrent stroke in patients with noncardioembolic stroke. According to the AHA/ ASA guidelines on prevention of recurrent stroke shown one trial was stopped and reformatted because of increased bleeding in patients taking highintensity oral anticoagulants. After reformulating the study to compare warfarin (coumadin) with aspirin alone or with aspirin plus extended-release dipyridamole, the trial was halted again because of the superiority in patients taking combination aspirin/ dipyridamole. Compared with patients taking aspirin alone, patients taking warfarin experienced a significantly higher rate of major bleeding, but a nonstatistically significant decrease in the rate ischemic events (American Family Physician, 2011). However, the medical management of stroke is often a dynamic process (Hickey & Todd, 2009). While treatment regimens have been established, practitioners and patients are constantly searching for new techniques to improve patient outcomes. Medication adherence is a prevalent issue surrounding recurrent stroke prevention (Evidence-Based Review of Stroke Rehabilitation [EBRSR], 2013; NSA, 2014).

Impacts of strokes The brain is an extremely complex organ that controls various body functions. Stroke patients also exhibit behavioral changes as a result of the brain dysfunction. If a stroke occurs and blood flow cannot reach the region that controls a particular body function that part of the body won’t work as it should. If the stroke occurs towards the back of the brain, for instance, it is likely that some disability involving vision will result. The effects of a stroke depend primarily on the location of the obstruction and the extent of brain tissue affected (Governor & Arnold, 2011). The impact of stroke can be divided to the impact of stroke disease on individual, the impact of stroke on caregivers/ family, and societal. Impacts of the stroke on individuals Impacts of the stroke on individuals depend on severity and the mechanism of the stroke, psychosocial consequences, age and family role, personal and family patterns of coping, and financial resources (Farzan, 1991). The impact of stroke

22 disease on individual included physical impact, psychological impact, social impact, and economic impact as follows: Physical impact Many survivors continue to live with their residual impairments and disabilities, which can pose a significant problem for the survivor’s well-being (Clarke et al., 2002). The specific symptoms depend on the location and amount of the brain involved, as well as the site of the occlusion. Physiological problems associated with the stroke including motor deficits such as hemiplegia (weakness or clumsiness on one side of the body), dysphagia (difficulty in swallowing) (British Society of Gerodontology, 2010; Perkdetch, 2002). Sensory deficits such as aphasia (language deficits as a result of brain damage) (Sandin & Mason, 1996). Visual deficits (defects in the visual fields, diplopia, decreased acuity), and cognitive deficits that includes the loss of the ability to concentrate, think, comprehend, formulate ideas, reason, remember, and judge or evaluate actions. Difficulties in cognitive function are problematic for the one who has had a stroke. Even mild or moderate difficulties with cognitive function limit a survivor’s ability to plan and develop goals in life, constraining their sense of purpose and meaning (Clarke et al., 2002). Moreover, Clarke et al. (2002) found that seniors living with stroke in the community experience more restrictions in ADL than seniors living without the effects of stroke. They are more than twice as likely to experience difficulty with bathing and meal preparation, and are also three times more likely to require assistance with walking and getting around outside the home than seniors who have not had a stroke. Moreover, excretion dysfunction is the most commonly found condition of incontinence. Acute stroke phase and type can cause brain stem dysfunction and resultant incontinence (Perkdetch, 2002). Bowel and bladder dysfunction after stroke is common because of physical inactivity, inadequate fluid and/ or dietary fiber, psychological disturbances, impact of neurological lesions on central defecation centers, side effects of medication or dietary supplements, bowel infection, or impaction of the intestine by prolonged constipation (Sandin & Mason, 1996). Psychological impact A stroke can lead to emotional problems. Stroke patients may have difficulty controlling their emotions or may express inappropriate emotions (NINDS, 2014).

23 Psychological impact in stroke survivors depends on the uniqueness of each individual who has had different life experiences, perceptions of stroke, coping mechanisms, and available financial resources. The two most common psychological conditions found in people after a stroke are depression and anxiety. 1. Depression Many stroke patients experience depression. The prevalence of depression after stroke has been estimated to range from 11 % to 68 % (Kelly-Hayes et al., 1998). Also, Nidhinadana et al., (2010) studied the prevalence of post-stroke depression in Thai stroke survivors. They found the prevalence of post-stroke depression was 46.53 %. Moreover, many stroke patients experience intense bouts of crying and feelings of hopelessness and a withdrawal from social activities. Post-stroke depression is one of the most common consequences of stroke. Stroke survivors are at a greater risk for depression. Depression can result either from the direct biological effects on brain infarction, such as those associated with the left anterior cortex and basal ganglia lesions, or the reaction to the significant losses associated with the stroke (Kelly-Hayes et al., 1998; NSA, 2011). Depression is an illness characterized by intense feelings of persistent sadness, helplessness and hopelessness. It is often accompanied by physical effects such as a loss of energy or physical aches. A stroke causes physical damage to the brain. When brain cells are damaged, the parts of the body and mental functions controlled by these cells may not work properly. This physical damage can cause a number of psychological effects such as emotionalism (having difficulty controlling emotions) and personality changes, as well as depression. Having a stroke can be a frightening experience. Stroke happens very suddenly and it can take some time to come to terms with the shock of what has happened. Many people feel frightened, anxious, frustrated or angry about what has happened to them, the impact of the disabilities they may be left with and the changes this may bring other life. These feelings can develop into depression (Stroke Association, 2012). Depressive symptoms showed a slower progression in achieving independence in basic activities of daily living [ADL] and Instrumental activities of daily living [IADL] when compared with patients without depressive symptoms (Lai, Studenski, Duncan, & Perera, 2002).

24 There are a number of symptoms of depression, the most common of which being: loss of self-esteem or self-confidence, feeling sad, blue or down in the dumps, losing interest in everyday activities and not being able to enjoy things (apathy), feeling worthless, guilty, helpless, hopeless or in despair, finding it difficult to concentrate or make decisions, feeling anxious or worrying a lot, changes in sleep pattern-being unable to sleep or sleeping too much, changes in your appetite-eating too much or too little, loss of energy, suicidal feelings, physical aches and pains, selfharming, loss of sex drive or sexual difficulties, avoiding people. As a general rule if patients have four or more of these symptoms on most days over a period of about two weeks, then they may have depression. Pharmacotherapy is usually effective in the treatment of depression. The treatments for depression are anti-depressant medication and counseling (Hickey & Todd, 2009; Stroke Association, 2012). 2. Anxiety After stroke, patients may experience general feelings of fear and anxiety, often punctuated by intense, uncontrolled feelings of anxiety (anxiety attack). Moreover, feelings of anger, anxiety, depression, frustration and bewilderment are all common, although they may fade over time (Stroke Association, 2012). Impacts of stroke on caregivers/ family A stroke not only impacts the survivors but also the family. Stroke occurs suddenly, and both the patients and their family do not have time to prepare themselves for the unavoidable changes that occur. Therefore, the disease affects every member of the family. The physical health of caregivers can be compromised by the stresses of caregiving. An injury to the caregiver may be caused by fatigue and lack of sleep, or sleeplessness may occur due to the demands placed on the caregiver. Also, many caregivers experience physical health problems, such as back pain, abdominal pain, wrist pain, muscle pain, headache, high blood pressure, and gastritis (Thipsamning, 2000). Some caregivers have been found to experience worry and uncertainty when the patient has returned home from the hospital. In addition, caregivers were engulfed by grief, feared losing the patients, and felt powerless to change the situation and guilty that they could not have prevented the patient’s stroke (Thipsamning, 2000). A study of Wilkinson et al. (1997) showed that about 50 percent of the caregivers had scores on the general health questionnaire indicating they were

25 stressed. However, caregivers who care for a stroke patient more independent in the activities of daily life tend to have better psychosocial health status. Impacts of stroke on societal The socio-economic impact of stroke is considerable world-wide (Wolfe, 2000). Physical and psychological changes due to stroke make the patients unable to take part in social activities leading to social problems (Perkdetch, 2002). Social impacts of stroke, especially decreased socialization, commonly occur after stroke. Patients often experience some social changes such as social isolation, a decrease in community involvement, economic strain, disruption of family life, loss of role (at home and/ or work), dependency and a decrease in satisfaction with life in general (Sandin & Mason, 1996). A decline in social activity participation has been found in many studies. Gresham et al. (1975 cited in Feibel & Springer, 1982) studied 119 stroke survivors and found that 62 % reported a decrease in social activity. A study that compared prior social activities and post stroke social activities between depressed and non-depressed stroke survivors found that 67 % of the depressed group showed a decrease in social activities, whereas there was only a 43 % decrease in the non-depressed group (Feibel & Springer, 1982). Stroke is one of the most frequently occurring, disabling and costly diseases. The socio-economic impact is considerable world-wide (Wolfe, 2000). Stroke also ranks in the top 20 causes of disability burden in Thailand. The prevalence of stroke has an increasing rate of survival. Stroke is expensive because many people end up in the hospital for a long period of time. Americans pay about 73.7 USD billion in 2011 for stroke-related medical costs and disabilities. In Thailand, the Thai stroke society reported that management of stroke costs 29,571 Thai baht [THB] per person, or 2,973 million Thai baht [THB] per year (100 million USD). The estimated cost for management of stroke disease in Thailand based on around 0.5 million sufferers amounts to at least 20,632 million Thai baht [THB] per year (Thai Stroke Society, 2013). Stroke has both direct and indirect costs. The direct costs of a stroke include hospitalization, in-patient rehabilitation, and outof-hospital care, such as home-rehabilitation. The indirect costs come from lost economic production (AHA, 2012; ASA, 2012; Ebrahim & Harwood, 1999).

26 The physical, psychological, and societal impacts usually occur after severe illnesses and reduce the patient’s capacity to function and his/ her quality of life [QoL]. Stroke has a major impact on a survivor’s including quality of life and HRQoL.

Health-related quality of life [HRQoL] concept Quality of life is a broad concept, many terms are used synonymously with QoL in the literature, such as well-being, happiness, condition of living and life satisfaction. QoL encompasses varying dimensions across the spectrum of living (Rapley, 2003). However, the concept of HRQoL can be clearly shown to affect health (either physical or mental). Quality of life is a broad multidimensional that usually uses subjective evaluations of both positive and negative aspects of life. Many terms are used synonymously with QoL in the literature, such as well-being, happiness, condition of living and life satisfaction (Rapley, 2003). To define the meaning of the HRQoL concept as the term ‘quality of life’ has been used to mean a variety of different things in the past. To help solve this problem, the term ‘healthrelated quality of life’ is intended to narrow the focus to the effects of health, illness, and treatment on quality of life. To date, many models have been focused on the identification of domains. However, the concept of HRQoL and its determinants have evolved since the 1980s to encompass those aspects of overall quality of life that can be clearly shown to affect health (either physical or mental). HRQoL originates from the WHO’s definition of health that “health is state of physical, mental, social wellbeing and not merely the absence of disease or infirmity” that offers a more narrow scope than the definitions of quality of life (Farquhar, 1995). The dimensions of HRQoL may vary from study to study. Many researchers state that health-related QoL is more specific to the people who are ill. When using the concept in health care, health-related quality of life is the extent to which one’s usual or expected physical, emotional, and social well-being are affected by a medical condition or its treatment (DeHaan, Limberg, Vander, & Anderson, 1995). Wilson and Cleary (1995) define the HRQoL as individual’s perspective regarding the effect of disease-specific impairment on quality of life and they illustrated that HRQoL should include at least include physical and emotional symptoms, and social status.

27 The Wilson and Cleary’s model (1995) was developed in order to help explain the relationships of the elements of HRQoL and their determinants. The model proposes causal linkages between five different types of patient outcome measurements. The arrows represent dominant causal relationships in a chain of five elements. First, biological and physiological variables are described as focusing on function which would be assessed through such indicators as laboratory tests, physical assessment, and medical diagnoses. Second, symptom status dimension refers to disease-related symptoms, physical, emotional, and cognitive symptoms perceived by a patient. Third, the functional status comprises self-care, mobility, and the capacity to perform various familiar and role function. Fourth, general health perceptions refer to a subjective rating that includes all of health concepts that precede it. Fifth, overall quality of life is described as subjective well-being, which means how happy or satisfied someone is with life as a whole. Moreover, Wilson and Cleary (1995) state it is influenced by characteristics of the individual and environment. Characteristics of the individual are categorized as demographic, developmental, psychological, and biological factors that influence health outcomes. Characteristics of the environment are categorized as either social or physical and have a conglomerate of external conditions that influence the life of a human being. Social environment characteristics are the interpersonal or social influences on health outcomes, including the influence of family, friends, and health care providers. Physical environment characteristics are those settings such as the home, neighborhood, and workplace that influence health outcomes either positively or negatively (Wilson & Cleary, 1995). Previous studies used Wilson and Cleary (1995) model guided their studies such as Kring and Crane (2009) studied factors affecting QoL in persons on hemodialysis. The framework provides guidance in selecting variables that may impact overall QoL, including health factors, characteristic of the individual and environment. Additionally, Frank et al. (2003) studies factors related to HRQoL among people with ESRD found that the strongest predictor of QoL was patient’s symptom. Moreover, Pholtana et al. (2014) studied the causal model of functional status among end stage renal disease patients undergoing hemodialysis. They found social support had a diminishing effect on the symptoms and a positive effect on

28 functional status. Therefore, Wilson and Cleary’s HRQOL will be used in this study because it show that the model can be effectively used in chronic illness such as stroke survivors. The model of Wilson and Cleary (1995) was selected as the conceptual framework of this study (see figure 2).

Figure 2 Wilson and Cleary model for health-related quality of life (Wilson & Cleary, 1995)

Measurement of HRQoL The gold standard of HRQoL measurement is for patients to self-report their HRQoL. The purpose of HRQoL measurement is to quantify the degree to which the medical condition or its treatment impacts the individual’s life in a valid and reproducible way. HRQoL is an important indicator along with traditional measures to capture the burden of disease or illness. These measurements can be used to measure changes in HRQoL over time (for example in clinical trials, observational studies, healthcare delivery settings, or for population surveillance), to compare the HRQoL of patients with different conditions or those who receive different treatments within clinical trials or comparative effectiveness research (International Society for Quality of Life Research [ISOQOL], 2013). Moreover, measuring HRQoL can help determine the burden of preventable disease, injuries, and disabilities, and it can provide

29 valuable new insights into the relationships between HRQoL and risk factors. Measuring HRQoL will help monitor progress in achieving the nation’s health objectives. Analysis of HRQoL surveillance data can identify subgroups with relatively poor perceived health and help to guide interventions to improve their situations and avert more serious consequences. Although, QoL and HRQoL is a broad construct which varies from study to study, the measurement of QoL and HRQoL in patients usually follows one or two approaches: general and disease specific instruments (Coelho, Ylvisaker, & Turkstra, 2005). 1. Generic instruments to measure quality of life Some well-known generic instruments are the sickness impact profile [SIP] by Bergner, Bobbit, Carter, and Gilson (1981) the Rand SF-36 health status profile by Ware and Sherbourne (1992) and the any measurement such as WHOQOL-BREF, quality of well-being scale, stroke impact scale [SIS] health utility index, and EuroQoL. All of these instruments attempt to provide a summary of quality of life and they can be standardized and applied widely to those with different types of illness to enable comparisons. The most commonly used generic instrument is the SF-36. The SF-36, the best-known general health questionnaire, grew out of work at the rand corporation in the late 1970’s and 1980’s. It searched for a means to determine a patient’s outcomes from disease and treatment, as well as a means to monitor a specific disease. The SF-36 gives a general assessment of an individual’s health status. The SF-36 could be used to measure changes in health status over time (Ware, Snow, Kosinski, & Gandek, 1993). This instrument is used wildly to evaluate HRQoL across various populations. The SF-36 has been found useful in surveys of general and specific populations, comparing the relative burden of disease. It has been translated in more than 50 countries. The Thai SF-36 was found to be reliable and valid for use in a general nonclinical population. In order to assess health related quality of life, this study uses the Thai short form -36 [SF-36] including multi-items scales to measure the following eight dimensions: Physical functioning (10 items in question 3), role limitations due to physical health problems (4 items in question 4), bodily pain (question 7 and 8), social functioning (questioning 6 and 10), general mental health , covering psychological

30 distress and well-being (5 items question), role limitations due to emotion problems, vitality, energy or fatigue (4 items: question ), general health perceptions (5 items: question 1, 2 and 11a-11d ). The SF-36 scoring criteria includes: Excellent, very good, good, fair, poor; Limited a lot, limited a little, not limited at all; yes/ no; not at all, slightly, moderately, quite a bit, extremely; none, very mild, mild, moderate, severe, very severe; All of time, most of the time, a good bit of the time, some of the time, a little of the time, none of the time; and others. The response for each item was recorded with a valve from 0-100. 2. Disease specific instruments for measuring HRQoL In order to monitor changes in disease outcomes over time, there is value in using disease specific measures, as these are more sensitive to the specific HRQoL issues of concern in the subpopulation with the disease of interest. Some of these include the St George’s respiratory questionnaire [SGRQ], the McMaster asthma quality of life questionnaire [AQLQ-McMaster], and the Sydney asthma quality of life questionnaire [AQLQ-Sydney] (Guyatt, Feeny, & Patrick, 1993). Because stroke survivors are living with chronic health problems, HRQoL is influenced from their illness. However, there are not any disease specific instruments for stroke patients, hence general instruments should be used for evaluating their individual’s health status and changes in health status over time. Thus, the Thai SF-36 will be used in this study. Health-related quality of life in stroke survivors HRQoL in stroke survivors decreased due to multiple physical and psychological symptoms, functional status decline, readmission, and a high mortality. In addition, stroke patients suffer through experiences from their disease and changing patterns in their life style. Previous studies on interventions for enhancing QoL have mostly been conducted with patients suffering from other chronic diseases, such as heart disease, cancer, and spinal cord injury rather than stroke. Stroke has a major impact on a survivor’s including quality of life and HRQoL. Quality of life related to stroke and life satisfaction after stroke is an important health care issue that has not received sufficient attention in Thailand. HRQoL measurements are potentially more relevant to patients than measurements of impairments or disability and are an important index

31 of outcome after stroke that can facilitate a broader description of disease and outcome (Abubakar & Isezuo, 2012). In stroke survivors, several factors that appear to contribute to a change of QoL have been reported. Factors associated with HRQoL in stroke survivors HRQoL is an important aspect of life after suffering a stroke. Previous research has revealed several variables associated with post stroke quality of life. The researcher reviewed literature that includes admission stage (both acute and subacute), intermediate stage or recovery stage, and rehabilitation stage, and explored the factors that could have a positive or negative effect on health-related quality of life among stroke survivors. In stroke survivors, several factors that appear to contribute to a change of QoL have been reported. The HRQoL is determined by certain factors such as age, gender, education, psychological factors, disease severity indices, social support and facility type. Age Client age at the time of admission was also a significant predictor of HRQoL and being discharged home following stroke rehabilitation. Almborg, Ulander, Thulin, and Berg (2010) studied the important factors for health-related quality of life after discharge in 188 patients with stroke. They found younger age was related to higher HRQoL. Moreover, patients younger than 65 were discharged home more often than those ages 85 and older. The association between increasing age and other factors, such as the presence of comorbidities, general frailty and a lower probability of the patient having a strong community support system to enable a successful transition home (Sirikangwalkul, 2002). Likewise, Lai, Duncan, and Keighley (1995) examined the prognosis for survival after an initial stroke in 662 patients who remained alive at least 30 days. They found older age and number of neurological deficits at the onset of initial stroke increased risk of death when compared with patients of the same age, stroke severity and comorbidities. Gender Gender or sex was also found to influence of HRQoL and discharge destination, although to a lesser degree than other factors. Male clients admitted for

32 stroke rehabilitation were discharged home faster than female clients. One study found QoL of females was lower than that of males (Hackett, Duncan, Anderson, Broad, & Bonita, 2000). A study found sex differences in stroke recovery and strokespecific quality of life in 373 acute stroke survivors. It found females were less likely to achieve activities of daily living independence. Female stroke survivors had lower functional recovery and poorer quality of life 3 months post-discharge (Gargano & Reeves, 2007). Education Almborg et al. (2010) studied the important factors for health-related quality of life after discharge in 188 patients with stroke. They found education (elementary school) was related to higher HRQoL. However, Kim, Warren, Madill, and Hadley (1999) found education did not correlate with QoL. Psychological factors Van et al. (2013) systematically reviewed the influence of psychological factors on HRQoL after stroke using nine studies. They found personality (i.e. problems of temperament and personality functions and neuroticism) was moderately negatively associated with health-related quality of life. Coping (i.e. situational and personal adaptation), internal locus of control, self-worth (i.e. self-esteem and selfefficacy), and hope and optimism were moderately positively associated with healthrelated quality of life. Moreover, Sirikangwalkul (2002) studied the influential factor on health-related quality of life in 150 stroke patients at Prasat Nerological Institute. The researcher found depression affected a patient’s quality of life in every domain including physical functioning, role physical, bodily pain general health, social functioning, vitality, role-emotional, and mental health. The effect was statistically significance at p < .001. Also, Almborg et al. (2010) studied the important factors for HRQoL after discharge in 188 patients with stroke. They found depressive symptoms were associated with lower HRQoL. Similarly, Sriwicha, Maprapo, and Jitaree (2003) studied quality of life of hemiplegic patients who lived in the community by in-depth interviews with 9 people. They found depression was highly correlated with a decreased quality of living. Kim et al. (1999) studied the quality of life of stroke survivors 1-3 years post-discharge. They found the most important predictors of QoL were depression, marital status, quality of social support, and functional status.

33 Therefore, depression was the strongest predictor of QoL. Disease severity indices Bay (2001) reviewed 39 studied that focused on QoL of stroke survivors during the recovery process. The author found variables negatively associated with stroke survivors' quality of life were severity of motor impairment, severity of aphasia, impaired cognitive function, inappropriate reactions to illness and pessimism, and inability to return to work. The independence in activities of daily living [ADL] was positively associated with stroke survivors' QoL. Moreover, in Thailand, Sriwicha et al. (2003) found comorbid health problem as a contributing factor in decreased quality of life. Social support/ family support Likewise, Kim et al. (1999) studied the quality of life of stroke survivors 1-3 years post-discharge. They found the most important predictor of QoL was quality of social support. Also, Bay (2001) studied the QoL of stroke survivors during the recovery process. The author found a variable positively associated with stroke survivors' quality of life was social support. Hence, social support has been found to be associated with a higher QoL in stroke survivors. Moreover, family involvement became more important when the patient was cared for at home after being discharged from the hospital. Tsouna-Hadjis, Vemmos, Zakopoulos, and Stamatelopoulos (2000) examined the impact of family social support on the rehabilitation process in terms of functional status, depression and social status changes of first stroke survivors. The study involved 43 patients admitted to the hospital with a first stroke over a five year period. Patient’s rehabilitation variables were assessed in the hospital before discharge and also at 1, 3 and 6 months from stroke onset at the patients’ homes. The study concluded that the amount of family social support can significantly predict the well-being of stroke patients. Similarly, the results of Sriwicha et al. (2003) found lack of perceived social supports was a factor that decreased quality of life in hemiplegic stroke patents. Facility type In contrast to several previous studies suggesting a difference in discharge outcome based on location of stroke care, the current analysis found no significant difference between specialty and general rehabilitation facility types with respect to

34 discharge destination following stroke. In previous studies, improved outcomes were related to care being provided by specialized stroke teams and in specialized stroke units. As well, Bay (2001) found the variable positively associated with stroke survivors' quality of life was healthcare resources. In summary, in rehabilitation on stroke survivors, there are many significant factors related to HRQoL in stroke survivors. Variables associated with better HRQoL were young age, male gender, higher educational level, better social support/ family support, and facility type; variables associated with worse HRQoL were higher age, female gender, psychological factors, and lower educational level. Moreover, factors such as depression, anxiety were found to be more correlated with HRQoL. Therefore, the results from previous studies could only partially explain factors influencing HRQoL in stroke survivors. So, in this study the researcher analyzed the above factors and select some factors that direct effect to HRQoL. According to the model’ Wilson and Cleary (1995) non-medical factors such as age, gender, education, and income can influence HRQoL through other concepts not directly related through functional status and health perception. In this study, some factors are associated with better HRQoL such as matching gender to manipulate between experimental group and control group by the researcher. Thus, these non-modifiable variables are not propose in hypothesize causal model of stroke survivors but are account for in the descriptive of sample characteristics. The Wilson and Cleary’s model (1995) was developed in order to help explain the relationships of the elements of HRQoL and their determinants. The model proposes causal linkages between different types of patient outcome measurements e.g. functional status and general health perceptions. Wilson and Cleary (1995) also provided a more complete and detailed of outcomes were reviewed as follow: Functional status Functional status has been associated with a patients care and research for nursing and it is crucial concept, the concept of functional has been defined in various ways both within the discipline of nursing and by other health-care disciplines. The term functional status can be frequently used interchangeably into function,

35 functioning, functional ability, and health. American Thoracic Society (2014) state functional status is an individual's ability to perform normal daily activities required to meet basic needs, fulfill usual roles, and maintain health and well-being. NSA (2012) state functional status is activities of daily living or basic elements of personal care. Personal ADL includes basic self-maintenance tasks such as eating, bathing, grooming, dressing, toileting, chair/bed transfer, ambulation, and, etc. Prompuk and Moongtui (2013) define the functional status is the actual performance of person’s activity to respond normal basic needs and well-being in a daily living. Wilson and Cleary (1995) define the functional status as the ability to perform specific tasks that have 4 domains of function is identified: physical function, social function, role function, and psychological function. Hence, to develop functional status of stroke survivors in this study will be used Wilson and Cleary (1995) and has to consider the individual's ability including their basic need in ADL. The meaning of functional status refers to the level of stroke survivor’s ability to perform activities of daily living, such as, eating, grooming, dressing, toileting, mobility, and has to consider the individual's ability including their basic need in ADL. The core components of current interventions on helping methods for promoting functional status among stroke survivors include early assessment, early exercise training after stroke onset, and psychological support, are critical to optimize rehabilitation until the patients are returned to their community (Dao, 2006; Van et al., 2004). To date, outcome after stroke has mainly been described in term of survival, neurologic impairment or functional disability, as frequency measured by the BI. The BI is a valid measure of disability (Colin, Wade, Davies & Horne, 1988). Many previous studies used BI for evaluating stroke rehabilitation at home. The BI has also been taught to many nurses, who have been helpful in evaluating patients prior to admission to the hospitals and after discharge (Mahoney & Barthel, 1965). The BI Thai version of the Prasat Neurological Institute of Thailand gives a score ranging from 0 to 100. It can categorize to be 5 grades of very severely disabled

36 (score 0-20), severely disabled (score 25-45), moderately disabled (score 50-70), mild disabled (score 75-95) and independently (score 100). The top score implies full functional independence, but not necessarily normal status. BI comprises 10 items measuring feeding, bathing, grooming, dressing, bowel control, bladder control, toileting, chair/ bed transfer, ambulation and stair climbing. The BI score is highly correlated with independent functional ability. Additionally, the BI score can assess the change in functional outcomes in stroke survivors who undergo rehabilitation. The BI assesses 10 activities of daily life, 8 of which can be described as self-care activities, and 2 as mobility related activities (Prasat Neurological Institute, 2007). Health perception The importance of health perceptions arises from the observation that they are among the best predictors of the use of general medical and mental health services as well as strong predictors of mortality, even after controlling for clinical factors. Health perception rating differs from many of the widely used component-specific measures of health status. Statistic Canada (2014) state perceived health refers to the perception of a person's health in general, either by the person themselves or, in the case of proxy response, by the person responding. Health means not only the absence of disease or injury but also physical, mental and social well-being. Iqbal (2014) state health perception is highly individual perception. For examples indicate individuals’ perceptions regarding health and would probably say they are healthy even though they have physical impairments. Some would consider it an illness. Goldberg and Williams (1988) state health perception are each one assessing the severity of a mental problem over the past few weeks. Wilson and Cleary (1995) define health perceptions are associated with physical, mental and social health domains. Wilson and Cleary (1995) described functional status has been shown to be associated with health perceptions. Health perceptions have been shown to be related to biological and physiological factors, but because of the numerous factors affecting health perceptions, there almost inevitably will be large variations within each stratum of clinical severity (Wilson & Cleary, 1995).

37 From the above, to improve health perceptions of stroke a survivor in this study was defined the health perceptions as level of stroke survivor in aspects of stroke disease that measured by the Thai GHQ-12. By understanding clients’ perception of health and illness, nurses can provide more meaningful assistance to help them regain or attain a state of health. For implication to clinical care, the optimal design of interventions to improve patient outcome requires identification of causal pathways that link different types of outcome to each other (Wilson & Cleary, 1995). Hence, the model of HRQoL of Wilson and Cleary (1995) is useful in the formulation of strategies to improve health perceptions. The general health questionnaire [GHQ] is a self-administered screening questionnaire, designed for use in consulting settings aimed at detecting individuals with a diagnosable psychiatric disorder (Goldberg & Hillier, 1979). In its original version, it had 60 items [GHQ-60], which were reduced to 30 [GHQ-30], 28 [GHQ28]; in Spanish population, and 12 items [GHQ-12] (Goldberg & Williams, 1988). The 12-Item general health questionnaire [GHQ-12] is the most extensively used screening instrument for common mental disorders, in addition to being a more general measure of psychiatric well-being. Its brevity makes it attractive for use in busy clinical settings, as well in settings in which patients need help to complete the questionnaire (Goldberg & Hillier, 1979). For Thailand, the Thai GHQ-12 of Nilchaikovit, Sukying, and Silpakit (1996), the original is the GHQ that developed by Goldberg (1972) and translated into Thai and administered to a sample of 100 people at clinical psychiatry health care unit in Nongchok district, Bangkok. Clinical psychiatric interview by psychiatrists was used as a gold standard. Sensitivity, specificity and area under the receiver operating characteristic curve [ROC], as well as the internal consistencies of items were calculated. The result of the study showed that all versions of the Thai GHQ (Thai GHQ-60, Thai GHQ-30, Thai GHQ-28, and Thai GHQ-12) had good reliability and validity, with the range of Cronbach’s alpha coefficients from 0.86 to 0.95, and the range of sensitivity and specificity from 78.1 % to 85.3 % and 84.4 % to 89.7 % respectively. In conclusion, the Thai versions of GHQ developed can be used as a self-administrative screening instrument to in Thai population (Nilchaikovit et al.,

38 1996). The score was used to generate a total score ranging from 0 to 12. The positive items were corrected from 0 (always) to 1 (never) and the negative ones from 1 (always) to 0 (never). High scores indicate worse health Thai GHQ-12 was used for measured the health perception in this study. From the aforementioned, stroke is a major cause of long-term disability, often with devastating consequences for individuals and their families. To decrease impacts of the factors associated with HRQoL in stroke survivors is very important and promote stroke to promote functional status, health perception not only promote

Rehabilitation and rehabilitation nursing The philosophy of rehabilitation is distinctly different from acute care. In acute care the patient’s survival is a primary focus. Rehabilitation actually starts in the hospital as soon as possible after the stroke. In patients who are stable, rehabilitation may begin within two days after the stroke has occurred, and should be continued as necessary after release from the hospital (NSA, 2013). Definitions of rehabilitation Rehabilitation has been defined in a number of ways. Many new developments within the discipline make this a challenging and desirable field in which to work. There are many definitions of rehabilitation in the context of contemporary society and health care. Rehabilitation is founded on the premise that all individuals have inherent worth and have the right to be experts in their own health care (Gender, 1998). Rehabilitation, often referred to as rehab, is an important part of stroke recovery (NSA, 2013). Each person is viewed as a unique, comprehensive, holistic being. Rehabilitation definition (2013) views rehabilitation as a treatment or treatments designed to facilitate the process of recovery from injury, illness, or disease to as normal a condition as possible. Jullamate, Azeredo, Paul, and Subgranon (2006) views rehabilitation means the activities or procedures which are dynamic processes performed by a person or a group of persons who have been academically/ professionally trained regarding rehabilitation for an individual who faces health-related problems or disease-induced disabilities by coordinating and combining use of several strategies in order to lessen

39 or diminish functional limitation, impairment, disability, or handicap, to restore the health condition, to achieve the highest level of independence. Booth and Jester (2007) view rehabilitation in health care as restoring individuals to their maximum potential following disease or trauma. From the above definitions it is clear that the target of general rehabilitation is a treatment to individual who faces health-related problems or disease-induced disabilities by coordinating and combining use of several strategies to restore the health condition, to achieve the highest level of independence. Besides the general definitions of rehabilitation mentioned above, however, rehabilitation can consider to two other important definitions: stroke rehabilitation and rehabilitation nursing. In this study focused on rehabilitation nursing for stroke survivors. The concept of rehabilitation nursing Nurses have four fundamental responsibilities: to promote, to prevent illness, and to perform curative and rehabilitative services duties (WHO, 1996). However, the goal of rehabilitation nursing is to assist individuals with disability and/ or chronic illness to attain and maintain maximum function. To define rehabilitation nursing, the definition must be based on rehabilitation setting and standards of rehabilitation nursing practice as follows: Mauk (2011) stated that rehabilitation nursing is responsible for providing the education and training to equip the person with the needed knowledge and skills to maximize self-care. The Royal College of Nursing (RCN, 2007) views rehabilitation nursing as a person-centered, active and creative process that involves adaptation to changes in life circumstances. It is a shared activity between the person, people close to them, and multi-professional teams who recognize the contribution of all concerned. ARN (2008) views rehabilitation nursing as the diagnosis and treatment of human responses of individuals and group to actual or potential health problems stemming from altered functional ability and altered lifestyle In stroke rehabilitation nursing, a full rehabilitation program might have many components. However, in this study the researcher defines the rehabilitation nursing refers to a set of home- based rehabilitation activities for 12 weeks to

40 identifying needs and planning, to gain more knowledge by provide education and skill training, and to promote psychosocial care. The all activities may maintenance and restoration of physical and psychological health necessary for independent living and functional independence. Role of nurses in rehabilitation The ARN (2014) states advanced practice nurses in rehabilitation must have a graduate degree in nursing. They conduct comprehensive assessments and demonstrate a high level of autonomy and expert skill in diagnosis and treatment. They manage complex responses of individuals, families, groups and communities to actual or potential health problems stemming from altered functional ability and altered lifestyle (resulting from physical disability or chronic illness). Advanced practice nurses in rehabilitation synthesize complex data to formulate decisions and plans that optimize health, promote wellness, manage illness, prevent complications or secondary disabilities, maximize function and minimize handicap. Nurses in advanced practice integrate education, research, and consultation into their clinical practice role. They function in collaborative relationships with nursing peers, the interdisciplinary team, and others who influence the healthcare environment. Nursing care is respectful of and unrestricted by conditions of age, color, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status. Nurses render health services to the individual, the family and the community and co-ordinate their service with those of related groups. Registered nurses regularly rotate among specialties within hospitals to gain experience in different nursing techniques and disciplines. With more experience and education, many hospital staff registered nurses become head nurses and supervise other nurses or move on to become nurse educators or researchers. Registered nurses may choose a specialty based upon the type of treatment administered and thus narrow their scope of job duties (Walden University, 2013). Some fields in which registered nurses can specialize are holistic medicine, long-term care, psychiatrymental health care or rehabilitation care. The roles of the nurse in stroke rehabilitation includes aiding physical recovery from stroke, facilitating independence in activities of daily living, reducing the risk of secondary complications and related conditions, and promoting holistic

41 adaptations to stroke related disability (Chambers, 2007). The ARN state essential role of the rehabilitation nurse has five core activities consisting of: 1. Managing complex medical issues 2. Collaborating with other professionals or disciplines 3. Providing ongoing patient/ caregiver education 4. Setting goals for maximal independence 5. Establishing plans of care to maintain optimal wellness Over the past three decades, the nursing home has emerged as an important site for rehabilitation. Accordingly, the United Kingdom central council for nursing [UKCC] (1994) definitions nurse has 4 levels of spheres of professional practice consisting of: novice, primary, specialist, and advanced. The development of specialist and advanced roles has been proliferation of advanced practice nurses [APNs] roles. So, in this study the researcher collaborate in stroke care between APNs, physician, physical therapist, pharmacologist, nutritionist, nurse in community to expect the positive outcomes. In addition, to evaluate all problems of stroke survivors, they have many potential tools uses in aiding measure. However, in this study the researcher developed a tool to screen for potential problems that help nurses to prioritize problem and identify their needs. Importantly, to manage continuing care and home-based rehabilitation nursing successfully, the researcher must corporative with all stakeholder that interdisciplinary are effective and fit with area context. According to ARN (2014) the roles of home care rehabilitation nurse are not limited. However, the home care rehabilitation nurse’s essential roles are as a clinical resource, a care coordinator, an advocate, a primary care provider, a teacher, a consultant, and a team member. Care coordination promotes greater quality, safety, and efficiency in care. Additionally, a nurse can increase support care by building up the stroke patient’s environment (e.g. caregivers, family members, community nurses, and health volunteers from the same community). The team can assist in preventing the feeling of helplessness that can often accompany illness. Resulting in improved healthcare outcomes and is consistent with nursing’s holistic, patient-centered care (Camicia et al., 2014).

42 Recent publications have addressed the evidence for comprehensive rehabilitation after stroke and compiled guidelines. The guidelines are organized into inpatient rehabilitation, community-based rehabilitation, and individual algorithms providing overviews of each step in the overall process of care. Early rehabilitation is critical in making an optimal recovery and should be initiated as early as possible, preferably within 24 to 48 hours of the stroke. An individualized rehabilitation plan includes phased interventions along with periodic evaluation of progress toward meeting individual goals. It also includes interventions to prevent a recurrent stroke. Phased interventions relate to implementing deficit specific interventions along a continuum from simple to complex actions (Saw & Truax, 2007). Stroke rehabilitation setting Stroke rehabilitation setting is considered. The current process of care transitions for individuals with disabling conditions is both ineffective and inefficient. Determining the best setting for the patient requires a thorough understanding of rehabilitation services and evidence-based outcomes to evaluate appropriateness of care for the patients (Congressional Research Service [CRS], 2010). Therefore, it is necessary to introduce home-based rehabilitation to stroke survivors to diminish those problems particularly in the case of the stroke victims who live in remote areas with limited access to institutional rehabilitation. After being discharged from the hospital, stroke patients may receive a continuous rehabilitation program, which is a hospital-based inpatient setting. Hospital-based rehabilitation program means that patients have performed programs within the hospital. Patients are generally seen by an interdisciplinary team twice a day for a total of at least 3 hours of therapy a day (Anderson et al., 2000; Saw & Truax, 2007). Moreover, community-based setting or home-based setting programs are conducted at a patient’s home and are individually tailored (Anderson et al., 2000; Chen et al., 2010). Community-based rehabilitation was first promoted by the WHO in the mid-1970s to address the limited nature of the rehabilitation workforce in developing countries, through the provision of basic services at a community level, incorporating principles of primary health care, relevant rehabilitation practices, and seeks to use local resources and build local skills. The active engagement of patients, families and even community members in service delivery is core to community-

43 based rehabilitation. As a strategy, community-based rehabilitation seeks to equip, empower and educate people with disabilities and all stakeholders towards an end goal of greater independence, community participation and quality of life. The community-based rehabilitation approach typically seeks to maximize personal agency, accessibility to resources, and opportunities for participation, leading to the same physical, psychosocial and other outcomes as other disability service models (Kuipers & Doig, 2012). Home-based rehabilitation is based on partnership and local context, linking formal and non-formal caregivers, empowering individuals, and providing a bridge between the individual, family, community, and the health care system (Chen et al., 2010). Additionally, Doig and Amsters (2006) reviewed the literature about the efficacy of community rehabilitation for aged clients after stroke. The studies found home-based interventions with institutional rehabilitation (i.e. rehabilitation provided in day hospitals) for outpatients with stroke largely indicated more positive benefits in terms of functional outcome more than community participation in the home-based rehabilitation groups. Many authors suggested that rehabilitation at home is more effective and cheaper (Hui-Chan et al., 2005; Ng et al., 2005; Studenski et al., 2005). Although, research has also been conducted to examine and show the transitional phase is also effective (Chanruengvanich, 2005; Khampolsiri, 2005; Oupra, Griffiths, Pryor, & Mott, 2010; Phongsri, 2009; Rodgers et al., 1999). Previous studied in Thailand conducted at home-based that their results showed positive outcomes (e.g. Chaiyawat, 2009; Khampolsiri, 2005; Srisoparb, 2007). Therefore, home-based setting is usually best suited for stroke survivors with transportation problems or those who required treatments. Although this allows flexibility for patients to tailor the program to their own schedules, and also gives them the opportunity to practice the skills they have learned in their own home. However, to optimally rehabilitate the stroke survivors, the nurse must consider the normal physiologic changes and their effects on functional status and patients sometimes are not motivated to perform ADL. However, previous research finding on HRQoL among stroke survivors do not clearly. Finding of this study was filling a gap in the literature. Summarizes, the researcher set the team to working in home visits together. At that point, home-based techniques will help stroke survivors deal with

44 negative mood to change in patient’ s thinking and protect depress symptom. The advantages and disadvantages of hospital-based, community-based, and home-based rehabilitation programs are described in table 1.

Table 1 The advantages and disadvantages of hospital-based, community-based, and home-based rehabilitation programs

Rehabilitation

Advantages

Disadvantages

programs Hospital-based

1. Decreased stress on caregivers

1. Uncomfortable

2. More social interaction

and irrelevant for

3. Wide range of facilities and equipment

each patient

4. Service provides more specialists, complete

2. High cost

medical equipment Community-

1. Can use portable equipment such as in their

1. Cannot provide

based

patient home

related

2. Shorter transportation times

training due to of a

3. Lower costs than hospital-based

lack of facilities

1. Satisfying patient choice

1. Wasteful time

2. Reducing the risks associated with inpatient

of treatment in

care through reduction in length hospital stay

therapist travel

Home-based

3. Convenient, comfort and privacy for patients, economic 5. Decreased distraction, and increased relevance for patients

Recommendation for rehabilitation in stroke survivors Nowadays, there are many guidelines for rehabilitation in stroke patients such as clinical guidelines for stroke rehabilitation from the AHA/ NSA/ National Stroke Foundation, and the Canadian best practice recommendations for stroke care. In Thailand there are the clinical nursing practice guideline for stroke by Prasat Neurological Institute (2007) and the clinical practice guideline for stroke rehabilitation by Prasat Neurological Institute (2007). Rehabilitation is a dynamic

45 process through which a person is assisted to achieve optimal physical, emotional, psychological, social, and vocational potential and to maintain dignity, self-respect, and a quality of life that is as self-fulfilling and satisfying as possible (Hickey & Todd, 2009). Rehabilitation is considered to development. Main principle of rehabilitation for practice including assessment, patient and family education, promote physical activity, promote psychological support (ARN, 2014; Chambers, 2007). 1. Assessment Literature in Thailand found that nurse led program has a wider effect for many patients (Monkong, 2012). The nurse’s assessment made a crucial contribution to the client’s rehabilitation, ensuring that actual problems and potential problems that might hinder rehabilitation were addressed. A wide range of areas were assessed, including the ability to self-care, family support, social circumstances, medication, mood, nutrition, and elimination. Other areas were considered according to the client’s diagnosis and morbid condition. In the specialist rehabilitation setting, nursing assessment focused specifically on gauging the extent to which the client would be able to live independently and on what mattered to the client. In the places where therapists are insufficient, nurses can also have an additional role to improve the patient rehabilitation (ARN, 2014). Especially, specific instruments are needed to determine the degree of patient participation in rehabilitation activities (Rettke, Geschwindner, & Heuvel, 2015). The assessment of patient needs and appropriate responses relies upon understanding what is physically happening to the patient, the likely responses of the patient and caregivers, and the resources which can be brought to bear upon the situation. Family and significant others will wish to know things like: What can they do to help the patient? What will the patient be able to do and by when? How can they be involved in the care? What care is being given and why? (Rosenthal, Pituch, Greninger, & Metress, 1993). 2. Patient and family education Patient and family education takes place within a compressed period of time in the acute care setting. It is unrealistic to expect that all education can be completed during this short period. Patient education must be viewed along a continuum that extends through the next level of care and into the community by the health care

46 provider (Hickey & Todd, 2009). So, patient education in rehabilitation needs to be well planned. Rehabilitation nurses should be assertive in their educational role. They should provide knowledge and support for patients, families and other staff to ensure that the patient has the best possible opportunity for recovery, independence and control. Moreover, nurses should highlight on the family’ need for planning about education and support them (RCN, 2007). However, assessing the patient’ prior knowledge and experience, drawing on an individual’s background as a basis for teaching and learning. Norach (2010) studied the needs of patients with stroke and families in physical, mental and social care from home health care teams. The results showed that patients with stroke in the early stage rated psychological care as the aspect they need from the home health care team the most, followed by physical and social care. Whereas, the family’s members needed cares for their patients in the aspects of psychological and physical cares equally, followed by the social care. The psychological cares included psychological support and encouragement. Physical cares included physical rehabilitation, nursing and medical cares. Social cares included harmonization with their neighbors. Besides physical, psychological, and social cares, the participants also identified need for economic support. Hence, there are three main sessions for education including providing about basic knowledge, healthy eating, and modifiable behavioral risk factors: 2.1 Providing about basic knowledge Education can play a role in improving skill to cope with illness. Stroke patients and their caregivers reported many diverse education needs. The educational needs of stroke patients and caregivers concerned knowledge about the clinical aspects of stroke, prevention, treatment and functional recovery, and recurrent stroke. Recurrent stroke is a major contributor to stroke-related disability and death, with the risk of severe disability or death from stroke increasing with each additional recurrent stroke. As a consequence of increasing stroke prevalence, an increasing number of persons will be at risk of recurrent stroke. Risk of recurrence is highest within the first 6 months, and has been reported to be 3 % within 30 days in patients diagnosed with ischemic stroke, and 9% at 6 months in patients who had a stroke or TIA. The 1-year recurrence rates have been found to vary between 7 % and 13 % in European, American and Australian populations, and 29 % in another study. Variation

47 in recurrence rates may partly be due to differences regarding the stroke populations, that is in or exclusion of patients with TIA or intracerebral hemorrhage, recurrent stroke is frequent; about 25 percent of people who recover from their first stroke will have another stroke within 5 years (NINDS, 2014). Recovery from stroke is a lifelong process. There are two types of recovery: intrinsic and adaptive. Intrinsic recovery is a degree of return of neural control (such as the brain reorganizing its own functioning). Adaptive recovery is the use of alternative strategies to overcome disability. Stroke survivors may have a good chance for recovery, but the time to achieve specific outcomes is influenced by many factors, especially stroke severity (Duncan & Lai, 1997). From the reviewed literature, it was found that recovery is fastest in the first few weeks after stroke, with a further 5-10 % of recoveries occurring between six months and one year after stroke. About 30 % of survivors are independent within 3 weeks, and by 6 months this proportion rose to 50 % (Sacco, Wolf, & Gorelick, 1999). The prevalence of stroke survivors with incomplete recovery in the U.S. has been estimated at 460/ 100,000 (Bonita, Solomon, & Broad, 1997). Nowadays, there are many stroke survivors suffering from stroke. About 40 % of stroke patients are left with moderate functional impairments and 15 % to 30 % with severe disability and others have no deficits at all (AHA, 2012; ASA, 2012; Baird et al., 2001; Ebrahim & Harwood, 1999). Some problems such as homonymous hemianopia, dysphagia, and sitting balance resolve very quickly in stroke survivors, whereas arm paralysis and language impairment recover more slowly and less completely. Perceptual problems may persist or take a very long time to recover. Completeness of recovery depends on the severity of the initial deficit and the NSA (2013) states that general stroke recoveries show: 10 % of stroke survivors recover almost completely 25 % recover with minor impairments 40 % experience moderate to severe impairments requiring special care 10 % require care in a nursing home or other long-term care facility 15 % die shortly after the stroke For many people, recovery begins with formal rehabilitation, which can restore independence by improving physical, mental and emotional functions (NSA,

48 2013). There are three phases of stroke rehabilitation: rehabilitation in the acute phase, rehabilitation in the recovery phase, and follow-up or after care (Jakkutip, 2011). Moreover, time is an important issue for stroke rehabilitation relating to functional status and HRQoL in stroke survivors. Gilman (2006) recommended initiating a therapeutic approach in subjects with first-ever ischemic strokes, whom, after 3 months of rehabilitation, continue to manifest disability and receive optimal management of risk factors to minimize recurrent stroke, other complications or death. Review of the literature showed an equal number of studies supported and disputed the benefits of stroke rehabilitation, the latter especially in light of the spontaneous recovery that occurs after stroke. However, overall, the studies suggest that rehabilitation enhances functional impairment beyond that which can be expected with spontaneous neurological recovery (but the selection of patients does play a role) (Saw & Truax, 2007). Wade (1994) summarizes the impairment/disability rates in acute (0-7 days), three week and six month of stroke as showed in the table 2. Table 2 The summary of impairment/ disability rates in acute (0-7 days), three week and six month

Phenomenon

Acute

3 weeks

6 months

(%)

(%)

(%)

Initial loss/ depression of consciousness

5

-

-

Not oriented (or unable to talk)

55

36

27

Marked communication problems (aphasia)

52

29

15

Motor loss (partial or complete)

80

70

53

Incontinent of feces

31

13

7

Incontinent of urine

44

24

11

Needs help grooming (teeth, face hair)

56

27

13

Needs help with toilet/ commode

68

39

20

Needs help with feeding

68

38

33

Impairments

Disabilities

49 Table 2 (continued)

Phenomenon

Acute

3 weeks

6 months

(%)

(%)

(%)

Needs help moving from bed to chair

70

42

19

Unable to walk independently indoors

73

40

15

Needs help dressing

79

51

31

Needs help bathing

86

65

49

Very severely dependent

38

13

4

Severely dependent

20

13

5

Moderately dependent

15

15

12

Mildly dependent

12

28

32

Physically independent

12

31

47

From table 2 as showed the summary of impairment/ disability rates and it is useful for knowledge about stroke and timing. Moreover, education can be provided in small groups or on an individual basis, depending on the needs of the patients, the site, the resources, and the design of the rehabilitation program. It should be tailored to the needs and environment of the patient, should be interactive, directed at improving quality of life, simple to follow, practical, and appropriate to the intellectual and social skills of the patient and the caregivers. Although education alone does not improve exercise performance, nevertheless it could play a role in improving skills for changing lifestyles to cope with illness. Hence, an education program should be a part of the consultations. According to current guidelines for prevention of recurrent stroke, a healthy lifestyle (implying intake of fruit and vegetables), increased physical activity, alcohol consumption as well as smoking cessation should be encouraged (AHA, 2014). Moreover, recurrent stroke can be defended against by antihypertensive treatments after the first stroke. Antiplatelet therapy provides secondary prevention in most types of ischemic brain disease (Boysen & Truelsen, 2009). 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

50 tailored to their situation (Hafsteinsdottir, Vergunst, lindeman, & Schuurmans, 2010). 2.2 Providing knowledge about healthy eating Eating well after stroke is a key to recovery. Choosing healthy foods can help control blood pressure, body weight, reduce a person’s risk of having another stroke, and may help with the demands of stroke therapy and other daily activities. Moreover, a diet low in saturated and trans-unsaturated fatty acids and caloric intake to achieve optimal body weight is a cornerstone in the management. An important strategy to reduce the risk of a stroke is to achieve a healthy body weight. Watching portion sizes, eating foods high in fiber and low in fat, avoiding fatty diets, increasing activity, and keeping track of eating habits are all ways to achieve a healthy body weight. Keep in mind weight loss does not happen overnight, so establish realistic short and long-term goals from the start. Also, most health professionals limit persons with a history of heart disease or stroke to 2,000 milligrams of sodium each day. However, if patient have high blood pressure, it is strongly recommended that sodium be limited to 1,500 milligrams daily. If the patient takes too much sodium they may retain fluids and increase blood pressure (AHA, 2014; American Family Physician, 2011; Antman et al., 2008; NSA, 2012). Further, lifestyle modifications include decreasing saturated fat and cholesterol intake, achieving ideal body weight. Diets high in saturated fats are linked to high cholesterol and an increased risk of cardiovascular disease. Saturated fats tend to be solid at room temperature and are found in animal products like meat, cheese, egg yolks, butter, and ice cream, and some vegetable oils (palm, palm kernel, and coconut). Limiting the amount of saturated fat foods is key to stroke prevention (NSA, 2012). More, diets high in trans fats are also associated with high cholesterol and increased risk of cardiovascular disease. Trans fats are formed when an unsaturated vegetable oil is turned into a more saturated one through a process called hydrogenation. Food products that contain partially hydrogenated vegetable oils should be avoided. Trans fats are found in anything made with partially hydrogenated fats (e.g. many processed foods including cookies, crackers, fried snacks, and baked goods), stick margarine, vegetable shortening, and most fried foods (AHA, 2014). Additional, limiting cholesterol in foods is another important step to cholesterol control and stroke management. Cholesterol is a fatty, waxy substance

51 made by the body and found in foods of animal origin. The body needs cholesterol to maintain the health of body’s cells. However, too much cholesterol in your blood can increase your risk of stroke and heart disease, and can be achieved by trimming visible fat from meats and removing the skin from poultry, cutting back on how frequently eat meats, poultry and other animal-derived foods, limiting portion size of meat to no more than 3 ounces at a sitting (size of a deck of cards), limiting butter, eliminating lard, and choosing nonfat or low-fat dairy foods (AHA, 2014; American Family Physician, 2011; Antman et al., 2008; NSA, 2012). 2.3 Providing knowledge about modifiable behavioral risk factors 2.3.1 Cigarette smoking Cigarette smoking accelerates coronary atherosclerosis in both sexes and at all ages and increases the risk of thrombosis and plaque instability. Cigarette smoking is an independent risk factor for ischemic stroke, and growing evidence has shown that exposure to environmental smoke increases the risk of cardiovascular disease, including stroke. Smoking cessation is recommended in persons who have experienced a stroke or TIA (American Family Physician, 2011; Antman et al., 2008). 2.3.2 Alcohol consumption Chronic alcoholism and heavy drinking are risk factors for stroke. According to the guideline source, the AHA/ ASA showed one cohort study found a significant increase in stroke recurrence in patients with previous heavy alcohol use who had experienced ischemic stroke. Although light or moderate drinking may provide a protective effect against ischemic stroke by increasing high-density lipoprotein levels, heavy drinking can cause hypertension, hypercoagulable state, reduced cerebral blood flow, and atrial fibrillation or cardio embolism from cardiomyopathy. Alcoholism has also been linked to insulin resistance and metabolic syndrome (American Family Physician, 2011). 2.3.3 Metabolic syndrome Metabolic syndrome is used to describe the convergence of several abnormalities that increase the risk of vascular disease, including hypertriglyceridemia, low high-density lipoprotein cholesterol levels, high blood pressure, and hyperglycemia. Patients with metabolic syndrome have an increased risk of diabetes, cardiovascular disease, and all-cause mortality. The prevalence of metabolic disease

52 in patients with ischemic stroke is 40 to 50 percent. Many studies have confirmed an association between metabolic syndrome and first ischemic stroke, but only one study has examined the association with recurrent stroke. Results found that participants with metabolic syndrome were more likely to have a stroke, myocardial infarction [MI], or vascular death within 1.8 years of follow-up than those without metabolic syndrome. Diet, exercise, and use of medications that enhance insulin sensitivity have been shown to benefit persons with metabolic syndrome (American Family Physician, 2011). 3. Promote physical activity Physical activity is the term used to describe any kind of everyday activity where the body’s movement burns calories. Exercise is a form of physical activity. Exercise usually describes a pre-planned physical activity that involves a series of repetitive movements that are performed to strengthen or develop a particular part of the body, including the cardiovascular system. Haskell et al. (2007) suggested the principles of physical activity consists of a) frequency, at least 3-5 times per week, b) duration, it should at least 30 minutes continuously but not more than 1 hour, c) intensity, it will build up an aerobic fitness. The highest intensity of physical activity is maximum heart rate. Physical activity has a beneficial effect on several stroke risk factors. However, persons who have had a stroke may experience substantial disability that can make exercising difficult. Studies have shown that aerobic exercise and strength training improve cardiovascular fitness, mobility, balance, and endurance after a stroke, but it has not been determined that therapeutic exercise reduces the risk of recurrent stroke. Some studies found that patients who received advice on physical activity after a stroke were more likely to exercise than those who did not receive advice. Also, those who exercised after surviving a stroke were less likely to have days with limited activity or poor physical health than those who did not exercise (American Family Physician, 2011; MyDr, 2014). Exercise can affect absolute health (physical, mental, social and health). The best known part that exercising improves is the physical part. The physical effect of exercising is that every part and system of body is in continuous movement. There are many parts in our body that benefit from exercise, but one of the most important parts that exercising helps is the cardiovascular system. For example, when

53 exercising, muscles move, and in order to move, muscles need oxygen in the blood, so the heart has to pump blood in a faster rhythm to keep the muscles moving. This trains the heart and lungs to give more strength in the future. Muscle exercise builds and strengthens muscles, which can protect the bones from injury, and support and protect joints affected by arthritis. Strong muscles also give stability and improve balance and coordination (MyDr, 2014). Another part of the definition of health is mental health. This aspect is relaxation. When exercising, people may experience many feelings and incommodities, such as stress. Many people feel that after exercising, all the problems and pressures of their lifestyle disappear or at least are forgotten for a while. While exercising some problems of patient’s lives can be solved. The social aspect of health is helped with exercise because many of the sports are or can be made with someone else. This makes stronger relationships because when like people meet and share the same things that this makes them feel more secure and helps them learn about human relationships (MyDr, 2014). Recommendations for physical activity and exercise by Skelton, Mcaloon, and Gray (2011) in people with comorbidities suggest specific tailored exercise regimens three times a week. Tailored exercise has a significant and large antidepressant effect in depressed older adults and improves psychological function. Individualised exercise interventions with balance training at the core of the program are most effective for rehabilitation (Skelton et al., 2011). Moreover, Justine and Hamid (2010) examined the effects of a multicomponent exercise program on depression and quality of life in institutionalized older adults. The experiment performed 60 minutes of supervised exercise three times per week for 12 week. They study found an improvement in quality of life. The nurses organize the patient’s schedule to ensure practice sessions are appropriate to foster learning. Repetition of the desired task will improve performance and motivation. This is important to ensure that the patient experiences success. Moreover, rest periods should be provided. Nurses are involved in helping patients maximize their independence, exercise choice and ability to regain control of their lives, and patients consider the constant presence of nurses to be particularly significant to the process of rehabilitation (RCN, 2007). Nurses training and coaching include activities such as self-care how to compensate for the loss of mobility or moving, physical activity for improve basic

54 activities of daily living. The basic activities of daily living consist of self-care tasks, including bathing and showering (washing the body), bowel and bladder management (recognizing the need to relieve oneself), dressing, eating (including chewing and swallowing), feeding (setting up food and bringing it to the mouth), functional mobility (moving from one place to another while performing activities), personal device care, personal hygiene and grooming (including brushing/ combing/ styling hair), toilet hygiene (completing the act of urinating/ defecating). Another study reported that 52 % of one-year survivors were independent in their ADLs. Of these, 32 % of patients were dependent when bathing, and 7 % were completely dependent for personal hygiene (Carod-Artal, Egido, Gonzalez, & Varela de Seijas, 2000). 4. Promote psychological support Stroke is one of the leading causes of morbidity. Moreover, when the patients are faced with physical illness, disease or trauma they have a decreased ability to move, talk, see, hear and generally get by in their life (Barr, 2007). It is characteristically considered to be a condition causing weakness and paralysis. In fact up to 20 % of people have no weakness, and a further unknown number of people have clinically silent stroke. More importantly, all patients with stroke are at risk of cognitive loss and some cognitive loss is probably present in almost all patients. Up to 75 % of patients will have significant cognitive impairment, including problems with memory, attention, language and perception as well as organization of movement and thoughts. Mood disturbance is common after stroke and may present itself as depression or anxiety. Psychological mood disturbance is associated with higher rates of mortality, long term disability, hospital readmission, suicide and higher utilization of outpatient services if untreated. In addition, serious psychological problems and strain are common in people with stroke. Psychological care is best delivered in a service. According to clinical guidelines by the NSA (2011), provision of psychological care after stroke recommends that routine assessment and management of stroke is multifaceted, involving many professions of mood and cognition after stroke e.g. health, social care, and voluntary. At present, there is previous research, which mentions the psychological support as service which are very important. The guidelines on psychological support suggest all staff should acknowledge the role of the client himself and his family in improving their ability. Health professionals

55 should invited family members to join in care. Because the family are part of the person’s everyday life (Barr, 2007). The strategies or techniques include nonverbal communication skills e.g. eye contact, and client communication e.g. dealing with a potentially distressing, listening and responding, asking open question, and offering information. All these skills are essential. Moreover, from systematic review and meta-analysis the effect of exercise on depression it was suggested that exercise tailored to individual ability will reduce depression severity (Bridle, Spenjers, Patel, Atherton, & Lamb, 2012). Hence, individual rehabilitation process comprise psychological support by home visit and use environment in community-based setting can assist the stroke patients to devise a plan for improve their HRQOL. 5. Collaboration and teamwork within community Comprehensive rehabilitation teamwork is enhanced when health care provider coordinate their efforts and collaborate with other personnel within the community. Care coordination promotes greater quality, safety, and efficiency in care, resulting in improved healthcare outcomes and is consistent with nursing’ holistic, patient-centered framework of care (ARN, 2008). A nurse with rehabilitation nursing training, knowledge, and experience is the healthcare professional who is best able to coordinate, support, and facilitate to promote quality outcomes and cost-effective care for individuals with disabling conditions. According to ARN (2014) recommends that nurses who promoting the health and welfare of clients with disabilities and ensuring that the patient receives the right care at the right time by the right provider. Therefore, the effective nursing management of people suffering a stroke is not the prerogative of any particular healthcare profession but a combined approach involving a team of healthcare professionals. Moreover, technological trends are rapidly disseminated to grant anyone access. For example, reading a newspaper, watching television, and using the internet. Information technology is changing how we live, work, and learn. However, even a casual observer cannot help but be amazed by the discoveries and new technologies that are emerging in almost every area of scientific study (Hickey & Todd, 2009). From literature reviews on neurorehabilitation, development of new, high-tech prosthetic devices, as well as the opportunity that new interventions offer for saving and restoring function, will have a profound effect on the quality of life of many

56 patients who have sustained neurological trauma or who have chronic neurological disease (Hickey &Todd, 2009). Therefore, in providing better care one may be able to reduce the psychological mood of the patient and their family by offering telephone support. The benefits of telephone support to stroke survivors and their caregivers can increase adaptation and functioning after stroke. The telephone calls will check on how the participants are doing after discharge and will assist with questions and concerns (Miller, 2005). In the nursing field, some studies used telephones to monitor in the process of intervention. For example, Thanh (2013) conducted the effectiveness of a diabetes self-management support intervention in Vietnamese adults with type 2 diabetes. The researcher used telephones (home phone/ or cell phone) for monitoring the process of providing and receiving support between peer leaders and participants in the intervention group and the researcher. The researcher called peer leaders monthly to give support and guide them in overcoming barriers as well as motivating them to provide support for other participants. Moreover, Chalermwannapong (2008) examined the effects of the transitional care program on functional ability and quality of life of stroke survivors. The transitional care program was conducted throughout hospitalization and through the first 4 weeks post discharge. The post-hospital phase included 2 weekly visits at the stroke survivors’ homes and 2 telephone visits. The findings revealed that the experimental group had significantly better than the control group. Therefore, to gain the effective outcomes the researcher was apply the recommendation of the principle of rehabilitation that the main practices including assessment, patient and family education, promote physical activity, and promote psychological support for stroke survivors. Rehabilitation practices may get rid of physical and psychological sufferings. Previous interventions for rehabilitation and quality of life in stroke patients Khampolsiri (2005) examined the home-based nursing intervention program for enhancing quality of life of stroke survivors. There were 30 stroke patients in the experimental group and 28 in the control group. The aim of this program was to enhance QoL of stroke survivors by providing health education, encouraging and

57 helping the survivors and their family caregivers manage their own health problems and providing the skills to manage their life post-stroke. The components of the homebased nursing intervention program included teaching using audiovisual aids, skill training in ADL and exercise including moving and physical activities, supporting, and counseling. The educational materials in the program consisted of 9 booklets and 13 pamphlets. Data was collected at baseline, week-6, and week-12 after the intervention. The results showed the experimental group had functional ability increased over time, whereas the control group increased in week-6 but remained unchanged in week-12. Depression in the experimental group significantly decreased over time, but in the control group it was unchanged. QoL increased in both groups but more in the experimental group. The results demonstrated that here was no significant difference in functional ability, depression, perceived social support from family, and QoL between the two groups in week-12. Also, Chanruengvanich (2005) examined the effects of a self-regulated exercise program on physical fitness, satisfaction and the risk factors for stroke among clients with transient ischemic attack and minor stroke. There are 62 transient ischemic attack and minor stroke patients in the experimental and control groups (31 persons per group). The program consisted of four steps, step I: Preparation of basic knowledge, step II: training to self-regulate techniques, step III: application of the program, and Step IV: monitoring. During the third week, the researcher conducted research at home. The findings revealed that the experimental group had significantly increased the 6-minute walk distance and were satisfied with the response to physical activity at the week-6 and the week-12 mark and had improved significantly more than the control group. Heart rate and blood pressure measurements of the experimental group had significantly decreased by week-12 but there was no discernible difference from the control group. Moreover, there were no differences in total cholesterol, HDL-cholesterol and fibrinogen between the experimental and control groups. Chalermwannapong (2008) examined the effects of the transitional care program on functional ability and quality of life of stroke survivors. Stroke survivors are persons within 24-48 hours after admission, including 67 survivors of ischemic, embolic or nontraumatic cerebral hemorrhagic stroke. The transitional care program

58 was conducted throughout hospitalization and through the first 4 weeks post discharge. The post-hospital phase included 2 weekly visits at the stroke survivors’ homes and 2 telephone visits. The study revealed that functional ability of stroke in the experimental and control group improved significantly between baseline and week 12 and the functional ability of survivors in the experimental group was significantly higher than the functional ability in the control group. Srisoparb (2007) examined the effects of a home-based rehabilitation program with a family-centered approach for chronic stroke patients on stroke patients’ motor function, gait speed, physical, mental and social conditions, and caregiver’s stress level. The study was conducted on 10 chronic stroke patients (five men and five women). The study period total 20 weeks. During the first four weeks, each patient’s problems and achievable rehabilitation goals were discussed amongst the patient, their caregiver and the investigator, after which the home-based rehabilitation program relevant to the patients was cooperatively designed. The patient and their caregiver were then instructed to perform the program for four weeks. After receiving the four week therapy program, a significant increase in the patient’s gait speed was noticed. However, results were not sustained throughout the study because of time limitations. Moreover, the researcher states complications included factors affecting any study among stroke patients (eg. undercurrent illness). Chaiyawat (2009) examined the effectiveness of an individual home rehabilitation program for ischemic stroke patients. There were sixty patients with recent ischemic stroke, 6-12 months after hospital discharge. The intervention was a home-based individual exercise program provided by a physical therapist once a month for 3 months. The physical therapist evaluated a range of functions related to indoor and outdoor mobility and some basic activities of daily living before providing a home rehabilitation program for the stroke patient. Individual counseling, which focused on education, applying information learned in practical situations, and solving problems occurring at home, was offered to the caregiver if needed. The intervention strategy was based on principles of exercise physiology and motor learning. It was developed by experts, stroke patients, physical therapists, occupational therapists, and speech therapists. It consisted of standard audiovisual materials [CD] of rehabilitation procedures, exercise, resistance exercise, and ADL. In the control group, patients and

59 family members were given instructions for home rehabilitation prior to discharge from the hospital and received the usual care after being discharged. The results showed that at 3 months the BI was significantly improved in the intervention group, more than the control group, and the absolute risk reduction [ARR] in the intervention group was significantly better for quality of life and generic health status than the control group. The author concluded that the early home rehabilitation program in ischemic stroke patients in the first 3-month period provides a significantly better outcome in improving function, reducing disability and increasing quality of life than usual care. Rimmer et al. (2000) tested the effects of a short-term health promotion intervention for a predominantly African-American group of stroke survivors. Participants were 35 stroke survivors (9 male, 26 female) recruited from local area hospitals and clinics. Participants were three months to 1.5 year after stroke. They found effects of a 12-week health promotion intervention for stroke survivors can reduced total cholesterol, reduced weight, increased cardiovascular fitness, increased strength, increased flexibility, increased life satisfaction and ability to manage self-care needs, and decreased social isolation. The authors suggested that short-term health promotion intervention for predominantly African-American stroke survivors was effective in improving several physiological and psychological health outcomes. Green, Forster,Bogle, and Young (2002) assessed the effectiveness of routine community physical therapy for patients who had mobility problems one year after stroke. Assessments were made at baseline, three, six, and nine months in 170 eligible patients assigned treatment (treatment group) and have no control group. The primary outcome measure was mobility measure by the Rivermead mobility index. Secondary outcome measures were gait speed, number of falls, daily activity, social activity, hospital anxiety and depression scale, and emotional stress of caregivers. Physical therapy treatment was done by an established community physical therapy service (13 staff) as part of their usual work. Initially, all patients were assessed by a physical therapist and then treated with a problem solving approach at home or in outpatient rehabilitation centers. Treatment period was 13 weeks with minimum three contacts per patient. The results of this study

60 demonstrated that community physical therapy caused and improvement in mobility and gait speed of patients at the third month. However, the effects were not sustained after the treatment ended. Hui-Chan et al. (2005) examined the effectiveness of a home-based rehabilitation program on lower limb functions after stroke. They assessed 109 subjects at four time intervals before and after 2 and 4 weeks of treatment, and 4 weeks after treatment. The results showed the home-based rehabilitation program improved the lower limb motor functions in patients who had sustained strokes more than 1 year previously. Moreover, the results showed decreased plantarflexor spasticity, improved ankle dorsiflexor and plantarflexor strength, and increased gait velocity. Desrosiers et al. (2007) examined the effect of a home leisure education program after stroke. The study was conducted on 62 stoke patients and there were two groups of intervention. The leisure education program was at home once a week for 8 to 12 weeks. Control participants were visited at home at a similar frequency. The results showed the effectiveness of the leisure education program for improving participation in leisure activities, improving satisfaction with leisure and reducing depression in stroke patients. Moreover, there was also a statistically significant difference between groups for improvement in depressive symptoms with a mean difference. Yu et al. (2009) test the effects of community-based rehabilitation on stroke patients in China. The rehabilitation group received additional standardized community-based rehabilitation therapy at home for five months. They were assessed before intervention and at the end of two and five months. The results showed both the rehabilitation group and the control group improved over time, but the rehabilitation group showed a greater improvement in clinical neurological function deficit scale scores. They suggested standardized community-based rehabilitation therapy may help stroke patients to improve their neurological function. According to results from the previous studies are widely employed in changing outcomes of rehabilitation. In summary, five were conducted in other countries and five studies were conducted in Thailand. Most of the studies were conducted in adult and older adult populations. Three studies used RCT design

61 (Chaiyawat, 2009; Desrosiers et al., 2007; Yu et al., 2009). The maximum follow-up was nine months after baseline (Green et al., 2002). The shortest program was for 4 weeks (Hui-Chan et al., 2005). 10-12 week programs improved several outcomes, such as physiological and psychological health (Chaiyawat, 2009; Rimmer et al., 2000). One study used an integrated care program consisting of a collaborating specialist team for education and coordination of input from other staff (Chaiyawat, 2009). The Thai study was composed of education about exercise and self-regulation exercise and telephone visits over 6 weeks (Srisoparb, 2007, Chaiyawat, 2009, Khampolsiri, 2005, Chanruengvanich, 2005, Chalermwannapong, 2008). One study employed motivation interviewing by telephone support (Chalermwannapong, 2008). There are two studies that used video material or video scripts (Chanruengvanich, 2005; Chaiyawat, 2009). One study was TIA sample and was conducted in the hospital and extended to the home (Chanruengvanich, 2005). There was one study that had an exercise poster that showed pictures of exercise (Chanruengvanich, 2005). Some studies selected stroke survivors who experienced a first stroke with moderate to severe disability (Chalermwannapong, 2008). Two studies used physical therapy for 13 weeks (Green et al., 2002; Hui-Chan et al., 2005). Individual and mixed approaches were the most favored approach of delivery. The previous programs were based on one or more subjects, almost all programs can be separate to 2 into 5 part/ phase or steps. They used many kind of materials in their program such as video script, handbook, and pamphlet. From the reviewed, previous intervention studied to helping stroke survivors were found many strategies that can be used to enhance the QoL of stroke survivors. However, whether the program should be hospital-based, home-based or communitybased will depend on the characteristics of the learners, and their health problems, as well as their living conditions. Thus, a home-based nursing intervention approach seems to be appropriate with stroke survivors and their family caregivers. It is hypothesized that home-based rehabilitation nursing practice not only decrease physical impacts but also decrease psychological impacts of stroke survivors. The HRNP had three phases and use some material from previous study suggestions such as CD, handbook, and telephone visit for become more motivate them (See the summary of previous intervention at table 6).

62

Development of stroke care in Thailand Stroke is a major leading cause of death and disability in Thailand. Rehabilitation services for people with disabilities and stroke survivors are also a major public health problem in Thailand when compared with developed countries. However, stroke is a major public health problem both in developed and developing countries (Chuenjairuang & Sritanyarat, 2012). Thailand is a developing country and moving rapidly towards an aging society and non-communicable disease. Formal health care system: main health care providers The Ministry of Public Health (MoPH) is the main health care provider. According to stastistic of hospitals, the MoPH shares around 62 % of total hospital number and beds. Other state organisations such as university and state enterprises also provide health care particularly the secondary and tertiary health care levels. Except the Bangkok metropolitan administration [BMA], other local governments/ authorities rarely provide health care to their responsible people. At present, private sector shares around 25 % of total hospital number and beds. However, at the primary care level share of private sector (clinic) is more than 50 %. The MoPH and the BMA are the main providers for almost all of the public health services, particularly health promotion and disease prevention activities. In 2001 the Thai Health Promotion Foundation has been set up for the promotion of health activities (Prachuabmob et al., 2013; Sirilak, 2011, Supawong et al., 2009; Division of Health Statistics, Ministry of Public Health, 1996, 1998, 2000, 2015). Secondary and tertiary health care levels Community hospitals and general hospitals are the main secondary health care organisations of Thailand. Community hospitals provide health promotive programmes, disease preventive programmes and curative services. Rehabilitative services do not receive sufficient attention. They are designed to be the first referral centres. However, as mentioned earlier, many patients go directly to the big hospitals and cause a failure of the referral network. Every province has either a general hospital or a regional hospital or both. These hospitals are designed to be the second and the third referral centres, respectively. The university and specialize hospitals, which are in Bangkok and a few cities, are the third referral centres and very specialized centres, which provide sophisticated medical services. Except for the

63 community hospitals, other secondary and tertiary health care institutes are located in the city areas. For the private sector, there is no formal referral system within the sector. Usually clinics or private hospitals refer patients to the second or the third referral centres of the public sector (Prachuabmob et al., 2013). Primary health care level The primary health services in Thailand are provided through networks of “Health centres” and “Community health centres” run by the MoPH and “Public health centres” run by the BMA. The Public health centres, which are available only in Bangkok, are generally staffed by 1-3 physicians and allied personnel. These centres provide curative, preventive and promotive but rarely on rehabilitative services. The health centres and the community health centres of the MoPH are usually located in rural areas of other provinces and are mainly staffed by new types of community health workers, namely “Primary health workers”. Promotive and preventive provisions are the main functions of these centres. They also provide some basic curative care to people living in their responsible areas but rarely rehabilitative care. Community hospitals, which are the first referal centres in rural areas, also provide primary health services for people living in their responsible areas. However, most health care personnel at the primary health care level are not trained for old age care. Only some have attended the short course programmes provided by the MoPH and academic organisations. The informal care provided by family is well recognized as the main strategy of the national policy for 15 years. Although the first National Long-term Plan mainly emphasized the informal care of the family, it ignored provisions needed to support the family. This was the reason why while the crucial role of informal care of the family has been recognized, state organizations paid little attention on developing home/community services to assist the older persons and their caregivers. Thus, the availability of community-based services to support caringcapacity of family is very limited at present (Prachuabmob et al., 2013; Sirilak, 2011, Supawong et al., 2009; Division of Health Statistics, Ministry of Public Health, 2015). It is recognized that primary care is the key to success in a universal health care coverage system. However, networking among these 3 levels of care to ensure quality and continuity of care is essential (Hanucharurnkul, 2007).

64 Health financing reform strategies of the UC policy offer improved equity in health care use and financial risk protection (International Health Policy Program Thailand [IHPP], 2010). However, the coverage of long-term system care is unable to respond to the needs of all population. So, there has been an attempt to develop a protocol for long-term care system by incorporating community participation (Prachuabmob et al., 2013). In addition, Thailand can classify in 3 levels including tertiary level hospitals, secondary level hospitals, and primary level hospitals (Ministry of Public Health, Thailand, 2010). Moreover, primary care unit [PCU] and tumbon health promotion hospital [THPH] serve both the community and the rural sub-district. Nowadays, several policies, plans and systems have been developed in response to various challenges relating to Thai population and quality of life. However, the works that have been initiated for preventing, assisting and recovering have not been adequate for Thai people (Prachuabmob et al., 2013). Many hospitals in Thailand are faced with a shortage of health professionals and other resource to assist long term care. Stroke rehabilitation service was found in some medical schools or the tertiary level hospitals and private hospitals. Therefore, it is rarely served in secondary and primary level hospitals. Also, in-patient rehabilitation units are not widely available. Rehabilitation in Thailand is still below the national target from the differentiation in each place (Prasat Neurological Institute, 2007). In Thailand there are only one for full rehabilitation service is Sirindhon national medical rehabilitation center at Bangkok (Riewpaiboon, 2001). A review of services provided, between 2006 and 2010, at a PCU in central Thailand, to persons with stroke warning signs revealed that services were provided to over 1,200 stroke survivors and more than 200 individuals did not regularly seek needed stroke care (Kitko & Hupcey, 2008). From the study of Oupra et al. (2010) found stroke survivors and family caregiver receive little information about how to assist their relatives, and as a result feel inadequately trained, poorly informed and dissatisfied with the support that is available after discharge. A study in Thailand found patients had no home visits from healthcare teams. 81.7 % and 86.6 % had 1-3 occurences of rehospitalization (Khachornrit, 2004). Moreover, in a study by Chuenjairuang and Sritanyarat (2012), they suggested development of primary

65 healthcare services for stroke prevention in persons with warning signs of stroke because their results showed the PCU healthcare providers were found to lack sufficient stroke screening instruments and guidelines (practice and referral) for dealing with strokes. Without these necessary elements, the PCU healthcare providers were not adequately identifying persons with stroke warning signs. Additionally, primary care units are also limited in competent healthcare providers who could provide service for stroke survivals. Many problems required competent health care providers to manage stroke continuity care. Additionally, several qualitative researches on stroke survivors have recommended about stroke services. The result revealed that problem of cerebrovascular patient care was readmission. Caregivers abandoned and refuse continuation care at home because of patient illness, lack of medical instruments, difficult to care, difficult to move, and communication problems. Problems of caregivers were lack of knowledge and experience, lack of caregivers, health problem or old age, economic problem, and residential problem. Problem of health care team were lack of good discharge planning and inefficient referral system. Most of health care providers and clients need home health care services (Pumcharoen, 2007). Additionally, Teerata (2010) studied about multidisciplinary patient care team experiences for stroke patient at a secondary hospital in center region. The results showed that they have the problems about difficulties in assessing patients with stroke, the function of multidisciplinary care team in caring stroke patients was space of collaboration. So, they recommended reducing the gap of working to promote quality of care. The Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health (2012) reported the prevalence rate and admission rate of stroke patients, in the year 2010 to 2012, in Kanchanaburi province, were high and increasing every year (see table 3).

66 Table 3 The prevalence rate and admission rate of stroke patients in the year 20102012 in Kanchanaburi province

Province

Kanchanaburi

2010

2011

Prevalence

Admit

2,414

2288.55

Prevalence Admit 2,834

3337.64

2012 Prevalence

Admit

2,826

3366.99

Moreover, Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health (2012) Ministry of Public Health reported 32,210 new stroke patients in the year 2011 with a prevalence rate of 50.56 per 100,000 populations. There were a total of 140,243 stroke patients in the year 2007 to 2011. New stroke patients, separated by gender, total led to 18,000 males and 14,210 females. This study was be conducted in the setting of Kanchanaburi province. These provinces are vast areas and combine urban and rural settings. Kanchanaburi is the largest of the central provinces. This province is located in the west of Thailand, and is situated 129 km from Bangkok and covers a total area of approximately 19,483 km². Kanchanaburi is subdivided into 13 districts. There are populations of about 734,394 people (Kanchanaburi province, 2013). This study was start at Paholpolpayuhasena hospital and focus on subjects in the Muang district. Paholpolpayuhasena hospital is a general hospital with 440 beds. The service of the outpatient department was approximately 479, 224 peoples in 2014. Stroke is treated as a neurological disease, and stroke fast track system. Admission rates of stroke patients at Paholpolpayuhasena hospital were 1593, 1544, and 1633 persons in 2012, 2013, and 2014 respectively and from October 2013 to May 2014 there were 391 ischemic stroke patients. They have stroke fast track program that was organized in 2012. In this group they received recombinate tissue plasminogen activator [rt-PA] 23 persons (Paholpolpayuhasena hospital record, 2014). When the stroke patient arrives at hospital he/ she will be checked following the guideline of the neurological society of Thailand such as almost all stroke patients will be scanned by Computer Tomography [CT] for diagnosis, special treatment and admitted. If the patient is in crisis he/ she will be admitted in I.C.U. When recovering he/ she will be moved to

67 medical ward. When the stroke survivor is in vital signs stable and out of the crisis he/ she will be prepared for going home by nurses and other health care provider. For referral system, some patients who live in the Muang district, they will be visited at the home and appointed to be follow up around 2-4 weeks after discharge. Especially, the summarized of Paholpolpayuhasena hospital that the barriers to continuing care for stroke survivors including Paholpolpayuhasena hospital has not specific for stroke patient care and rehabilitation ward. Hence, system such as lacking of the standard for monitoring and evaluation about stroke rehabilitation may still have problems and solutions. So, stroke survivors and caregiver lacked of rehabilitation knowledge and skill. Especially, to continuing care for stroke survivors after discharge the working connection in the hospitals is not smooth now, there are home visit team from home health care department but they visit for general and the continuing rehabilitation service after discharge for stroke are not sufficient (Paholpolpayuhasena hospital record, 2014). In role of community nurse at PCU, nurse in PCU have routine home visit. However, there are 2-3 community nurses in each PCU that shortage of health professionals staff and insufficient resources. Therefore, their home visit and continuing care for stroke survivors may incompletely performed care. Healthcare services are also lack of specific service systems, long-term and chronic care for stroke survivors (Kositamongkol, 2015). Also, inadequate preparation and the ineffective coordination among staff from hospital and PCU. Paholpolpayuhasena hospital showed the high occurrences of rehospitalization in stroke patients with 887/ 927, 892/ 932, and 1082/1121 persons/ times in 2012, 2013, and 2014 respectively (Paholpolpayuhasena hospital record, 2014). In brief, most importantly, the above stroke statistics show that the high prevalence rates of stroke patients are increasing every year. Stroke survivors face many types of challenges when returning to everyday life after stroke. Stroke disease is associated with progressively severe symptoms such as inability to perform normal activities of daily living, and depression, which may have a negative impact on a patient’s HRQoL. The rehabilitation nursing care of patients with stroke is aimed at assisting each individual to improve his or her of self-care by providing patient and family education, promote physical activity, and promote psychological support. However, rehabilitation knowledge and training alone is not sufficient to overcome

68 rehabilitation of stroke survivors. Therefore, it should suggest that the quality improving process should be implement especially at Paholpolpayuhasena hospital by efforts at promoting rehabilitation must go beyond the individual level and to the family and community level. Involving family, social support networks, the health care provider of the hospital/ community in rehabilitation can be justified on grounds not only of effective functional status change, but also of satisfy his/ her health perception, and HRQoL.

The home-based rehabilitation nursing program [HRNP] In order to achieve specific outcome, the expect outcome in this study are functional status, health perception, and HRQoL. The researcher intends to develop the home-based rehabilitation nursing program [HRNP] by synthesize the problems of previous intervention studies. Previous studies reported decrease in both QoL and HRQoL after stroke (Edwards, Koehoorn, Boyd, & Levy, 2012). Some studies showed at 3 months after stroke an unsatisfactory QoL (Rachpukdee, 2007). Some previous studies showed poorer HRQoL after post-stroke 3 to 9 months (NicholesLarsen et al., 2005). Moreover, Naess, Waje-Andreassen, Thomassen, Nyland, & Myhr, (2006) studied HRQoL among young adults with ischemic stroke on long-term follow-up of 6 years. They found reduced scores in HRQoL correlated with fatigue and depression. Stroke patients who were depressed, suffered from fatigue, or unemployed were correlated with low HRQoL. Moreover, individual factors were identified as a powerful when related to HRQoL in stroke survivors. Lai et al. (1995) examined the prognosis for survival after an initial stroke in 662 patients who remained alive at least 30 days. They found older age and number of neurological deficits at the onset of initial stroke increased risk of death when compared with patients of the same age, stroke severity and comorbidities. Also, Ahlsio, Britton, Murray, and Theorell (2012) found depression and anxiety to be of similar importance for quality of life as was physical disablement. Therefore, stroke rehabilitation and individual factors have been associated with poorer HRQoL in stroke survivors. A previous experimental study in Thailand showed that nursing intervention with a rehabilitation program for stroke survivors improved quality of life and functional ability after a 3 month follow-up measurement (Khampolsiri, 2005).

69 In summary, stroke survivors are associated with progressively severe symptoms and impact of physical, psychological, and social from stroke disease, which may have a negative impact on a patient's HRQoL. It is critical for nurse to provide the opportunity for stroke survivors to heighten their self-care and gain their knowledge in recognizing the signs and symptoms after stroke. Better knowledge improved self-care in ADL and can give stroke survivors more control of their daily lives and are expected to help their deal better psychological and social function (e.g. In their role in family). As a result, they may have an influence on their HRQoL state. If their can take better care of themselves and adhere to stroke treatment, it can be expected that they will have fewer symptoms and better functional status, feeling better health perception leading to improved HRQoL. To start the HRNP activities the researcher considers timing fter stroke occurred. Sacco et al. (1999) concluded that about 30 % of survivors are independent within 3 weeks, and by 6 months this proportion rose to 50 %. So, the participants in this study must had experienced first stroke attack and had been discharged around 6 month before the research. Hence, for Thai adults following stroke are necessary to help them to improve HRQoL by 12 week of three phases. The intervention activity of program as follow and the development of HRNP intervention by integration the HRQoL, the rehabilitation nursing concept, and EBP was shown in the table 4. Phase I: Comprehensive individual need assessment and planning, in this phase the objective is to identifying needs and planning. The researcher begins with identifying needs. The researcher assesses participants’ illness experience such as biological, physical functioning, health perception, psychological factor, social, and overall quality of life. Moreover, researcher test function, physical examination, and patient’s perception such as emotional, cognitive state to examined the relationships of symptom. All of these the researcher can determine their impairment and need specific skill. The researcher, stroke survivors, and caregiver share the planning process, setting goal together, and plan to work toward achieving the goals. Phase II: Individualized home-based rehabilitation, in this phase the objective is to gain more knowledge. The researcher provides education and skill training e.g. basic knowledge about stroke, healthy eating, risk factors of disease, and enhance the skill of modifiable behavioral risk factors disease. The researcher

70 explains the principles of physical activity. For example, exercise can have an effect on absolute health (physical, mental, and social health), benefit the everyday activity of the body’s movement, have a beneficial effect on several stroke risk factors, and promote physical activity. All of these activities and training the participants can relearning and changed in pathological state and complications from stroke disease. From reviewing the literature on rehabilitation nursing, there are recommended including a stroke handbook, a pamphlet, and a CD about stroke are positive outcomes. Hence, the researcher bring a handbook, pamphlet, and CD about stroke disease that developed by Prasat Neurological Institute (2015) and selects some materials (e.g. pamphlet, and CD about stroke disease) as appropriate to each person. Moreover, the researcher will develop a record form for daily monitoring of exercise training, and a flow chart for monitoring complications that can be used to record the exercise activities of stroke survivors and track data concerning the frequency of physical activities, amount of exercise, occurrence of illness and its treatment during the period of the program and prevent complications occur. Moreover, the team can check when visits at the stroke’s home from their plot and records. Phase III: Continuing comprehensive care, in this phase the objective is to promote psychosocial care and support by the team, the team that set up before start the intervention will continue to support them in the program for week 6-12. The team must home visit 1-2 times, and a telephone visit 1-2 times. When team do home visits, the team discusses the performance of new lifestyle changes and the problems occurring at their home visits in order to find solutions and other support. For telephone visits by the team, the team must telephone call to the home’s subject in order to ask and assign subjects to practice each skill at home under family supervision, which leads to a decrease in the psychological symptoms. The researcher also monitors the team in providing care and consults together.

71 Table 4 Development of HRQoL, the rehabilitation nursing concept, and EBP to the HRNP

The HRQoL concept

The rehabilitation nursing

The HRNP

(Wilson & Cleary, 1995)

concept and EBP

process/ activities

1. Biological and

1. Comprehensive

The HRNP activities:

physiological variables are

assessments such as

1. Comprehensive

described as focusing on

physical assessment,

assessments such as

function which would be

medical diagnoses,

biological, physical,

assessed through such

symptom status, physical,

health perception,

indicators as laboratory

emotional, and cognitive

psychological factor,

tests, physical assessment,

symptoms

social, and overall

and medical diagnoses

2. Management of complex

quality of life, test

2. Symptom status

responses of individuals,

function, physical

dimension refers to disease-

families, groups and

examination, and

related symptoms, physical,

communities to actual or

patient’s perception

emotional, and cognitive

potential health problems

such as emotional,

symptoms perceived by a

stemming from altered

cognitive state to

patient

functional ability and

examined the

3. The functional status

altered lifestyle (resulting

relationships of

comprises self-care,

from physical disability or

symptom dimension

mobility, and the capacity to chronic illness)

refers to disease-

perform various familiar

3. Synthesize complex data

related symptoms,

and role functions

to formulate decisions and

2. Researcher,

4. General health

plans that optimize health,

patient, and caregiver

perceptions refer to health

promote wellness, manage

make planning by

perceptions of stroke

illness, prevent

make a mutual plan

survivors by the affected

complications or secondary

and goal setting

individual of his/ her health

disabilities, maximize

3. Provide education

or suffering and associated

function

e.g. provide basic

with physical, mental and

knowledge about

72 Table 4 (continued)

The HRQoL concept

The rehabilitation nursing

The HRNP

(Wilson & Cleary, 1995)

concept and EBP

process/ activities

social health domains

4. Nurses integrate

strokes, enhance the

5. Overall quality of life is

education, research, and

skill of modifiable

described as subjective

consultation into their

behavioral risk factors

well-being, which means

clinical practice role.

disease,

how happy or satisfied

5. Collaborate relationships

4. Skill training by

someone is with life as a

with nursing peers, the

relearning skill in

whole. The influence of

interdisciplinary team, and

activities of daily

individual characteristics

others who influence the

living

categorized as demographic, healthcare

5. Collaborate to

psychological, and

continue promote

biological factors that

psychosocial care and

influence health outcomes.

support by the team,

The influence of

team do home visit

characteristics of the

and telephone visit

environment categorized as either social or physical which have a conglomerate of external conditions that influence the life of a human being, social environment including the influence of family, friends, and health care providers, Physical environment characteristics are those settings such as the home, neighbourhood, and

73 Table 4 (continued)

The HRQoL concept

The rehabilitation nursing

The HRNP

(Wilson & Cleary, 1995)

concept and EBP

process/ activities

workplace that influence health outcomes either positively or negatively

In summary, both concepts offer potential to develop program to improve stroke survivors’ health. Moreover, in this study integrated with evidence from previous studies the strategies/ activities consist of comprehensive assessments, planning, education, skill training, collaboration with team of health care team, continuing enhanced support, home visits and telephone visits (ARN, 2014; Wilson & Cleary, 1995) In brief, the researcher will apply Wilson and Cleary’s model (1995) of HRQoL integrated with the concept of nursing rehabilitation and previous study brings lead continuing rehabilitation to merge with taking care at home call “Homebased rehabilitation nursing program”. The aiming is to improve functional status, health perceptions, and HRQoL in Thai ischemic stroke survivors. The HRNP may enable the stroke survivor’s recovery from impact of stroke by depending on the rehabilitation needs of the individual, and should begin once the condition of the patient permits around one month after discharge. Stroke survivors will benefit from organized and pertinent rehabilitation services, concern with the severity of the stroke, age, timing of rehabilitation, setting, and continue care approach throughout the person’ s rehabilitation process in the home, establishing a team to provides necessary for effectively at home. The intervention process, the researcher makes assessment of the patient’s need, develop a plan of care, implements that plan both educating and skill training, and continue psychological support in the home by team. All of these activities organize into three phases for 12 weeks intervention that may appropriate response the role of the nurse is to carry out that activity, the patient and the caregiver may decrease the impact of stroke on physical, psychological, and other factors affecting stroke survivors. The results might improve functional status, health

74 perceptions, and HRQoL among stroke survivors. An overview of the statements and significance of the problems is described in chapter 1, a more detail of the research methodology is present in chapter 3.

75

CHAPTER 3 RESEARCH METHODOLOGY This chapter presents the research methodology including research design, research setting, population and sample, sample size, research instruments, quality of instrument, protection of human subjects, intervention and data collection, and data analysis.

Research design This study was a quasi-experimental research design, two group pretest posttest design. The purpose of this study was to test the effectiveness of the homebased rehabilitation nursing program [HRNP] on functional status, general health perceptions, and HRQoL among ischemic stroke survivors. The experimental group receives a12 -week intervention program, whereas the control group receives usual care. The outcomes in both groups were measured at the baseline, week 4, week8, and week 12 after the baseline measurement. The research design of this study looks as follows (Figure 3).

E

O1X1

C

O5 WK1st

X2O2

X2

O6 4WK

X3O3

O7 8WK

X3

O4

O8 12WK

E = Experimental group, C = Control group X1 = Intervention phase 1 (Wk1), X2 = Intervention phase 2 (Wk2-6), X3 = Intervention phase 3 (Wk7-12) O1, O5 = Collect data at baseline, O2, O6 = Collect data at week 4 O3, O7 = Collect data at week-8, O4, O8 = Collect data at week-12

Figure 3 The research design of this study

76

Research setting This study was conducted in the Muang district, Kanchanaburi province, Thailand. The Muang district covered 23 communities and had one government hospital was Paholpolpayuhasena hospital. The study was conducted with Thai adult, who live in Kanchanaburi province and used health care services at Paholpolpayuhasena hospital. Paholpolpayuhasena hospital is a general hospital and treats stroke disease and has a capacity of 440 beds. The hospital has a policy to fast track stroke patients in order to decrease mortality, complication, and disability in patients who have had ischemic stroke occlusion symptoms or TIA. When the stroke patient arrives at the hospital he/ she is checked according to the guidelines of the neurological society of Thailand e.g. almost all stroke patients were scanned by CT for diagnosis, special treatment and admitted. If the patient is in crisis he/ she will be admitted in I.C.U. When recovering he/ she will be moved to the medical ward. When the stroke survivors show stable vital signs and are out of the crisis he/ she will be prepared for going home by nurses and other health care providers. Some patients who live in the Muang district, will be visited at home and appointments made to follow up around 2-4 weeks after discharge (Paholpolpayuhasena hospital report, 2014). Paholpolpayuhasena hospital admitted 1593, 1544, and 1633 stroke patients in 2012, 2013, and 2014 respectively (Paholpolpayuhasena hospital report, 2014). Hence, there are about 130-150 stroke survivors per month that came to the Paholpolpayuhasena hospital. Moreover, the hospital organized visits to those who lived in the Muang district area. Patients were visited after discharge in accordance with their policy of chronic care. However, the home visit team visited almost all patients after discharge. The frequency of home visits per person was once a month. Hence, they did not have a program for home visits specifically designed for stroke survivors. They had home health care team for general visits and individual counseling. They had a monthly plan for a multidisciplinary team to provide ongoing care at 10 PCU, but they did not have a specific team for stroke patients and rehabilitation (Paholpolpayuhasena hospital report, 2014). However, stroke illness creates complex problems for survivors that short time care not be able to solve all their problems.

77

Population and sample The population of the present study was comprised of adults who had been diagnosed with ischemic stroke, were living in the Muang district, Kanchanaburi province, and were treated at the Paholpolpayuhasena Hospital in 2015-2016. The sample in this study was ischemic stroke survivors who met the inclusion criteria as follows: 1. Adult patient who aged 30-65 years old 2. They had first stroke attack and had been discharged around 6 month 3. Slightly to moderate disability level when assessed by the modified rankin scale (MRS scores 2-4) 4. No cognitive impairment when completing the Chula mental test [CMT] (CMT must more than 14 scores) 5. Able and understand communication in Thai language 6. Willing to participate in the study 7. Had one person (a family member) who lived with them, a major caregiver to assist rehabilitation. Inclusion criteria of caregivers 1. Caregiver had access to a telephone 2. Willing to participate in the study Exclusion criteria If the subjects had increase cognitive impairment or due to serious illness from the stroke or co-morbid disease they may not continuing the program.

Sample size To determine sample size in this study, based on Hedger’1982 formula and previous studied of Chalermwannapong et al. (2010) that examined the effect of transitional care program on functional ability and quality of life of stoke survivors. The result showed that the mean score of functional ability in the experimental group was 33.77 (SD = 5.02) and in the control group showed the mean score was 27.79 (SD = 9.97).

78 Hence, the criteria of the significant level of .05, power of .80, and effect size of .80 were used; the required need sample size was 25 persons per group or all sample size 50 persons (25*2 = 50) (Polit & Hungler, 1987) (see sample size determination appendix I). However, there was only 48 stroke survivors completed all aspects of study. The intervention group (n = 24) and the control group (n = 24). Sampling procedures The simple random sampling method was used to obtain qualified samples in this study. The following steps were used to recruit the samples: Step 1: The researcher recruited these stroke survivors based on their health records from stroke’s clinic department of Paholpolpayuhasena hospital between January-February 2016. The researcher reviewed records of subjects who were aged 30-65 years old, first diagnosed with ischemic stroke and had been discharged around 6 month before the research (inclusion criteria 1 and 2). Step 2: The researcher met the stroke survivors at stroke’ clinic. The researcher explained the study to stroke survivors who identify possible participants. The participants were invited to ask questions, details of the consent were explained to the participant, read and sign a consent form before joining groups. Step 3: The researcher screened for level of impairment by the modified rankin scale [MRS scores 2-4], screened for cognitive impairment by the Chula mental test [CMT] (CMT must more than 14 scores) (inclusion criteria 3 and 4). Step 4: The researcher screened the stroke survivors who eligibility was yield 60 subjects. There are only 48 stroke survivors were met the following criteria. The random assignment technique was done as follows; a note indicating that group 1 (control group) and group 2 (the HRNP group), which the researcher had already set up. This random assignment of the provision of subjects into two groups was aimed to prevent biases of the recruitment process. For group matching it begin by grouping male and female patients before randomly selecting them. Each group contained 24 participants

79

Research instruments The research instruments used in this study were divided into three types. The first was a screening instrument, the second an instrument for data collection, and the third type was an intervention instrument. 1. The screening instruments There were two screening instruments, the CMT, and the modified rankin scale (Appendix 1). 1.1 To screen a stroke survivor’s cognitive level this study used the CMT. This questionnaire was used to screen the level of cognitive impairment among older adults. The CMT was developed by the Jitapunkul, Lailert, Worrakul, Sriokiatkhachorn, and Brahim (1996) to assess the cognitive function of elderly who had difficulties in reading and writing. There are 13 items measuring cognitive function. Responses to the items are coded on a dichotomous scale of 0 (incorrect) and 1 (correct), in which item 5 and item12 had two-sub scales, and item 3 and item 13 had three sub-scales. The total possible score from all items measuring cognitive function ranged from 0-19. The summed score represented the cognitive function. The interpretations of the categorical cognitive function are as follows: Score 0-4 means severe cognitive impairment Score 5-9 means moderate cognitive impairment Score 10-14 means mild cognitive impairment Score 15-19 means normal cognitive impairment The content validity of the CMT was determined by an expert panel of two neurologists, two psychiatrists, and two psychologists. The CMT was administered to 212 residents of the home for the elderly in Bangkok (Jitapunkul et al., 1996). The results showed that concurrent validity was indicated by the strong correlation with both the mini mental state examination [MMSE] (r = 0.78) and the abbreviated mental test [AMT] (r = 0.76). Criterion validity was demonstrated by the ability of the CMT to detect clinically diagnosed dementia with a sensivity of 100 percent and a specificity of 90 percent (Jitapunkul et al., 1996). The results of the CMT reliability testing using test-retest kappa coefficient and Cronbach’s alpha internal consistency coefficient were 0.65 and 0.81, respectively (Jitapunkul et al., 1996). This test was used on Thai older adult studies (Jitapunkul et al., 1996). Moreover, a previous study

80 used CMT to test the cognition of stroke survivors is Khampolsiri (2005) (Appendix 1). 1.2 The MRS is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability, and it has become the most widely used clinical outcome measure for stroke clinical trials. It was originally introduced in 1957 by Dr. John Rankin of Stobhill Hospital Glasgow, Scotland (Van Swieten, Koudstaal, Visser, Schouten, & Gijn, 1988). The scale runs from 0-6, running from perfect health without symptoms to death (Appendix 1). Modified rankin scale [MRS] 0 = No symptoms at all 1 = No significant disability despite symptoms; able to carry out all usual duties and activities 2 = Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 = Moderate disability requiring some help, but able to walk without assistance 4 = Moderate severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 = Severe disability; bedridden, incontinent, and requiring constant nursing care and attention 6 = Dead This study selected stroke survivors with a score of the 2-4 on the MRS meaning slight disability to moderate severe disability. Moreover, previous studied widely used MRS to determine neurological patients for instance Punthasane and Vejapanpesaj (2010) and to determine function in post stroke is Abubaker and Isezuo’ study (2012). The MRS is widely used in acute stroke trials (Sulter, Steen, & De Keyser, 1999) and can assessed within 14 days post stroke and re-evaluated at 1, 3, and 6 months (Duncan, Lai, & Keighley, 2000) 2. The instrument of data collection There were two types of instruments used in data collection. They included the demographic record form, and the instrument of outcome measurement. The

81 instruments of outcome measure are the BI, the Thai GHQ-12, and the SF-36. 2.1 The demographic record form The demographic record form developed by the researcher includes 15 items of the subject’s data and socioeconomic data such as age, gender, education level, career, marital status, religion, income, having caregiver, co-morbid, medicine usage, hospital usage, currently smoking, currently alcohol intake, and type of health insurance scheme use. 2.2 The BI In this study were used the BI of the Prasat neurological Institute of Thailand to assess the functional status among stroke survivors. The BI which gives a score ranging from 0 to 100. It can categorize 5 grades of very severely disabled (score 0-20), severely disabled (score 25-45), moderately disabled (score 50-70), mild disabled (score 75-95) and independently (score 100). The top score implies full functional independence, but not necessarily normal status. BI comprises 10 items measuring feeding, bathing, grooming, dressing, bowel control, bladder control, toileting, chair/ bed transfer, ambulation and stair climbing. The BI score is highly correlated with independent functional ability. Additionally, the BI score can assess the change in functional outcomes in stroke survivors who undergo rehabilitation. The BI assesses 10 activities of daily life, 8 of which can be described as self-care activities, and 2 as mobility related activities. The BI widely used in stroke trials (Sulter et al. 1999). 2.3 The Thai general health questionnaire [Thai GHQ-12] In this study the Thai GHQ-12 was used to assessed the health perceptions of stroke survivors. The GHQ was a well-known instrument for measuring minor psychological distress and has been translated into a variety of languages. In this study the Thai GHQ-12 of Nilchaikovit et al. (1996) was used. The original GHQ was developed by Goldberg (1972) and translated into Thai and administered to a sample of 100 people at a clinical psychiatry health care unit in Nongchok district, Bangkok. Clinical psychiatric interview by psychiatrists was used as a gold standard. Sensitivity, specificity and area under the receiver operating characteristic curve [ROC], as well as the internal consistencies of items were calculated. The result of the study showed that all versions of the Thai GHQ [Thai

82 GHQ-60, Thai GHQ-30, Thai GHQ-28, and Thai GHQ-12] had good reliability and validity, with the range of Cronbach’s alpha coefficients from 0.86 to 0.95, and the range of sensitivity and specificity from 78.1 % to 85.3 % and 84.4 % to 89.7 % respectively. The GHQ-12 itself comprises six items that was positive descriptions of mood states (e.g "felt able to overcome difficulties") and six that are negative descriptions of mood states (e.g. "felt like a worthless person"). The GHQ-12 comprised of positive and negative items as follow: The positive item consisted of 1, 3, 4, 7, 8, 12 The negative item consisted of 2, 5, 6, 9, 10, 11 In conclusion, the Thai versions of general health questionaire developed to use as a self-administrative screening instrument in the Thai population (Nilchaikovit et al., 1996). The scale consists of 12 items and each one assesses the severity of a mental problem over the past few weeks. The score was used to generate a total score ranging from 0 to 12. The positive items were corrected from 0 (always) to 1 (never) and the negative ones from 1 (always) to 0 (never). High scores indicate worse health (Appendix 2). 2.4 The Thai SF-36 [SF-36] The SF-36 questionnaire is a tool commonly used as a generic measure to assess HRQoL. Since its translation into Thai in 2000 (Lim, Seubsman, & Sleigh, 2008) the SF-36 health survey has been used extensively in many different clinical settings in Thailand. The Thai SF-36 instrument was found to be reliable and valid for use in a general non-clinical population. Its popularity has increased despite the absence of published evidence that the translated instrument satisfies scoring assumptions. The SF-36 Thai version was developed by Leurmarnkul and Meetam (2005). The SF-36 Thai version was proved by using the forward-backward method and tested on construct validity and internal consistency reliability. Four hundred and forty eight people were administered the retranslated version. Multitrait scaling analysis was used to examine the item-scale correlations and item discriminant validity. The results showed that the amount of missing data was low (1.20 %). Factor analysis showed that factor correlation of the new version were comparable to that found in the old version. Cronbach’s alpha coefficients of the new version exceeded the 0.7 level (0.72-0.86) in all dimensions.

83 This study, in order to assess the health related quality of life, used the Thai SF-36 [SF-36]. The SF-36 includes 35 item scales and 1 reported health transition to measure in 8 dimensions: Physical functioning (10 items in question 3), role limitations due to physical health problems (4 items in question 4), bodily pain (question 7 and 8), social functioning (questioning 6 and 10), general mental health , psychological distress and well-being (5 items question), role limitations due to emotional problems, vitality, energy or fatigue (4 items: question ), general health perceptions (5 items: question 1,2 and 11a-11d ). The scoring followed SF-36 scoring criteria. The response for each item is recorded with a value from 0-100. The scale is calculated without missing items. If more than 50 % of the items are missing from any scale, it cannot be calculated. A higher score indicates a better quality of life. The SF-36 items and scales are scored so that a higher score indicates a better health state. For example, functioning scales are scored so that a high score indicates better functioning and the pain scale is scored so that a high score indicates freedom from pain. After data entry, items and scales are scored in three steps; 1. Item recoding, for the 10 items that require recoding 2. Computing scale scored by summing across items in the same scale (raw scale scores) 3. Transforming raw scale scores to a 0-100 scale Previous studies used the SF-36 by Roopsawang, Aree-Ue, and Putwatana, (2001), Jirattanaphochai, Jung, Sumananont, and Saegnipanthkul (2005), Jumpangern (2007), Ruangpowpun, Khuwatsamrit, Junda, and Kanogsunthrnrat (2007). In this study, the researcher used the Thai SF-36 of Leurmarnkul and Meetam (2005) to measure three times comprising the baseline, week-4, and week-8 for final outcome. 3. The intervention instruments Instruments for intervention are the HRNP, and the materials for promoting home-based rehabilitation among stroke survivors (Appendix 3). 3.1 The home-based rehabilitation nursing program The HRNP is a set of nursing rehabilitation activities developed by the researcher. It highlights individualize ischemic stroke survivors rehabilitating at the stroke survivor’s home. The program was developed from the concept of HRQoL, and integrated with the concept of rehabilitation nursing. The strategies can active

84 ingredients of three phases including: phase I comprehensive individual need assessment and planning, phase II individualized home-based rehabilitation, and phase III continuing comprehensive care (Appendix 3).Moreover, in this study the researcher reviewed literature from previous studies. Some material from previous studies recommended including a stroke handbook, a pamphlet, and a CD about stroke are positive outcomes. The researcher plans to bring a handbook, pamphlet, and CD about stroke disease that developed by Prasat Neurological Institute (2015) and selects some materials (e.g. pamphlet, CD about stroke disease) as appropriate to each person. Moreover, the researcher will develop a record form for daily monitoring of exercise training, and a flow chart for monitoring complications that can be used to record the exercise activities of stroke survivors and track data concerning the frequency of physical activities, amount of exercise, occurrence of illness and its treatment during the period of the program and prevent complications occur (Appendix 4). The team can check when home visits to the stroke victim’s home have occurred from their plot and records.

Quality of instrument The two types of quality of instruments consist of content validity, and reliability. Content validity For content validity the HRNP was judge content validity using four experts who have experience in teaching, practice, and investigating on strokes i.e. medical physician, stroke-nurse specialist, and 2 nursing instructors who are experts in stroke care and psychological care. The four persons were considered about content, language suitability, and arrangement. Researcher was revised according to the recommendation of the experts and developed plan to try out with three stroke survivors who meet the inclusion criteria at Kanchanaburi province in order to assure their understanding of content validity. For the content validity index [CVI] of BI, GHQ, and SF-36 were .95, 1.00, and 1.00 respectively. Reliability Reliability of the Thai version of the BI, Thai GHQ-12, and the Thai SF-36 instruments were tested using Cronbach’s alpha for internal consistency reliability.

85 These questionnaires were piloted with twenty stroke survivors who have similar characteristics to the participants in the study and living in Kanchanaburi province. For the Cronbach’s alpha cofficient of BI, GHQ, and SF-36 were .80, .76, and .90 respectively.

Protection of human subjects Prior to beginning the program, this proposal and its research instruments were evaluated ensure the protection of human rights by the ethical committee of Faculty of Nursing, Burapha University and Review Board Committee of Paholpolpayuhasena hospital. Information from the study will be provided to the stroke survivors and their families. The sampling was informed of the objectives of this study and its depend on their willingness to participate. The study was only possible once the consent form had been signed. Prior to signing the consent form, they were assured about confidentiality and anonymity and were given an opportunity to ask questions about the study. The researcher explained the objectives, procedures of the study, potential risks and benefits of participation and the protection of confidentiality. The study was designed to minimize risks and harm to the subjects. If the subjects were harmed, they would have support of the researcher or referred to the hospital. After receiving permission and conducting inform consent, the data collection procedure began. No permanent record of the study participant’s name and other information was made. Data was kept strictly confidential and reported only as group data. Furthermore, the samples were free to discontinue their participant with the research before it ended. The control group received all materials (as does the experiment group) when the program is completed to protect the patient’s right. The pilot study The pilot study in this study had two objective: 1) to training relevant research assistants in used of implement in the HRNP and 2) to test the HRNP intervention’ benefits, and to refine the intervention was assess the feasibility of a rigorous.

86

Experiment and data collection This study was started after receiving approval from the ethical committee of Faculty of Nursing, Burapha University.After the research ethics of this study were approved, a letter asking for permission to collect the data was sent to the Review board committee of Paholpolpayuhasena hospital. The director had agreed to conduct the study. Prior to data collection and experimentation, the procedure of the initial stage as follows: Initial stage of experiment The initial stage was the preparing step before the start the program. It consisted of the research assistant preparation, the team preparation, and major caregiver preparation Research assistant preparation The research assistants were 2 registered nurses. The researcher selected research assistants that had experience working for more than two years as assistants in this research study. All the research assistant recruiters received orientation before beginning recruitment. Primarily, the researcher was to train them about the objectives of the HRNP, and the set of instruments and the methods for collecting data. This training was consisted of using all instruments. Additionally, the research assistants were trained to correct data and to determine inter-rater reliability, the research assistants independently collected measures on three Thai stroke patients to determine intra-class correlation. Retraining of the research assistants continued until an intraclass correlation of 0.8 is reached. Further researcher was given as data collection is performed. Well prepared research assistants helped increase the internal validity of the instrument. Team preparation Team refers to the group of workers in the HRNP including the researcher, 6 peoples representative from Paholpolpayuhasena hospital include 1 physician, 2 nurses, 1 physical therapist, 1 pharmacologist, 1nutritionist, and 3 community nurses, one main caregiver of stroke survivors, and others who can cooperated working in HRNP at the stroke’s home. The role of each person in team as follows: 1. The representative from Paholpolpayuhasena hospital refers to 1 physician, 2 nurses, 1 physical therapist, 1 pharmacologist, 1 nutritionist of

87 Paholpolpayuhasena hospital who can provide service as a team and/ or delivery. The researcher acts as a collaborator. The most obvious example of collaboration occurs between the researcher responsible for managing care and up to stroke’ problem and share information and exchange finding with other health care worker. 2. The 3 communities’ nurses refer to those community nurses that who can provide service as a team and/ or delivery. They were working at Kaopurang tambon health promoting hospitals, Pakprag subdistrict, Muang district, Kanchanaburi provience. The researcher acts as a collaborator and leader in the work of team building, team building must receive continuous attention and care together. The team must take time to evolve and home visit/ telephone visit. To provide social environment support to the sample, the researcher set up to continuing care after they discharge by make commitment and acknowledgement with the team including 3 steps the follows: Step 1: To establish a collaborative team working 1.1 Development of a collaborative team by the researcher in order to explain the object of the research study. 1.2 For continuous relationship the researcher invites the representative from the Paholpolpayuhasena hospital and the representative from Kuapurang tambon health promoting hospitals who are involved in patient care in their community from the same community to join with the program for 12 weeks. Moreover, it is to secure their commitment to the study and allow staff to participate. Step 2: Refresher workshop about the knowledge of strokes and rehabilitation for the representative from the hospital or the community nurses (the researcher spends 3 hours for the refresher workshop). 2.1 Researcher provided knowledge about strokes and information that facilitates effective development of the program. The team was essential to the research process and the benefits of this study, e.g. how to make a comprehensive assessment. 2.2 Researcher explained the materials used in this study including stroke handbook, pamphlet, record form for daily monitoring of exercise training, and the flow chart for monitoring complications. The researcher confirmed that the patient’s family was monitored daily.

88 2.3 Researcher explained the schedule time for home visit and telephone visit with the team and commitment when the program started. Step 3: Researcher discusses with the team by meeting, telephone or/ and Line application about the problems that stroke survivors encounter for their awareness and to encourage their interest in the research. The researcher commitment with the team about the plans to carry out at stroke patient’s home by setting the appointment dates. The team went to home visit at least two times per month to encourage both the patient and the family, and to telephone call to stroke survivors at least two times per month to enhance psychosocial support. Major caregiver preparation The researcher spent 30-60 minutes for inform of the family/ major caregivers at their home. A caregiver is a volunteer who is the main person taking care of stroke survivors, who want to participate in this study. Initially, the researcher spent 30-60 minutes for orientation about the purpose of the study, procedures, methods, and explaining the concern for protection of the participants was explained. The researcher was trained caregiver to help provide exercise for the stroke survivor. They had trial practice with the researcher before a real practice upon the program. Intervention phase The researcher carried out at the stroke patient’s home by setting the appointment dates for the experimental group to participate. The program content was divided into three phases. The subjects in the intervention group received the 12-weeks intervention at their home and the control group received usual care. Control group 1. The subjects who were assigned to the control group received the usual care. 2. The researcher did not interfere with any treatment or follow up pattern. 3. The subjects in the control group maintain their daily life as usual. The timing for data collection are at baseline, week-4, week-8, and week-12. The program assessment was week-4, repeated again at week-8, and week-12 (last), before finishing the program, the control group of protocols were added if a problem is found.

89

60 subjects at Paholpolpayuhasena Hospital 48 stroke survivors completed all aspects

24 allocated to the control group

24 allocated to the Home-based Rehabilitation Nursing program group

Baseline assessment (Week 0) Qtd - Personal data form

Baseline assessment (Week 0) -Personal data form

- The Barthel Index [BI]

- The Barthel Index [BI]

- The Thai General Health

- The Thai General Health Questionnaire

Questionnaire [Thai GHQ-12]

[Thai GHQ-12]

- The SF-36

- The SF-36

Usual care of

Usual care of Paholpolpayuhasena

Paholpolpayuhasena (Week 0)

hospital and HRNP group at subject’s

Nurses teach general education

home (Weeks 1-6)

about stoke and follow up

Phase 1 (Week 1) Phase 2 (Weeks 1-6) Phase 3 (Weeks 7-12)

Figure 4 The intervention process

Phase I the comprehensive individual need assessment and planning Day 1 meeting 1 (at stroke clinic/ stroke’ home, 1st week 1) (60 minutes) The objective is comprehensive assessment and planning To comprehensive assessment of the information related to health and illness such as socio-demographic characteristics, functional status, psychological, cognition symptoms, their knowledge about stroke, the perception of stroke condition, and social support and to make a mutual plan between the stroke survivors and the researcher. The specific steps involved in assessment and planning activities as

90 follows: 1. The researcher was builds relationships with stroke survivors. 2. Assess learning needs: what does the person know? Is it accurate? What does the person need to know? How does he/ she learn best? 3. Assess other significant factors to gain insight to a person’s problems and beliefs as well as taking into account psychosocial factors. 4. Understanding in order to make changes by setting goals together. 5. Development of a program and plan to work toward achieving the goals. 6. Set time schedule, target dates with patient: what will the end result be? In this phase if the samples have complex problems form analyze the data. The researcher will collaborate with other multidisciplinary colleagues to support in the delivery of rehabilitation. Phase II individualized home-based rehabilitation (at stroke’ home week 1st, 2rd, 3nd, 5th, 6th) Day 2 meeting 2 (at stroke patient’s home week 1st, 2-3 days later meeting 1) (60-90 minutes) The provide education about basic knowledge of stroke 1. Before starting the program the researcher was assessed vital signs of stroke’ survivors. 2. After physical assessment the researcher talking about their health and impairment. During this step, the subject and the family share information. They were share experiences with regard to their knowledge problems and needs including competency, and available resources. 3. The researcher ask about individuals and respond to feedback to share their views of life and their life experience relating the past, present and future. The researcher was monitor subject’s symptoms and complications. Moreover, the researcher was provided a greater insight into their health. 4. To improve their basic knowledge, the researcher identifies the needs of the stroke survivors/ family. These needs include definition, cause, symptom, treatment. 5. After educating activities, the researcher gave the participants feedback about their knowledge of stroke disease.

91 6. The researcher was reminded the dates of the next program with the participant at their home. Day 3 meeting 3 (at stroke patient’s home week 1st 2-3 days later meeting 2) (60-90 minutes) To provide education about healthy eating and modifiable behavioral risk factors disease 1. The researcher assess the patient’s basic physical condition, vital signs, and talk about their health 2. Assess learning needs: what does the person know about healthy eating and risk factors disease? 3. The researcher explained about the overview of healthy eating and modifiable behavioral risk factors disease and share information with regard to his or her problems. 4. After educating activities, the researcher gave the person reflection about healthy eating and modifiable behavioral risk factors disease, how to choose healthy food, and how to reduce risk factors. 5. The researcher was reminded the dates of the next program with the participant at their home. Meeting 4 (at stroke patient’s home week 2nd) (60-90 minutes) To provide individual skill training 1. For the meeting 4, the researcher was monitoring the outcome of meeting 1, 2, and 3, from week 1. All data will be reviewed and determined whether the goals set earlier were met. 2. The researcher assesses such as basic physical assessment, vital signs, and talk about their health. 3. The researcher assesses the ability of stroke survivors for to appropriate of physical exercise. 4. The researcher explained the principles of physical activity. For example, exercise can have an effect on absolute health (physical, mental, and social, health), benefit the everyday activity of the body’s movement, have a beneficial effect on several stroke risk factors, and promote physical activity.

92 5. The researcher explained the basic of physical exercise for example: 5.1 Frequency, at least 3-5 times per week 5.2 Duration, it about least 30 minutes continuously but not more than 1 hour 5.3 Intensity, the highest intensity of physical activity is the maximum heart rate. 6. Researcher demonstrates physical exercise to the patient. 7. Researcher helps the stroke patient practice physical exercise, further education or skill training that they will provide to ensure that the patients have performed the exercise training. 8. The researcher encourage the subject and the family to continually improve training and activities to reduce chances of a stroke in the future. 9. After demonstrating the physical exercise activities, the researcher will evaluate how the patient responded to physical exercise. 10. To assure that the patients adhere to the exercise prescription, the researcher was give and explain the record form for daily monitoring of exercise training, and the flow chart for monitoring complications. 11. The researcher was remind them of the appointment for the next program with the participant at their home in the next week. Meeting 5 (at stroke patient’s home week 3th) (60-90 minutes) To skill training activities in ADL 1. For the meeting 5, the researcher was monitor the outcome of meeting 1, 2, 3, and 4 from week 1-2. All data was be reviewed and determined whether the goals set earlier were met. 2. The researcher assesses such as basic physical assessment, vital signs, and talk about their health. 3. The researcher assesses ability of stroke survivors on ADL due to appropriate training activities that they need. 4. The researcher provided individual skill training activities. For example, training activities consist of help needed with grooming, help needed with toilet use, help needed with bathing, grooming, dressing, help needed with chair/ bed transfers, help needed with walking, and help needed with climbing stairs.

93 5. Demonstrate the procedure of each activity on their needs. 6. Moreover, the researcher was provided education if they have some problems such as with feeding, bowel control, and bladder control. Thus, all necessary skills were be taught and coached to ensure that subjects are able to manage by themselves. 7. Ask the person to repeate the demonstration or restate the information in his or her terms. 8. The researcher was remind them of the appointment for the next program with the participant at their home in the next week. Meeting 6 (at stroke’ home week 4th) (60-90 minutes) To add specific individual skill training 1. For meeting 6, the researcher was monitoring the outcome of meeting 1, 2, 3, 4, and 5 from week 1-3. The researcher checked about their exercise training from the record form for daily monitoring of exercise training. 2. The researcher assesses such as basic physical assessment, vital signs, and talk about their health. 3. The researcher was adding specific individual skill training if needed. The researcher was reminded them of the appointment for the next program with the participant at their home in the next two week. Meeting 7 (at stroke’ home week 6th) (60-90 minutes) To add specific individual skill training 1. For meeting 7, the researcher was monitoring the outcome of meeting 1, 2, 3, 4, 5, and 6 from week 1-5. The researcher was checking about their exercise training from the record form for daily monitoring of exercise training. 2. The researcher was adding specific individual skill training if needed. 3. The researcher explained the role of team about social reinforcement to the stroke survivors. Because this is the last visit of the researcher, the conclusion of the study in order to give recommendations that was useful for the stroke survivors. 4. The researcher was confirm that their family and daily monitor by telephone visit, and explain to them about the team of community nurses who was visit the patient twice a month to encourage both the patient and the family or telephone visit.

94 After that the researcher thank them, give a small souvenir and closes the meeting. Phase III continuing comprehensive care (at stroke patient’s home week 6-12) This step is to promote psychosocial care and support by the team, the team will continue to support them in the program for week 6-12. The team did home visit 1-2 times, and a telephone visit 1-2 times. To continue to promote psychosocial care 1. During the monthly home visits by the team, the team discusses the performance of new lifestyle changes and the problems occurring at their home visits in order to find solutions and other support. 2. Telephone visits by the team. The team was telephone call to the home’s subject in order to ask and assign subjects to practice each skill at home under family supervision. 3. The researcher was also monitor the team in providing regular psychosocial support to the patient and family at least twice a month with the community nurse encouraging the family to assist the patient in sustainable rehabilitation (especially exercise). The summary of the objective and activities in the HRNP intervention was shown in table 5.

95 Table 5 The summary of the objective and activities of the team in the HRNP

Team The

Objective Establishing collaboration

Activities 1. Establishing mutual commitment

representation team working

and collaboration

from hospital

2. Identifying the roles and the potential of the HRNP 3. The researcher explains the tools of the study 4. Researcher discusses the problems of stroke survivors for their awareness to continuing care as the team 5. Understanding in order to plan together

Community

Establishing collaboration

1. Establishing mutual commitment

nurses

team working

and collaboration.

(3 nurses

2. Identifying the roles and the

from the

potential of the HRNP

PCU) and

3. The researcher explains the tools of

other

the study 4. Researcher discusses about the problems of stroke survivors for their awareness 5. Researcher exchanges and refreshes stroke knowledge and the necessary skills to support them after discharge to encourage and provoke interest in the research

96 Table 5 (continued)

Team

Objective

Activities 6. Mutual the team about carry out to home visit by a community nurse Raising awareness of community nurses regarding their significant role in psychological support and visiting once a month to encourage both the patient and the family, and telephone visit for counseling to enhancing psychosocial support and maintaining activities practice

Caregiver

Establishing collaboration

1. Establishing mutual commitment

team working

and collaboration. 2. Identifying the roles

Data collection Data collection procedure was conducted as follows: 1. Data collection began after the participant had signed the inform consent form. 2. At the stroke clinic, the research assistants who were trained by the researcher, were introduced to the objective of the study, research methods, and ask for cooperation in this study. The research assistants assess the CMT, and the MRS. 3. The researcher was selected the prospective subjects who met the criteria and randomly assigns them into intervention group and control group. 4. The research assistants were collected data 4 times using the BI, Thai GHQ-12, and the SF-36 at baseline, week 4, week 8, and week 12.

97

Data analysis After completion of the assessment of the statistical assumptions, the all data were analyzed. The significant level of the hypothesis testing is at .05. 1. The subjects’ demographic data was tested by using the descriptive statistic comprising frequency, percentage, mean, and standard deviation. 2. The instruments of outcome measures were the BI to measure functional status, the Thai general health questionnaire [Thai GHQ-12] to measures health perceptions, and the SF-36 to measure HRQoL. These were analyzed, presenting the mean and standard deviations. 3. A chi-square test was conducted to compare the difference between the experimental and control groups’s baseline measurements on demographic data, such as age, MRS level, income, gender, education, marital status, occupation, comorbidity, smoking, alcohol drinking, medical treatment, and alternative medication usage . 4. A repeated measure multivariate analysis of variance (RepeatedMANOVA) was tested the hypotheses. It was examine the significant combintion mean scores in group of health outcomes (the functional status, health perception, and the HRQoL) with group assignment as the independent between-subjects variable, as the within-subjects variable, and more time points gave a clear indication of how the effect. More time points were increased reliability of measurement.

98

CHAPTER 4 RESULTS The research results were presented into three sections. The first section included characteristics of the participants, the second section reported changes over time of means scores for outcome variables of the participants, and the final section reported the effects of the home-based rehabilitation nursing program on functional status, health perceptions, and HRQoL in persons with ischemic stroke survivors and between control groups.

Part 1 Characteristics of the participants The characteristics of the participants of this study were analyzed by the descriptive statistics which including frequencies, percentages, means and standard deviations. The participants in this study consisted of 48 participants (24 participants in the intervention group and 24 participants in the control group). There were 48 stroke survivors who were eligible to participate in the study. Of the 48, 24 were randomly assigned to the intervention group and 24 to the control group. Both groups have not dropped out. There were 2 participants in intervention group moved outside other province and the investigator was able to continue care by telephone visit. Of the 48 participants, the majority of stroke survivors in both groups were male 18 participants (75.0 %) and 6 participants (25.0 %) were females. The mean age of participants in the HRNP group was 56.75 (SD = 7.742). The mean age of participants in the control group was 55.96 (SD = 6.132). All of the participants in both groups were Buddhists (100 %). The majority of the participants were married (79.2 %) had completed primary school (66.7 %, 54.2 % respectively). The majorities of participants in the HRNP group were employees (33.37 %) and in control group were unemployed (33.37 %). The modified rankin scale [MRS] provides an assessment of degree of disability, the majorities of participants in both groups were slight disability level (58.3 %, 79.2 % respectively). The majority of participants in the HRNP group had incomes of 10,001-15,000 baht per month and in control group

99 had incomes of  5,000 baht per month. All of the participants in both group had caregiver (100 %) and most of them were spouse (60.9 %, 62.5 % respectively). The majority of the both group were currently smoke and alcohol intake 62.5 %. The majority of participants in the HRNP group and control group had universal health coverage 45.8 %. Hence, the participant’ characteristics were analyzed to determine the homogeneity between intervention group and control group by means of the chi-square test (see table 6 and 7). The result showed that there were no significant differences of demographic characteristics of participants between both groups (see table 6 and 7) at baseline.

Table 6 Demographic characteristics of participants

Characteristics

HRNP group

Control group

(n = 24)

(n = 24)

N

(%)

N

(%)

Male

18

(75.0)

18

(75.0)

Female

6

(25.0)

6

(25.0)

< 45

2

(8.3)

1

(4.2)

46-55

6

(25.0)

9

(37.5)

56-65

16

(66.7)

14

(58.3)

X2

p-value

Gender

Age (year)

(Min =33, Max = 65)

(Min = 39, Max = 65)

(Mean = 56.75, SD = 7.74)

(Mean = 55.96, SD = 6.13)

Religion Buddhist

24

(100)

24

(100) .53

Marital status Married

19

(79.2)

19

(79.2)

Single

1

(4.2)

2

(8.3)

Widowed/ Divorced

4

(16.6)

3

(12.5)

.06

100 Table 6 (continued)

Characteristics

HRNP group

Control group

(n = 24)

(n = 24)

N

(%)

N

Without Formal

0

(0)

3

(12.5)

Primary School

16

(66.7)

13

(54.2)

Secondary School

3

(12.5)

2

(8.3)

Diploma and higher

5

(20.8)

6

(25.0)

Occupation Unemployed

4

(16.7)

8

(33.3)

Employees

8

(33.3)

7

(29.2)

Merchant

7

(29.2)

2

(8.3)

Official

4

(16.7)

3

(12.5)

Agriculture

1

(4.2)

4

(16.7)

MRS level Slight disability

14

(58.3)

19

(79.2)

Moderate disability

3

(12.5)

2

( 8.3)

Moderate severe

7

(29.2)

3

(12.5)

Income 3

(12.5)

4

 5,000

5

(20.8)

8

(33.3)

5,001-10,000

7

(29.2)

7

(29.2)

10,001-15,000

9

(37.5)

5

(20.8)

(Min = 2,000, Max = 15,000)

p-value

8.79

.06

.54

.37

2.56

.28

4.86

.18

1.02

1.00

(%)

Education

No income

X2

16.7)

(Min = 2,000, Max = 15,000)

(Mean = 9240.95, SD = 3835.781) (Mean = 9130.00,8526.189) Family caregiver Spouse

14

(58.3)

15

(62.5)

Offspring

6

(25.0)

6

(25.0)

Relative

4

(16.7)

3

(12.5)

101 Table 6 (continued)

Characteristics

HRNP group

Control group

(n = 24)

(n = 24)

N

(%)

N

(%)

Yes

15

(62.5)

15

(62.5)

No

9

(37.5)

9

(37.5)

Yes

15

(62.5)

15

(62.5)

No

9

(37.5)

9

(37.5)

X2

p-value

4.44

.11

Currently smoking

Currently alcohol intake

Type of health insurance scheme Government support Universal health coverage Civil servant medical

6

(25.0)

4

(16.7)

11

(45.8)

18

(75.0)

7

(29.2)

2

(8.3)

benefit

As illustrated in table 6, there were no significant differences in demographic characteristics between the HRNP and control group in terms of: marital status, education, occupation, MRS level, income, family caregiver, currently smoking, and alcohol intake, type of health insurance scheme (p > .05).

102 Table 7 Descriptive statistics related to the health condition of the participants

Characteristics

HRNP group

Control group

(n = 24)

(n = 24)

N

(%)

N

X2

p-value

.82

.55

1.61

.34

.36

1.00

1.02

1.00

.60

.70

3.05

.18

.14

1.00

3.20

.23

(%)

Comorbid Hypertension Yes

14

(58.3)

17

(70.8)

No

10

(41.7)

7

(29.2)

Hyperlipidemia Yes

9

(37.5)

5

(20.8)

No

15

(62.5)

19

(79.2)

Coronary disease Yes

2

(8.3)

1

(4.2)

No

22

(91.7)

23

(95.8)

Renal disease Yes

0

(0)

1

(4.2)

No

24

(100)

23

(95.8)

Diabetic Mellitus Yes

3

(12.5)

5

(20.8)

No

21

(87.5)

19

(79.2)

Others (Gout) Yes

5

(16.7)

1

(4.2)

No

0

(0)

23

(95.8)

Medical treatment Antihypertensive Yes

19

(79.2)

20

(83.3)

No

5

(20.8)

4

(16.7)

Anticoagulant drug Yes

24

(100)

21

(87.5)

No

0

(0)

3

(12.5)

103 Table 6 (continued)

Characteristics

HRNP group

Control group

(n = 24)

(n = 24)

N

(%)

N

X2

p-value

7.11

.01

.60

.70

1.18

1.00

(%)

Hypolipidemic drug Yes

22

(91.7)

14

(58.3)

No

2

(8.3)

10

(41.7)

Diabetic drug Yes

3

(12.5)

5

(20.8)

No

21

(87.5)

19

(79.2)

Alternative medication usage Yes

6

(25)

5

(20.8)

No

18

(75)

19

(79.2)

As illustrated in table 7, the majority of HRNP group and control group had comorbidity which the most disease was hypertension (58.3 %, 70.8 % respectively) and had medical treatment was antihypertensive drug (79.2 %, 83.3 % respectively). Most of the participants in HRNP and control group did not use alternative medication 75 %, 79.2 % respectively) (p > .05). However, only medical treatment was difference in hypolipidemic drug (p < .05).

104 Table 8 Descriptive statistics related to the health condition of the participants

Characteristics

HRNP group

Control group

(n = 24)

(n = 24)

N

(%)

N

X2

p-value

1.23

.46

(%)

rt-PA treatment

Yes

18

(75)

21

(87.5)

No

6

(25)

3

(12.5)

As illustrated in table 8, there was no significant difference of characteristic between the HRNP and control group in the aspects of rt-PA treatment (p > .05).

Table 9 Descriptive statistics of the blood pressure condition of the participants

Variables

SBP

DBP

Groups

Baseline

Week 6

Week 12

(n = 24 per group)

Mean (SD)

Mean (SD)

Mean (SD)

Intervention group

141.50 (12.96)

136.42 (11.34)

128.13 (9.86)

Control group

139.38 (10.23)

139.75 (8.07)

141.33 (9.10)

Intervention group

89.91 (8.93)

84.46 (7.76)

80.63 (7.28)

Control group

88.58 (11.30)

90.04 (10.93)

90.91 (7.57)

As in table 9, the mean of the systolic blood pressure [SBP] level in the intervention group, after receiving the HRNP intervention, the mean SBP level decreased from baseline to week-8 and week-8 to week-12, while in the control group the mean SBP level increased from baseline to week-8 and week-8 to week-12. The mean of the diastolic blood pressure [DBP] level in the intervention group, the mean DBP level increased from baseline to week-8 and week-8 to week12, while in the control group the mean DBP level increased from baseline to week-8 and week-8 to week-12.

105

Part 2 Change over time of mean score and standard deviation of the functional status, health perception and health related quality of life[HRQoL] Table 10 Mean score of the functional status, health perception and HRQoL

Variables

Group

Baseline

Week 4

Week 8

Week 12

(n = 24

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

per group) Functional

HRNP

70.63 (27.73)

86.25 (20.12)

89.38 (16.24)

92.50 (8.34)

status

Control

72.08 (18.35)

83.12 (15.32)

84.58 (15.24)

82.91 (16.21)

Health

HRNP

5.63 (4.42)

1.29 (2.18)

0.58 (1.44)

0.41 (0.20)

Perception

Control

6.63 (4.52)

5.29 (3.8)

4.88 (3.49)

5.20 (3.21)

HRQoL

HRNP

55.29 (9.91)

100.63 (12.69)

117.63 (15.19)

134.12 (7.65)

Control

54.54 (12.14)

83.08 (16.75)

84.21 (17.79)

83.58 (16.42)

As in table 10, the functional status were measured by the BI, health perception were measured by the GHQ and HRQoL were measured by the SF-36 score of the intervention and control group at each point of measurement were presented. The mean of functional status score in the HRNP group was lower than the control group (Mean = 70.63, SD = 27.73 vs. Mean = 72.08, SD = 18.35, respectively) when compared at baseline. However, the intervention group, after receiving the HRNP intervention, the mean scores of functional status increased from baseline to week 4 and increased from week 4 to week 8, and week 8 to week 12 (Mean = 86.25, SD = 20.12 Mean = 89.38, SD = 16.24, and Mean = 92.50, SD = 8.34 respectively), while in the control group the mean score of functional status slightly increased and inconsistent over time. (Mean = 72.08, SD = 18.35, Mean = 83.12, SD = 15.32, Mean = 84.58, SD = 15.24 respectively), However, at week 8 to week 12 the mean score of functional status slightly decrease (Mean = 82.91, SD = 16.21) Moreover, the health perception score of the intervention group and control group was lower than the control group (Mean = 5.63, SD = 4.42 vs. Mean = 6.63, SD = 4.52, respectively) at baseline. Though, the intervention group after receiving

106 the HRNP program, the mean health perception, score decreased over time (Mean = 5.63, SD = 4.42, Mean = 1.29, SD = 2.18, Mean = 0.58, SD = 1.44, and Mean = 0.41, SD = 0.20 respectively), while in the control group slightly decreased overtime. (Mean = 6.63, SD = 4.52, Mean = 5.29, SD = 3.8, Mean = 4.88, SD = 3.49, and Mean = 5.20, SD = 3.21 respectively). For the mean of HRQoL scores in the HRNP group was higher than the control group (Mean = 55.29, SD = 9.91 vs. Mean = 54.54, SD = 12.14, respectively) when compared with baseline. However, the intervention group after receiving the HRNP program, from baseline to week 4 and increased from week 4 to week 8, and week 12 (Mean = 100.63, SD = 12.69, Mean = 117.63, SD = 15.19, Mean = 134.12, SD = 7.65 respectively) Whereas, the mean score in the control group of the HRQoL was slightly increased from at the baseline to week 4 (Mean =83.29, SD = 16.36) week 4 to week 8 (Mean = 84.21, SD =17.79) but there was decrease at week 12 (Mean = 83.58, SD = 16.42). This result supported the research hypothesis 2.

Part 3 Reported the effects of the home-based rehabilitation nursing program on functional status, health perceptions, and HRQoL in Ischemic stroke survivors The assumptions for multivariate analysis of repeated measures MANOVA was tested before data analyzed as follows (Hair, Black, Babin, & Anderson, 2010; Tabachnick & Fidell, 1996). 1. Outlier Fisher’ measure of skewness was calculated by dividing the skewness coefficients value must between -1.96 -+ 1.96 indicate that distribution is significantly. 2. Test of normality For test of normality in this study found the barthel index and general ealth perception were normality, but only the HRQoL not normality. However, it can consider at the scatterplot. The scatterplot of the HRQoL showed normality.

107 3. Independence of observation The researcher had sampling assign the participants to the HRNP group and the control group in order to independence of sample. 4. Homoginity of variance The Box’s test of equality of covariance matrices shown Box’s Mean = 301.26, F = 2.78, p = .000 indicated the observed covariance matrices of the dependent variables are no equal across groups, this study could violated by determined Pillai’s Trace values substance to Wilk’s lamda and sample size are equal (n = 24) (Tabachnick & Fidell, 1996). After test the assumptions were met, thus the effects of the HRNP intervention were presented by the outcome variables as 12 weeks. The results of hypothesis tested by MANOVA with repeated measures were shown in table 11.

Table 11 Comparison measures of functional, general health perception and between groups and, within groups

Effect

Value

F

Hypothesis

Error

df

df

p-value

Between subjects Pillai’s

Group

.56

18.84

3

44

< .001**

.96

1.08

9

38

< .001**

.83

20.54

9

38

< .001**

Trace Within subjects Pillai’s

Time

Trace Time * Group

Pillai’s Trace

** p < .001

As illustrated in the table 11, the results revealed that participants after 12weeks showed an overall between HRNP and control groups were significantly at .05

108 level (V= .56, F(3.44) = 18.84, p < .001). There was also a significant multivariate main effect for time at.05 level (V = .96, F(9.38) = 1.08, p < .001). Moreover, when comparing between group interaction across time, the HRNP group were good health outcome at .05 level (V = .83, F(9, 38) = 20.54, p < .001). This result supported the research hypothesis 1and 3.

Table 12 The multivariate simple effects of functional status, health perception and HRQoLindicators of times within intervention and control groups

Group

Intervention

Value Pillai’s

F

Hypothesis

Error

df

df

p-value

.82

13.90

9

207

< .001**

.78

8.04

9

207

< .001

Trace Pillai’s

Control

Trace ** p < .001

As in table 12, the simple effects of the combination of three dependent variables (functional status, health perception and HRQoL) in four time points. The intervention group had significant simple effects between four time points (V = .56, F (9, 207) = 13.90, p < .001). While the control group were also significant (V = .56, F, F (9, 207) = 8.04, p < .001). Because of the results showed both groups significant, then the pairwise comparison in each group and time interval should be explored (Table 13, 14, and 15).

109 Table 13 Pairwise comparison between the mean difference of functional status in intervention and control group

Group

Time

Time

Mean

SE

p-value

difference baseline

Intervention

Week 4

Week 8 baseline

Control

Week 4

Week 8

Week 4

15.63*

3.13

.00

Week 8

18.75*

3.66

.00

Week 12

21.88*

4.38

.00

Week 8

3.13*

1.03

.00

Week 12

6.25*

2.78

.03

Week 12

3.13

1.99

.13

Week 4

11.04

*

2.59

.00

Week 8

12.50*

2.78

.00

Week 12

10.83*

3.06

.00

Week 8

1.46*

.88

.00

Week 12

-.21

1.36

.06

Week 12

-1.67

.94

.53

P < .05

As illustrated in the table 13 showed pairwise comparison of functional status between groups. At week 12, the functional status was no statistically significant difference between the two groups (P > .05). The pairwise comparison showed no significant of functional status of the HRNP only between week 8 to week 12 (Mean difference = 3.13, SE = 1.99, p = .13). However, in the control group showed no significant of functional status between week 4 to week 12, and week 8 to week 12 (Mean difference = -.21, SE = 1.36, p =.06, Mean difference = -1.67, SE = .94, p = .53, respectively) Yet, the mean score of the functional status in the HRNP intervention group were significantly higher than control group (Table 10). When comparing the mean scores of the functional status at baseline to week 4, week 8 and week 12 were showed in figure 5.

110

Figure 5 Change in functional status between the HRNP and control group at baseline, week 4, week 8, and week 12

As in figure 5, based on estimated marginal means for pairwise comparison using Bonferroni procedure, the mean score of the functional status in the intervention group was increased from baseline to week 4, week 8, and week 12. In the meanwhile, the mean score of the control group was increased from baseline to week 4, and slightly increase at week 8 but decrease at week 8 to week 12. Furthermore, the profiles showed that the mean score of functional status in the intervention group was increase higher than the control group at four time points.

111 Table 14 Pairwise comparison between the mean difference of health perception in intervention and control group

Group

Time

Time

Mean

SE

p-value

difference baseline

Intervention Week 4

Week 8 baseline

Control

Week 4

Week 8

Week 4

-4.33*

.81

.00

Week 8

-5.04*

.86

.00

Week 12

-5.58*

.88

.00

Week 8

-.71*

.02

.02

Week 12

-1.25*

.01

.01

Week 12

-.54

.09

.09

Week 4

-1.33

*

.62

.04

Week 8

-1.75*

.79

.04

Week 12

1.42

.91

.13

Week 8

.42

.47

.39

Week 12

.08

.74

.91

Week 12

.33

.66

.62

P < .05

As illustrated in the table 14 showed pairwise comparison of health perception between groups. At week 12, the health perception was no statistically significant difference between the two groups (P > .05). The pairwise comparison showed no significant of health perception in the HRNP and control group between week 8 to week 12 (Mean difference = -.54, SE = .09, p = .09, Mean difference = -.33, SE = 66, p = .62, respectively). Moreover, in the control group was no statistically significant difference between the baseline to week 12, week 4 to week 8, week 4to week 12, and week 8 to week 12 (Mean difference = 1.42, SE = .91, p = .13, Mean difference = .42, SE = .47, p = .39, Mean difference = .08, SE = .74, p = .91, Mean difference = .33, SE = .66, p = .62, respectively) Moreover, the mean score of health perception in the HRNP intervention group was significantly higher than control group (table 10). When comparing the

112 mean scores of the health perception at baseline to week 4, 8 and 12 were showed in figure 6.

Figure 6 Change in health perception between the HRNP and control group at baseline, week 4, week 8, and week 12

As in figure 6, based on estimated marginal means for pairwise comparison using Bonferroni procedure, the mean score of health perception in the intervention group was decreased from baseline to week 4, week 8, and week 12. In the meanwhile, the mean score of the control group was decreased from baseline to week 4, and week 8. However, between week 8 to week 12 was increased. Furthermore, the profiles showed that the mean score of health perception in the intervention group was decrease higher than the control group at four time points.

113 Table 15 Pairwise comparison between the mean difference of HRQoL in intervention and control group

Group

Time

Time

Mean

SE

p-value

difference baseline

Intervention

Week 4

Week 8 baseline

Control

Week 4

Week 8

Week 4

45.33*

1.84*

.00

Week 8

62.33*

2.75*

.00

Week 12

78.83*

2.01*

.00

Week 8

17.00*

2.27*

.00

Week 12

33.50*

2.02*

.00

Week 12

16.50*

1.71

.00

Week 4

28.58

*

2.13

.00

Week 8

29.71*

2.94

.00

Week 12

29.08*

3.25

.00

Week 8

1.12

1.61

.49

Week 12

.50

2.78

.86

Week 12

-.62

1.84

.74

P < .05

As illustrated in the table 15 showed pairwise comparison of HRQoL between groups. At week 12, the HRQoL mean difference was statistically significant difference between the two groups (P < .05). The pairwise comparison showed significant of HRQoL in the HRNP and control group between week 4 to week 8 (Mean difference = .17, SE = 2.27, p = .00, Mean difference = 1.12, SE = 1.61, p = .49, respectively). Moreover, in the control group was no statistically significant difference between week 4 to week 12, and week 8 to week 12 (Mean difference = .50, SE = 2.78, p = .86, Mean difference = -.62, SE = 1.84, p = .74, respectively) Moreover, the mean score of HRQoL in the HRNP intervention group was significantly higher than control group (table 10). When comparing the mean scores of the HRQoL at baseline to week 4, 8 and 12 were showed in figure 6.

114

Figure7 Change in HRQoL between the HRNP and control group at baseline, week 4, week 8,and week 12

As in figure 7, based on estimated marginal means for pairwise comparison using Bonferroni procedure, the mean score of HRQoL in the intervention group was increased from baseline, to week 4 to week 8, and week 12. In the meanwhile, the mean score of the control group was slightly increased from baseline, to week 4, and week 4 to week 8 and week 8 to week 12 was slightly increases. Furthermore, the profiles showed that the mean score of HRQoL in intervention group was increase higher than the control group at three time points.

115

CHAPTER 5 CONCLUSION AND DISSCUSSION This chapter presents a summary and discussion of the study findings that includes three parts. The first part presents the summary of this study. The second part presents discussion of the research findings which includes the characteristics of the participants, and the effects of the HRNP on functional status, health perceptions, and HRQoL among ischemic stroke survivors. Finally, strengths and limitation, implications, and recommendations for future study are also described.

Summary of the study This study aimed to test the effectiveness of the HRNP and to compare the differences of functional status, health perceptions, and HRQoL between ischemic stroke survivors receiving the HRNP and those receiving usual care at baseline, week 4, week 8, and week 12 after baseline. A quasi-experimental design was used to recruit and allocate the sample. The sample size for this study was a total of 48 participants using simple random sampling and assigned into the intervention or the control group, 24 per group. Implementation and data collection were conducted from December 2015 to May 2016. Variables of all participants were measured 4 times, at baseline (week 0), intervention (week 4), intervention (week 8), and intervention (week 12) after baseline. The instruments of outcome measures were the BI to measure functional status, the GHQ-12 to measures health perceptions, and the SF-36 to measure HRQoL. The CVI of BI, GHQ, and SF-36 were .95, 1.00, and 1.00 respectively. The reliability of all instruments were tested using Cronbach’s alpha for internal consistency reliability and were piloted with twenty stroke survivors who had similar characteristics to the participants in the study and lived in Kanchanaburi province. The Cronbach’s alphas were: for the BI = .80, the GHQ-12 = .76, and the SF-36 = .90. The instruments for intervention were the HRNP. The materials for promoting home-based rehabilitation among stroke survivors included a stroke handbook, a CD about stroke that was developed by Prasat Neurological Institute (2014), a stroke

116 pamphlet, a record form for daily monitoring of exercise training, and a flow chart for monitoring complications. The HRNP had three phases: Phase I, comprehensive individual needs assessment and planning, Phase II, individualized home-based rehabilitation, and Phase III, continuing comprehensive care. Descriptive statistics were used to analyze demographic data. Chi-square was used to compare the differences of characteristics between the intervention and control groups at baseline. A repeated measure multivariate analysis of variance (Repeated-MANOVA) was used to test the hypotheses and compare the difference in mean scores of functional status, health perceptions, and HRQoL between intervention and control groups and across the four assessment points in time. Characterization of the participants showed that the majority of the participants were males, of late middle age, and married. The majority of participants in both groups had completed primary school. The majority of participants in the intervention group was employees and in the control group was unemployed. All of participants were Buddhists. The income in the intervention group was about 10,00115,000 baht per month and the income in the control group was mostly less than 5,000 baht per month. The MRS of participants in both groups showed a slight disability level. All participants had caregivers and most of them were spouses. The majority of both group had a history of hypertension and hyperlipidemia, and most of them used hypertensive, anticoagulant, and hypolipidemic drugs. The majority of the participants had smoking and alcohol intake, and did not use alternative medications. The majority of the participants in both groups had access to universal health coverage through the Thai system. The effect of the HRNP intervention on outcome variables showed that the HRNP intervention could change all outcome variables. Results showed improvement of the functional status, health perceptions, and HRQoL in the mean scores at week 4, week 8, and week 12. Conversely, the participants in the control group had only slight improvements in functional status and HRQoL, and health perception mean scores had slightly decreased over time. This result supported research hypothesis 2. Results revealed that participants after 12-weeks showed an overall health outcome (functional status, health perceptions, HRQoL ) between group (HRNP vs. control) significant improvement at the .05 level (V = .56, F(3.44) = 18.84, p < .001).

117 There was also a significant multivariate main effect over time at the .05 level (V = .96, F(9.38) = 1.082, p < .001). Moreover, when comparing between group interaction across time, the HRNP group showed better health outcomes at the .05 level (V = .83, F(9, 38) = 20.54, p < .001) than the control group receiving usual care. This result supports research hypotheses 1 and 3.

Discussion of the research finding The effects of the HRNP intervention on research outcomes are discussed as follows: 1. The effects of the HRNP intervention on functional status The scores of functional status changed over time from week 4, week 8, and week 12 after initiation, but the HRNP intervention group was not significantly changed when compared with the control group at week 12. However, the functional status mean scores of the HRNP intervention group were higher than for the control group over time. There are many reasons to explain this phenomenon as follows: There are many possible explanations for relative impairments of pathology from stroke. In this study, participants were selected after screening was conducted, including each stroke survivor’s cognitive level by CMT and degree of disability by MRS. This study selected stroke survivors with a score of 2-4 on the MRS, meaning slight to moderately severe disability matching by sex. However, this study was not comparing level of stroke. The level of disabilities in the control group showed moderate disability levels in 79.2 % of subjects, while in the intervention group 58.3 % had this level of disability. However, in the intervention group there was more moderately severe disability than in the control group, 29.2 %, versus 12.5 %. However, this study was not comparing level of stroke or subtype of ischemic stroke. So, the individual underlying pathology may affect individual functional activities and recovery. The important etiologies of ischemic stroke are large-artery atherosclerosis (macroangiopathy), cardioembolism, and cerebral small-vessel disease (microangiopathy). Other causes of ischemic stroke are cervical artery dissection, cerebral vasculitis, coagulopathies, hematologic disorders, and other conditions. The differences in causes may affect the differences in severity, treatments and outcomes of the patients (Songkhla, Tantirittisak, Hanchaiphiboolkul, & Wattanasen, 2014).

118 Hence, underlying pathology may affect the individual functional activities and recovery of subjects in the two groups. This result supports the recommended practices for understanding rehabilitation, that rehabilitative measures target body functions and structure, and personal factors. These measures contribute to a person achieving and maintaining optimal functioning (Finch et al., 2002). Moreover, rt-PA treatment was compared as to the health conditions of the participants. The results showed there was no significant difference in characteristic of treatment between the two groups (p > .05) (table 9). However, the participants in the control group had rt-PA treatment more than the HRNP group. They may have returned to work with less physical impact from stroke than the participants in the HRNP group. Participants in both groups had 100 % caregiving from a spouse or others which may have provided good physical and physiological support. Moreover, most caregivers were spouses, and some may have received more support from others. Participants in the HRNP group had 100 % caregiving, but most caregivers were spouses who did/ could not take care of the stroke survivor all the time. Timing to start this program could have affected its effectiveness. This study was conducted with stroke survivors who experienced a first stroke attack and had been discharged around 6 months before this research. This study could not start with acute care because the design of care must be planned with a multidisciplinary professional team and the family of patients. Thus, it may occur too late for functional recovery. The participants in both groups may also have had spontaneous recovery (Promkaew, 2015). However, findings indicate that the mean scores of functional status in the HRNP group are higher than in the control group over time. The researcher is concerned with restoring and compensating for the loss of patient function, and preventing or slowing deterioration of function. So, after comprehensive assessment the researcher used strategic planning to provide education and exercise training to contribute about increased strength, endurance, and flexibility of joints. In this study education services are the ones most often available. The participants lack knowledge about stroke. They require knowledge on pathology, problem-solving, healthy eating, modifiable behavioral risk factors, preventing complication and recurrent stroke.

119 Exercise training was the most frequent service provided in this study. Exercise training in rehabilitation includes grooming, moving, bathing, walking, and exercise. The researcher conducted this service at the patient’s home, which is most relevant to their problems. This strategic can empower the patient. It is convenient and provides comfort to the stroke survivor. Previous study also suggests that rehabilitation at home is more effective and cheaper (Chaiyawat, 2009; Hui-Chan et al., 2005; Ng et al., 2005; Studenski et al., 2005). These findings support the hypotheses 1, 2, and 3. However, when pairwise comparison were made at each time, findings showed improvement of functional status of participants only from weeks 8 to 12 (p = .13) in the intervention group. In the control group, functional status was unchanged from week 4 to week 12 (p = .06), and from week 8 to week 12 (p = .53). These findings are congruent with Khampolsiri (2005) who studied a home-based nursing intervention for stroke survivors. The results showed that functional ability improved over time in the experimental group, whereas the control group improved at week 6 but remained unchanged at week 12. The results demonstrate that there was no significant difference in functional ability between the two groups at week 12. In addition, this study contrasts with findings by Chaiyawat (2009) that examined the effectiveness of an individual home rehabilitation program for ischemic stroke patients. The result showed that functional status at 3 months was significantly improved in the intervention group over the control group. Moreover, in stroke survivors, several factors that appear to contribute to a change in recovery have been reported such as facilitating beliefs of family caregivers, social support of family caregivers, and rehabilitation behavior (Sornarkas, Deoisres, & Wacharasin, 2015). This study used the principles of the HRNP which are based on the HRQoL concept, the rehabilitation nursing concept, and recommendations from previous studies to test program effectiveness. Results of this study provide basic knowledge and necessary information for nurse and health care providers. It is necessary that nurses make comprehensive assessments and that they develop a plan to increase rehabilitation for stroke survivors and caregivers by focusing on important factors (individual characteristics categorized as demographic, psychological, and biological factors that influence health outcomes). The characteristics of both groups had

120 caregiving that may have affected the functional status of the stroke survivors. Moreover, the home, neighborhood, and workplace can influence health outcomes either positively or negatively (Wilson & Cleary, 1995) 2. The effects of the HRNP intervention on health perceptions The results of health perception findings supported hypotheses 1, 2, and 3.The mean scores of health perception changed at week 4, week 8, and week 12 after initiation of the HRNP intervention group and was significant as compared to the control group (p < .05). Moreover, there was a significant difference in mean scores of health perception across the four assessment times in at least one pair. The HRNP had a major impact on health perceptions as explained below. The HRNP intervention involved providing knowledge and a continually supportive approach. The participants in the HRNP gained more knowledge about prevention of recurrent stroke, a healthy lifestyle, increased physical activity, alcohol consumption as well as that smoking cessation should be encouraged (AHA, 2014). A certain number of Thai stroke survivors were still smoking and/or drinking alcohol (62.5 %). Rates of smoking and/or drinking were high among men. The researcher and team gained more knowledge about controlling risk factors and preventing the complications of stroke. It was clear that risk behaviors such as alcohol drinking and smoking must be stopped. Promoting psychological support is also important. Findings were congruent with a systematic review of the literature of Hafsteinsdottir et al. (2010) that reported the most common needs of stroke survivors and caregivers which involved patients’ moving and lifting, exercises, psychological changes and nutritional issues. Patients and caregivers wanted information that was tailored to their situation. Continuous care management of stroke patients is very important to help them to regain a nearly normal life (Promkaew, 2015). In addition, this intervention used teams for home and telephone visits. This process of the intervention used empathic understanding reflecting and enhancing health perceptions which focus on psychological effects after stroke for controlling feelings and observing problems. Moreover, the participants can telephone to the researcher or health care provider in the team at any time for consultation about their problems. This is an easy way to communicate when they have problems and need

121 help to solve their problems. These findings were congruent with those of Chalermwannapong (2008) who studied the effects of the transitional care program for stroke survivors conducted during and after hospitalization and through the first 4 weeks post discharge. The post-hospital phase included 2 weekly visits at the stroke survivors’ homes and 2 telephone visits. Findings were similar to those in the study of Jullmate et al. (2008) about information for rehabilitation performed by Thai caregivers of elderly stroke patients. The findings suggest that health care professionals should be concerned about positive and negative feelings of stroke survivors. Therefore, positive health perceptions consisting of emphatic understanding, collaboration, motivation, autonomy and responsibility provided useful techniques that were effective in improving the general health perceptions of the stroke survivors. This finding is consistent with reports by Chaiyawat (2009) that examined the effectiveness of an individual home rehabilitation program for ischemic stroke patients. The intervention group was significantly better for generic health status than the control group. In addition, Desrosiers et al. (2007) examined the effect of a home leisure education program after stroke. The study was conducted with 62 stoke patients and there were two intervention groups. The leisure education program took place at home once a week for 8 to 12 weeks. Control participants were visited at home at a similar frequency. The results showed the effectiveness of the leisure education program in improving participation in leisure activities, improving satisfaction with leisure and reducing depression in stroke patients. Moreover, there was also a statistically significant difference between groups with improvement in depressive symptoms with a clear mean difference. Also, this finding was congruent with the study of Rimmer et al. (2000) that examined the effects of a short-term health promotion intervention for a predominantly African-American group of stroke survivors. The results showed increased life satisfaction and ability to manage selfcare needs, and decreased social isolation. Moreover, the author suggested that a short-term health promotion intervention for predominantly African-American stroke survivors could be effective in improving several physiological and psychological health outcomes.

122 Most stroke survivors and their caregiver in this study expressed both positive and negative emotional feelings while providing informal rehabilitation at home. There were several different views about positive and negative feelings during the three different periods. The researcher provided specific care to prevent negative feelings for both stroke survivors and caregivers during the three phases of rehabilitation. Negative feelings were found in caregivers, for example, fear, stress (resulting from not knowing how to take care of the stroke survivor), denial, and anxiety about providing care and rehabilitation. Caregivers still felt that they had insufficient information or inaccurate knowledge about providing rehabilitation or taking care of a stroke survivor at home. Another possible explanation is that providing informal rehabilitation effectively at home requires more precise and specific knowledge, strategies and good practice. Regardless of the explanation, caregivers still needed to know more about physical activities and psychological support at home. Additionally, social support networks, which comprise several useful resources in the community, should be established since these are useful for caregivers providing caregiving to stroke survivors. 3. The effects of the HRNP intervention on Health-related quality of life The mean scores of HRQoL changed at weeks 4, 8, and 12 after initiation of the HRNP intervention and were significant as compared to the control group (p < .05). Moreover, there was a significant difference in mean scores of HRQoL over the four assessments in at least one pair. Possible explanations include the following. Stroke survivors and caregivers may have been well prepared for the intervention at the first home visit. Many activities of the HRNP intervention were used as a guideline to educate and train stroke survivors. The information on stroke guidelines was successfully applied. The educational needs of stroke patients and caregivers were assessed and addressed concerns before planning activities together. The program also assured the family and relatives that they would be able to provide adequate care. Also, believes, values and traditions, which come from Buddhism, are social norms in Thai society which ensure positive caregiving (Division of Health Statistics, Ministry of Public Health, 1996, 1998, 2000, 2015).

123 The basic knowledge included about the clinical aspects of stroke, prevention, treatment and functional recovery, recurrent stroke, and knowledge about modifiable behavioral risk factors. Also, training promoted physical activity and psychological support. The program also used a VDO and handbook material that showed good benefits and were congruent with two previous studies using video material or video scripts (Chanruengvanich, 2005; Chaiyawat, 2009). In phase III, the investigator and team continued with encouragement, support, reinforcement, and sometimes stimulated stroke survivors to adapt their self-care activities. Moreover, in the home setting the caregivers/ family members had an important role to perform. They were trained to assist stroke survivors in exercising, ADL, psychological support. They also were encouraged to motivate stroke survivors to regularly perform activities within the limits of their physical impairments. In this study, most of the participants were married (79.2 %), and had a caregiver. That major caregiver was their spouse. This finding was congruent with those of Chalermwannapong (2008) who examined the effects of the transitional care program on functional ability and quality of life of stroke survivors. Results showed the quality of life of stroke patients in the experimental group was significantly better than for those in the control group. This finding supports other previous research which indicates that the information needs of people following stroke, and of their caregivers, are not being fully met. Information needs still remain important for stroke survivors and caregivers (Jullmate et al., 2008) The researcher cooperated with other health care professionals and this strategy helped the team to provide long-term care. Some studies have shown that interdisciplinary team training develops collaboration, reduces staff burnout, improves rehabilitation implementation, and increases client participation and satisfaction (Corrigan & McCracken, 1999). Moreover, in this study the researcher developed a LINE internet application that used appropriate technologies to connect the team and stroke survivors. For example, the researcher adapted this technology to assign the health professional in the team to home visits, and/or to conference about the health status of stroke survivors.

124 Moreover, in phase 3, the one or two telephone visits by the team or the researcher showed good benefits and confirmed their usefulness. The team made telephone calls to the subjects’ homes in order to ask and assign subjects to practice exercise skills. Psychological support to participants was given and the average telephone call averaged 8.0 minutes per patient. Stroke survivors reported their health status and were satisfied with the HRNP intervention. These strategies were congruent with Chalermwannapong (2008) that employed motivation interviewing with telephone support. Results showed the quality of life of stroke patients in the experimental group was significantly better than for those in the control group.

Strengths and limitation of the study It was clear that continuous care management and rehabilitation was needed for stroke survivors to improve their HRQoL and help them to regain a near normal life. The HRNP developed for this study is effective in improving the health outcome of Thai stroke survivors over 8weeks, and the changes were sustained over the 12 week follow-up period. Nurses and health care providers can apply this program as a guide for providing stroke care and to assist caregivers. Based on findings, the cooperation of all stakeholders was a key success factor of this health project. This program has potential benefits for all communities, especially in urban areas. The manual and model developed in this HRNP can be distributed and used in other communities. Results of this study can be used to inform and guide policies and the development of training programs in other areas. As strengths, we targeted improving functional status, health perceptions, and HRQoL for ischemic stroke survivors and used interventions that were homebased. The researcher was connected with stroke survivors after discharge and on an ongoing basis into their homes for 12weeks. Moreover, a team was established through collaboration with health professionals from Paholpolpayuhasena hospital and a health care team in the community. Health care providers should promote rehabilitation and provide supportive care. This 12 week intervention was developed by building knowledge that emerged in three phases. Phase I was comprehensive individual needs assessment and planning. The process in this phase was assessment and analysis of all existing data and coordination with the team as to any complex

125 problems. Then, there was the setting of goals through mutual goal setting involving stroke survivors, caregivers, and the researcher. Phase II was an individualized, homebased rehabilitation program. The process in this phase was to provide education and skill training strategies. The core knowledge included basic knowledge about stroke disease, healthy eating, modifiable behavioral risk factors, and the core activities of skill training for activities of daily living that addresses patient needs. Phase III was continuing comprehensive care to enhance psychosocial care and support by the team. The processes in this phase were home and telephone visits by the team to ask and assign subjects to practice skills, to provide motivation to continue exercise, and to encourage medication adherence. Non-adherence was a common problem found in this study. Non-adherence can result in recurrent stroke. Stroke survivors may be enabled to perform activities of daily living independently and satisfyingly after stroke. They may be able to minimize the impact of psychosocial impairment. Stroke survivors may improve functional status, health perceptions, and HRQoL. The continuing rehabilitation services through a collaborative team strategies after post-hospital discharge is an important environmental support to help them. So, continuing rehabilitation was also intended to improve the functional status of stroke survivors. Improving independence in performing the activities of daily living is expected to increase stroke survivors’ health perceptions, and HRQoL. Moreover, we provided resources necessary for stroke survivors and caregivers. Lastly, we had multiple data collection points after baseline (3 times) that built confidence in the accuracy of our outcome data. As limitations, the HRNP intervention was only provided to adults whose ages ranged from 33-65 years. Thus, its application to other age groups such as older adults may be limited. Second, this study did not comparing the level of impairment between groups. However, all levels of impairment would have to be considered in the HRNP intervention in order to confirm the program’s outcome. Third, there are other variables that may affect the outcome and which were not controlled (such as MRS level, size of stroke, rt-PA treatment). Forth, this study the parent and community involvement are difficult to address in the HRNP because of time constraints. An important thing that needs to be discussed is the role of the coordinator of the HRNP that would replace the researcher’s role. The coordinator

126 would be a vital part of the HRNP intervention. Lastly, in this study, the HRNP intervention was conducted with adults residing in urban areas. So, the application of this program for adults who live in rural areas may differ and need further verification.

Implications Based on research findings, some implications are given below. In addition, recommendations for future research are presented. 1. Nursing practice Nurses who care for stroke survivors, such as community nurses, can apply the HRNP to help clients to improve their functional status, health perceptions, and HRQoL. The HRNP is a guideline for helping ischemic stroke survivors to improve their self-care for ADL through education and relearning skills for performing the basic activities of daily life. It also caters to special needs such as emotional support and the prevention of complications after a stroke that could lead to readmission. Additionally, this program connects all stakeholders for coordinated care. Thus, this study may motivate nurses to work independently in rehabilitation in homes and/ or together with other professionals. Nurses in communities can gain more knowledge of stroke disease through supportive information to family members, neighbors and volunteers and through providing skills, resources, and emotional support. These strategies will establish and/or strengthening partnerships and networking. 2. Nursing education The results of this study can be used as basic information for nursing professionals or educators to develop a plan to care for ischemic stroke survivors. The HRNP can serve as a guideline to teach nursing students and staff nurses. In addition, this program can prepare staff for teaching and contributing to other members of the health care team. Staff development efforts should encourage staff involvement in patient teaching and the elimination of barriers perceived by nurses. 3. Nursing administration The new body of knowledge from the HRNP, based on real evidence of communities and their separate needs, can be used in primary and secondary settings. These services deliver and achieve good health outcomes. Moreover, nurses can take a

127 greater lead in the rehabilitation team. These findings will be beneficial to guide decision making as well as improving the quality of professional standards. 4. Nursing research and the health care system The findings of the HRNP may guide further studies generalizing to other settings such as the PCU of Paholpolpayuhasena hospital or other settings in Thailand. It would be useful to compare the impact of the program with different contextual features present; this may affect the implementation of the intervention. Additionally, this study may provide evidence for the ministry of public health or municipality authorities to build Thai health care capacity and establish such services in communities to improve the quality of care and professional standards in the future. Moreover, policies for home-based rehabilitation for stroke survivors need to be established in each community, including for training of health care providers, the use of health volunteers to provide clear information and knowledge of rehabilitation when working with family caregivers, and to help promote self-care for ADL and psychological support.

Recommendations for future research 1. Longitudinal studies are recommended since these would further permit a more in-depth understanding of rehabilitation and clinical correlations or what else is needed to maintain positive outcomes. 2. Intervention studies to increase functional status and the processes of recovery are recommended for further research because this study showed no significant improvement in functional status between groups. 3. This study focused on adults in an urban area in a 12 week intervention. Future study should test the effectiveness of this program in a rural area and a longitudinal study should be undertaken. Conclusion Nurses who come in contact with stroke survivors can play an important role in the lead team for continuing stroke care to improve rehabilitation by initiating discussion of stroke health information using the three phases of the HRNP model. The HRNP consists of first creating a comprehensive assessment in which real needs and desires of survivors are investigated. Nurses must recognize that some individuals

128 are highly interested in physical activity after a stroke whereas others are more focused on returning to functional status. Investigating the major factors such as environmental factors that can be improved is important. The second phase of the HRNP entails providing factual information that may include addressing information on recurrences or complications that can occur after stroke. In this step of HRNP, a nurse provides specific suggestions and skill training based on the needs of the participants that may include advice about healthy eating or other skill training. Nurses interested in learning about practical ways to assist stroke survivors to cope with physical and psychological changes that may affect society are directed to this work. The third phase of the HRNP provides continuing care by cooperation with other health professional in the community who can give care and support. The strategies may include home visits and telephone visits once per week. During telephone calls, nurses should provide opportunities for stroke survivors to express their emotions and should initiate the topic of continuing exercise. This model identifies effectiveness through performance measurement, resources, and true collaboration.

129

REFERENCES Abubakar, S. A., & Isezuo, S. A. (2012). Health related quality of life of stroke survivors: Experience of a stroke unit. Int J Biomed Sci, 8(3), 183-187. Ahlsio, B., Britton, M., Murray, V., & Theorell, T. (2012). Disablement and quality of life after stroke. Stroke. 15(5), 886-890. Almborg, A. H., Ulander, K., Thulin, A., & Berg, S. (2010). Discharged after strokeimportant factors for health-related quality of life. J Clin Nurs, 19(15-16), 2196-206 American Family Physician. (2011). Practice guidelines: AHA/ ASA guidelines on prevention of recurrent stroke. Retrieved from http://www.aafp. org/afp/ 2011/0415/p993.html American Heart Association [AHA]. (2012). Heart disease and stroke statistics 2012. Retrieved from http://www.americanheart.org/presenter.Jhtml American Heart Association [AHA]. (2014). Nutrition tips for stroke survivors. Retrieved from http://www.strokeassociation.org/STROKEORG/LifeAfter Stroke/HealthyLivingAfterStroke/Nutrition/Nutrition-Tips-for-StrokeSurvivors_UCM_308569_SubHomePage.jsp American Psychological Association [APA]. (1994). Publication manual of the American psychological association (5th ed.). Washington, DC: Author. American Stroke Association [ASA]. (2012). Heart disease and stroke statistics 2012. Retrieved from http://www.strokeassociation.org/ STROKEORG/ AboutStroke/Impact-of-Stroke_UCM_310728_Article.jsp American Thoracic Society [ATS]. (2014). Functional status. Retrieved from http://qol.thoracic.org/sections/key-concepts/functional-status.html Anderson, C., Rubenach, S., Mhurchu, C. N., Clark, M., Spencer, C., & Winsor, A. (2000). Home or hospital for stroke rehabilitation? Results of a randomized controlled trial. Stroke, 31(5), 124-31. Antman, E. M., Selwyn, A. P., Braunwald, E., & Loscalzo, J. (2008). Ischemic heart disease. In A. S. Fauci, D. L. Kasper, D. L. Longo, E. Braunwald, S. L. Hauser, & J. L. Jameson (Eds.), Harrison’s principles of internal medicine (pp. 1514-1520). New York: McGrew Hill Meical.

130 Association of Rehabilitation Nurses [ARN]. (2008). Standards and scope of rehabilitation nursing practice. Glenview.IL: Association of Rehabilitation Nurses. Association of Rehabilitation Nurses [ARN]. (2013). Role descriptions: The home care rehabilitation nurse. Retrieved from http://www.rehabnurse.org/pubs/ role/Role-The-Home-Care-Rehab-Nurse.html Baird, A. E., Dambrosia, J., Janket, S, K., Eichbaum, Q., Chaves, C., & Silver, B. (2001). A three-item scale for the early prediction of stroke recovery. Retrieved from http://www.thelancet.com/journals/lancet/ article/ PIIS01406736%2800%2905183-7/abstract Barr, D. (2007). Psychological issues in rehabilitation. In R. Jester (Ed.), Advancing practice in rehabilitation nursing (pp. 42-65). Singapore: Blackwell Publishing. Bay, C. L. (2001). Quality of life of stroke survivors: A research synthesis. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/11776713 Bergner, M., Bobbit, R. A., Carter, W. B., & Gilson, B. S. (2012). The sickness impact profile: Development and final revision of health status measure. Med Care, 19, 787-805. Bonita, R., Solomon, N., & Broad, J. (1997). Prevalence of stroke and stroke related disability: Estimate from the Auckland stroke studies. Stroke, 28, 1898-1902. Booth, S., & Jester, R. (2007). The rehabilitation process. In R. Jester (Ed.), Advancing practice in rehabilitation nursing (pp. 106-122). New York: Blackwell. Boysen, G., & Truelsen, T. (2009). Prevention of recurrent stroke. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10938183 Bridle, C., Spanjers, K., Patel, S., Atherton, N. M., & Lamb, S. E. (2012). Effect of exercise on depression severity in older people: Systematic review and metaanalysis of randomised controlled trials. Br J Psychiatry, 201(3), 180-5. Bridle, C., Spanjers. K., Patel, S., Atherton, N. M., & Lamb, E. L. (2012). Effect of exercise on depression severity in older people: Systematic review and metaanalysis of randomized controlled trials. The British Journal of Psychiatry, 201, 180-185.

131 British Society of Gerodontology. (2010). Guidelines for the oral healthcare of stroke survivors. Retrieved from http://[email protected] Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health. (2012). Chronic disease surveillance report 2011. Weekly Epidemiological Surveillance Report, Thailand, 43(5), 257-281. Bureau of Epidemiology. (2013). Number and rate of in-patients according to causes of disease from hospital, Ministry of Public Health per 100,000 population by region. Retrieved from http://instedd.org/our-work/network/bureau- ofepidemiology-thailand/ 03.157.19.191/table%202.4.2.xls Bureau of Non Communicable disease [NCD]. (2010). Stroke rate. Retrieved from http://www.thaincd.com/information-statistic/non-communicable-diseasedata.php Burns, N., & Grove, S. (2005). The practice of nursing research: Conduct, critique, & utilization (5th ed.). SL, Missouri: Elsevier/ Saunders. Camicia, M., Black, T., Farrell, J., Waites, K., Wirt, S., & Lutz, B. (2014). The essential role of the rehabilitation nurse in facilitating care transitions: A paper by the association of rehabilitation nurses. Rehabilitation Nursing, 39, 3-15. Carod-Artal, J., Egido, J. A., Gonzalez, J. L., & Varela de Seijas, E. (2000). Quality of life among stroke survivors evaluated 1 year after stroke: Experience of a stroke unit. Stroke, 31, 2995-3000. Chaiyawat, P. (2009). Effectiveness of individual home rehabilitation program for ischemic stroke. Doctor dissertation, Medical Sciences, Faculty of Medicine, Thammasat University. Chalermwannapong, S. (2008). Effects of the transitional care program on functional ability and quality of stroke survivors. Doctor dissertation, Nursing Sciences, Graduate Study, Chiangmai University. Chalermwannapong, S., Panuthai, S., Srisupan, W., Panya, P., & Ostwald, S. (2010). Effects of the transitional care program on functional ability and quality of stroke survivors. CMU. J. Nat. Sci., 9(1), 49-66. Chambers, T. (2007). Stroke care. In R. Jester (Ed.), Advancing practice in rehabilitation nursing (pp. 106-122). Singapore: Blackwell.

132 Chanruengvanich, W. (2005). The effect of a self-regulated exercise program on physical fitness, satisfaction and the risk factors for stroke among clients with transient ischemic attack and minor stroke. Doctor dissertation, Nursing Science, Graduate Studies, Mahidol University. Chemerinski, E., Robinson, R. G., & Kosier, J. T. (2001). Improved recovery in activities of daily living associated with remission of poststroke depression. Stroke, 32, 113-117. Chen, J. Y-S., Lin, K-C., Chen, C-Y., Chen, C-L., Liu, W-Y., Liaw, M-Y., & et al. (2010). Comparison between hospital-based and community-based services for the special health care needs of children with developmental delays. Chang Gung Med J, 33(2), 164-172. Chueluecha, C. (2012). Rehabilitation in stroke. Thammasat Medical Journal, 12(1), 97-111. Chuenjairuang, P., & Sritanyarat, W. (2012). Development of primary health care services for stroke prevention in persons with warning signs of stroke. Pacific Rim, 16(4), 313-325. Clarke, P. J., Marshell, V., Black, S. E., & Colantonio, A. (2002). Well-being after stroke in Canadian seniors: Finding from the Canadian study of health and aging. Stroke, 33, 1016-1021. Coelho, C., Ylvisaker, M., & Turkstra, L. (2005). Nonstandardized assessment approaches for individuals with traumatic brain injuries. Seminars in Speech & Language. 26(4), 223-41 Cohen, J. (1969). Statistical power analysis for the behavioral sciences. New York: Academic Press. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum. Colin, C., Wade, D. T., S. Davies, S., & Horne, V. (1988). The Barthel ADL index: A reliability study. Int Disabil Stud, 10(2), 61-3. Congressional Research Service [CRS]. (2010). Medicare hospital readmissions: Issue, policy opinions and PPACA. Retrieved from http://www.Hospitalmedicine.org/am/pdf/advovacy/crs_readmissions_report. pdf.

133 Corrigan, P. W., & Mc Cracken, S. G. (1999). Training teams to deliver better psychiatric rehabilitation programs. Psychiatric Services, 50, 43-45. Current Practical Guide for Stroke Management. (2012). Stroke. Retrieved from http://qic.ksphosp.com/attachments/article/27/2.Acute%20Cerebral%20Infar ction%202558.pdf Dao, D. Q. (2006). Relationships among patients’ knowledge, family support and success in rehabilitation program of the stroke patient in Quangtriprovience general hospital-Vietnam. Master’s thesis, Nursing Science, Faculty of Nursing, Burapha University. Dashe, J. F. (2013). Medical complications of stroke. Retrieved from http://www.uptodate.com/contents/medical-complications-of-stroke DeHaan, R., Limberg, M., Vander, M. J., & Anderson, N. (1995). Quality of life after stroke: Impact of stroke type and lesion location. Stroke, 26, 402-408. Desrosiers, J., Noreau, L., Rochette, A., Carbonneau, H., Fontaine, L., Viscogliosi, C., & Bravo, G. (2007). Effect of a home leisure education program after stroke: A randomized controlled trial. Arch Phys Med Rehabil, 88, 1095-1100. Division of Health Statistics, Ministry of Public Health, 1996, 1998, 2000. (2015). Older population and health system: A profile of Thailand. Retrieved from http://www.who.int/ageing/projects/intra/phase_one/alc_intra1_cp_thailand. pdf Doig, E., & Amsters, D. (2006). The efficacy of community rehabilitation for aged clients after stroke-a review of the literature. Retrieved from http://www.health.qld.gov.au/qhcrwp/docs/efficacystroke.pdf

Duncan, P.W., & Lai, S.M. (1997). Stroke recovery. Topics Stroke Rehabil, 4(17), 51-58. Duncan, P. W., Lai, S. M., & Keighley, J. (2000). Defining post-stroke recovery: Implications for design and interpretation of drug trials. Neuropharmacology, 39(5), 835-841. Duncan, P. W., Wallace, D., Studenski, S., Lai, S. M., & Johnson, D. (2001). Conceptualization of a new stroke-specific outcome measure: The stroke impact scale. Topics in Stroke Rehabilitation, 8(2), 19-33.

134 Duncan, P. W., Zorowitz, R., Bates, R., Choi, J. Y., Glasberg, J. J., Graham, G. D., Katz, R. C., Lamberty, K., & Reker, D. (2005). Management of adult stroke rehabilitation care: A clinical practice guideline. Stroke, 36, 100-143. Ebrahim, S., & Harwood, R. H. (1999). Stroke: Epidermiology, evidence, and clinical practice. Rehabilitation Nursing, 17(3), 127-132. Edwards, J. D., Koehoorn, M., Boyd, L. A., & Levy, A. R. (2012). Is health-related quality of life improving after stroke? A comparison of health utilities indices among Canadians with stroke between 1996 and 2005. Retrieved from http://www.stroke.ahajournals.org Evidence-Based Review of Stroke Rehabilitation [EBRSR]. (2013). Introduction and Methods. Retrieved from http://www.ebrsr.com/evidence-review/1introduction-and-methods Farquhar, M. (1995). Definitions of quality of life: A taxonomy. J Adv Nurs, 22(3), 502-8. Farzan, D. T. (1991). Reintegration for stroke survivors: Home and community consideration. Nursing Clinics of North America, 26(4), 1037-1048. Faul, F, Erdfelder, E., Lang, A.G., & Buchner, A. (2007). Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19897823 Feibel, J. H., & Springer, C. J. (1982). Depression and failure to resume social activities after stroke. Archives of Physical Medicine and Rehabilitation, 63, 276-278. Finch, E., Brooks, D., Stratford, P.W., & Mayo, N. E. (2002). Physical rehabilitation outcome measures: A guide to enhanced clinical decision-making (2nd ed.). Hamilton, Ontario, Canadian Physiotherapy Association. Forster, A., & Young, A. (1996). Specialist nurse support for patients with stroke in the community: A randomised controlled trial. BMJ, 312, 1642-1646. Frank, A., Auslander, G.K., & Weissgarten, J. (2003). Quality of life of patients with end-stage renal disease at various stages of the illness. Social Work in Health Care, 38, 1-26.

135 Gargano, J. W., & Reeves, M. J. (2007). Sex differences in stroke recovery and stroke-specific quality of life: Results from a statewide stroke registry. Stroke, 38(9), 2541-8. Gender, A. (1998). Scope of rehabilitation and rehabilitation nursing, In P. A. Chin, D. Finocchiaro, & A. Rosebrough (Eds), Rehabilitation nursing practice (pp. 3-20). New York: McGraw-Hill. Gilman, S. (2006). Time course and outcome of recovery from stroke: Relevance to stem cell treatment. Experimental Neurology, 199, 37-41. Goldberg, D. P. (1972). The detection of psychiatric illness by questionnaire. Oxford: Oxford University Press. Goldberg, D. P., & Hillier, V. F. (1979). A scaled version of the general health questionnaire. Psychol Med, 9(1), 139-45. Goldberg, D., & Williams, P. (1988). A user’s guide to the general health questionnaire. Windsor, UK: NFER-Nelson. Governor, P. T., & Arnold, D. (2011). A scaled version of the general health questionnaire: Facts about stroke. Retrieved from http://www.idph.state. il.us/about/ womenshealth/factsheets/stroke.htm Green, J., Forster, A., Bogle, S., & Young, J. (2002). Physiotherapy for patients with mobility problems more than 1 year after stroke: A randomized controlled trial. Lancet, 359, 199-203. Guyatt, G. H., Feeny, D. H., & Patrick, D. L. (1993). Measuring health-related quality of life. Ann Intern Med, 118(8), 622-9. Hackett, M. L., Duncan, J. R., Anderson, C. S., Broad, J. B., & Bonita, R. (2000). Health-related quality of life among long-term survivors of stroke: Result from the Auckland Stroke Study, 1991-1992. Stroke, 31, 440-447. Hafsteinsdottir, T. B., Vergunst, M., Lindeman, E., & Schuurmans, M. (2010). Educational needs of patients with a stroke and their caregivers: A systematic review of the literature. Patient Educ Couns, 85(1), 14-25. Hair, J. F., Black, W. C., Babin, J., & Anderson, R. E. (2010). Multivariate data analysis. Retrieved from http://biocomp.cnb.csic.es/~coss/Docencia/adam/ Notes/MultivariateAnalysisSlides.pdf

136 Hanucharurnkul, S. (2007). Nurses in primary care and the nurse practitioner role in Thailand. Contemporary Nurse, 26, 83-93. Haskell, W., Lee, I., Pate, R. R., Powell, K. E., Blair, S. N., Franklin, B. A., Macera, B. A., Heath, Z. G., W., Thompson, P. D., & Bauman, A. (2007). Physical activity and public health: Update recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation, 116, 1081-1093. Heart and Stroke Foundation. (2009). Stroke treatments. Retrieved from http://www.heartandstroke.com/site/pp.aspx?c=ikIQLcMWJtE&b=3483943 &printmode=1 Hedger, L. V. (1982). Estimation of effect size from a series of independent experiments. Psychological Bulletin, 92, 490-499. Hickey, J. V., & Todd, A. Q. (2009). Stroke. In J. V. Hickey (Ed.), The clinical practice of neurological and neurosurgical nursing. (pp. 588-619). Singapore: Wolters Kluwer Health. Hui-Chan, C., Ng, S., & Mak, M. (2005). Effectiveness of a home-based rehabilitation programme on lower limb functions after stroke. Hong Kong Med J, 15(3 Suppl 4), 42-6. International Health Policy Program Thailand. (2010). Nation Health Accounts of Thailand 2009-2010. Bangkok: The Bureau of Policy and Strategy, Ministry of Public Health. International Society for Quality of Life Research [ISOQOL], (2013). International Society for quality of life research. Retrieved from http://www.isoqol.org/ UserFiles/AC16/2016ISOQOLProspectus.pdf Iqbal, M. (2014). Health-perception and health management. Retrieved from http://www.kmu.edu.pk/ins/sites/kmu.edu.pk.ins/files/Lectures/Health%20P erception%20and%20health%20management%20pattern%20lecture.pdf Jakkutip, P. (2011). Stroke care at home handbook for health care provider. Bangkok: Public Health Nursing Division, Health Department. Jedsadayanmata, A. (2013). Principles of pharmacotherapy in ischemic stroke. Retrieved from http://www.slideshare.net/UtaiSukviwatsirikul/principles of prarmacotherapy in ischemic stroke 56 01 24

137 Jirattanaphochai, K., Jung, S., Sumananont, C., & Saegnipanthkul. (2005). Reliability of the medical outcomes study short-form survey version 2 (Thai version) for the evaluation of low back pain patients. Journal of the Medical Association of Thailand, 88(10), 1355-1361. Jitapunkul, S., Lailert, C., Worrakul, P., Sriokiatkhachorn, A., & Brahim, S. (1996). Chula mental test: A screening test for elderly people in less developed counties. International Journal of Geriatric Psychiatry, 17(8), 715-720. Jones, V. N. (2006). The forgotten survivor. Retrieved from http://www.stroke.org/ site/PageServer?pagename= SS_MAG_so2006_feature_forgot. Jullamate, P., Azeredo, Z. D., Paul, C., & Subgranon, R. (2006). Informal stroke rehabilitation: What do Thai caregivers perform. International Journal of Rehabilitation Research, 29(4), 309-314. Jumpangern, J. (2007). Health related quality of life in patients with musculoskeletal disorders treated with THAI massage at Tayang hospital. Master’s thesis, Pharmacy, Graduate Study, Silpakorn University. Justine, M., & Hamid, T. A. (2010). A multicomponent exercise program for institutionazed older adults. Journal of Gerontological Nursing, 36(10), 32-41. Kalra, L., & Crome, P. (1993).The role of prognostic score in targeting stroke rehabilitation in elderly patients. Journal of American Geriatric Society, 41(4), 396-400. Kanchanaburi province. (2013). Kanchanaburi information. Retrieved from http://www.kanchanaburi.go.th/au/travel/kanintro.php Kelly-Hayes, P. M., Robertson, J. T., Broderick, J. P., Duncan, P. W., Hershey, L. A., Kernich, C. A., & Robb, G. (1988). Development of a stroke family support and education program. Journal of Neuroscience Nursing, 20(3), 193-197. Khachornrit, S. (2004). Characterisitcs of clients rehospitalized after stroke. Master’s thesis, Adult Nursing, Graduate Study, KhonKaen University. Khampolsiri, T. (2005). A home-based nursing intervention program for enhancing quality of life of stroke survivors. Doctor dissertation, Nursing Science, Graduate Study, Chiang Mai University.

138 Kim, P., Warren, S., Madill, H., & Hadley, M. (1999). Quality of life of stroke survivors, 8(4), 293-301. Kitko, L., & Hupcey, J. E. (2008). Factors that influence health-seeking behaviors of patients experiencing acute stroke. Journal Neurosci Nursing, 40(6), 333-340. Kositamongkol, S. (2015). Rehabilitation care and therapy in patients with stroke. Bangkok: Mahidol University. Kring, D., & Crane, P. B. (2009). Factors affecting QOL in persons on hemodialysis. Nephrology Nursing Journal, 1, 15-55. Kuipers, P., & Doig, E. (2012). Community-based rehabilitation. Retrieved from http://cirrie.buffalo.edu/encyclopedia/en/article/362/ Lai, S. M., Duncan, P. W., & Keighley, J. (1995). Prediction of functional outcome after stroke: Comparison of the orrington prognostic scale and NIH stroke scale. Stroke, 29(9), 1838-42. Lai, S. M., Studenski, S., Duncan, P. W., & Perera, S. (2002). Persisting consequences of stroke measured by the stroke impact scale. Stroke, 33, 1840-1844. Langhorne, P., Bernhardt, J., & Kwakkel, G. (2011). Stroke care 2: Stroke rehabilitation. Lancet, 14, 1693-702. Leurmarnkul, W., & Meetam, P. (2005). Properties testing of the retranslated SF-36 (Thai version). Thai J Pharm Sci, 29(1-2), 69-88. Lim, L., Seubsman, S., & Sleigh, A. (2008). Thai SF-36 health survey: Tests of data quality, scaling assumptions, reliability and validity in healthy men and women. Health and Quality of Life Outcomes, 6, 52. doi: 10.1186/14777525-6-52 Lotrakul, M., Sumrithe, S., & Saipanish, R. (2008). Reliability and validity of Thai version of the PHQ-9. Bio Med Central Pshchiatry, 8(46), 1-8. doi 10.1186244x-8-46 Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: The Barthel index. Maryland State Medical Journal, 14, 56-61. Mauk, K. L. (2011). General concepts and principles of rehabilitation nursing. Retrieved from http://www.freepdfdb.com/pdf/overview-of-rehabilitation22513800.html

139 Mayo, N. E., Wood-Dauphinee, S., Ahmed, S., Gordon, C., Higgins, J., & McEwen, S., & Salbach, N. (1999). Disablement following stroke. Disability and Rehabilitation, 21(5/6), 258-268. Medical News Today [MNT]. (2009). Stroke. Retrieved from http://www.medicalnewstoday.com/articles/7624.php Mericer, L., Audet, T., Herbert, R., Rochette, A., & Dubois, M. F. (2001). Impact of motor, cognitive, and perceptual disorders on ability to perform activities of daily living after stroke. Stroke, 32(11), 2602-8. Miller, E. L., Murray, L., Richards, L., Zorowitz, R. D., Bakas, T., Clark, P., & Billinger, S. A. (2010). Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: A scientific statement from the American Heart Association. Stroke, 41, 2402-2448. Miller, I. V. (2005). Efficacy of a family telephone intervention for stroke. Retrieved from http://www.clinicaltrials.gov/show/NCT00031265 Ministry of Public Health. (2010). Thailand health profile 1999-2000. Retrieved from http://wwwmoph.go.th/ops/thealth_44/index_eng.htm. Monkong, S. (2012). Plan for caring chronic patient in caring for the family caregiver. Bangkok: Ramathibodi School of Nursing, Mahidol University. MyDr. (2014). Physical activity benefits to your body. Retrieved from http://www.mydr.com.au/sports-fitness/physical-activity-benefits-to-yourbody Naess, H., Waje-Andreassen, U., Thomassen, L., Nyland, H., & Myhr, K. (2006). Health-related quality of life among young adults with ischemic stroke on long-term follow-up. Stroke, 37(5), 1232-6. Nation Institute of Neurological Disorders and Stroke [NINDS]. (2011). Post-stroke rehabilitation fact sheet. Retrieved from http://www.ninds.nih.gov/ disorders/stroke/stroke.htm Nation Institute of Neurological Disorders and Stroke [NINDS]. (2014). NINDS stroke information page. Retrieved from http://www.ninds.nih.gov/disorders/ stroke/stroke.htm National Stroke Association [NSA]. (2011). Clinical guidelines for stroke management 2010. Retrieved from http //www.strokefoundation.com.au

140 National Stroke Association [NSA]. (2012). Recovery after stroke: Healthy eating. Retrieved from http//www.stroke.org Accessed 3/5/2012 National Stroke Association [NSA]. (2013). Recovery & rehabilitation. Retrieved from http://www.stroke.org/site/PageServer?pagename=REHABT National Stroke Association [NSA]. (2014). Stroke survivors. Retrieved from http://www.stroke.org/site/PageServer?pagename=surv Ng, S., Chu, M., Wu, A., & Cheung, P. (2005). Effectiveness of home-based occupation therapy for early discharged patients with stroke. Hong Kong Journal of Occupational Therapy, 15(1), 27-36. Nicholes-Larsen, D., Clark, P. C., Zeringue, A., Greenspan, A., & Blanton, S. (2005). Factors influencing stroke survivors’ quality of life during subacute recovery. Retrieved from http://www.stroke.ahajournals.org/by guest on February 28, 2012 Nidhinadana, S., Chinvarun, Y., Supakasem, S., Sithinamsuwan, P., Wongmek, W., & Suwantamee, J. (2010). Prevalence of poststroke depression in Thai stroke survivors studied in Phramangkutklao hospital. Journal Medical Association Thai, 93(6), 60-64. Nilchaikovit, T., Sukying, C., & Silpakit, C. (1996). Reliability and validity of the Thai version of the general health questionaire. Journal of the Psychiatrist Association of Thailand, 41(1), 2-17. Norach, W. (2010). Needs of patients with stroke and families in physical, mental and social cares from home health care team. Master’s thesis, Public Health, Graduate Study, Chiang Mai University. Oupra, R., Griffiths, R., Pryor, J., & Mott, S. (2010). Effectiveness of supportive educative learning programme on the level of strain experienced by caregivers of stroke patients in Thailand. Health and Social Care in the Community, 18(1), 10-20. Paholpolpayuhasena hospital record. (2014). General report. Retrieved from http://www. Phahol.go.th/index.php Pandian, D. J., Padma, V., Vijaya, P., Sylaja, P. N., & Murthy, J. M. (2007). Stroke and thrombolysis in developing countries. Int J Stroke, 2(1), 17-26.

141 Pekdetch, B. (2002). The influences of amount of care, communication problems and caregiver’s factors on roles strain of stroke patients’s caregivers. Master’s thesis, Graduate Study, Mahidol University, Bangkok, Thailand. Pholtana, S., Duangpaeng, S., & Kangchai, W. (2014). A causal model of functional status among end stage renal disease patients undergoing hemodialysis. Journal of health science research, 8(2), 25-34. Phongsai, N. (2009). Effect of transitional care on activities of daily living among stroke patients. Master’ thesis, Nursing Science, Graduate Study, Chiang Mai University. Polit, D. F., & Beck, B. P. (1987). Nursing research: Principles and methods (3rd ed.). Philadelphia: J. B. Lippincott. Polit, D. F., & Hungler, C. T. (2014). Essentials of nursing research: Appraising evidence for nursing practice (8th ed.). Philadelphia: J. B. Lippincott. Prachuabmob, V., Chayovan, N., Wongsit, M., Siriboon, S., Suwanrada,W., Pothisiri,W., Bangkae,B., & Milintangul, C. (2013). The project on monitoring and evaluation of the second national plan (2002-2021) round 2 (2007-2011). Bangkok: College of population studies Chulalongkorn University. Prasat Neurological Institute. (2007). Clinical nursing practice guideline for stroke. Bangkok: Prasat Neurological Institute. Prasat Neurological Institute. (2012). Thai epidemiologic stroke (TES) study. Retrieved from http://www.pni.go.th/pnigoth_en/wp-content/uploads/ 2010/11/Research_TES_study_PNI.pdf Priest-Bakerjian, D. (2007). The nurse practitioner in the skills nursing facility In B. White, & D. Truax (Ed.), The nurse practitioner in long-term care: Guidelines for clinical practice (pp. 3-24). Philadelphia: Jones and Bartlett. Promkaew, O. (2015). Stroke management in the continuing care. Buddhachinaraj Med J, 32(3), 180-90. Prompuk, B., & Moongtui, W. (2013). A concept analysis: Functional status. Nursing Journal, 40, 129-137.

142 Promsen, N. (2008). The effect of family support program for caring patients with stroke home. Master’s thesis, Adult Nursing, Graduate Study, Burapra University. Pumcharoen, P. (2007). Health care providers and clients perception’s of home health care services for patients with carebrovascular disease in selected hospital under department of medical services of Bangkok metropolitan. Master’s thesis, Nursing administration, Graduate Study, Burapha University. Punthasane, W., & Vejapanpesaj, S. (2010). Surgical decompression for the treatment of massive middle cerebral artery infarction: Systematic review and metaanalysis. Neurological Surgery, 1(4), 99-111. Puwarawuttipanit, W. (1995). Stroke patients in recovery stage and their families. TJN, 44(2), 88-92. Rachpukdee, S. (2007). Quality of life of stroke survivors: A 3-mouth follow up study. Master’s thesis, Public Health, Graduate Studies, Mahidol University. Rapley, M. (2003). Quality of life research: A critical introduction. Retrieved from http://www.scholar.google.com/citations?view_op=view_citation&hl=en&u ser=BpS5QHgAAAAJ&citation_for_view=BpS5QHgAAAAJ:u5HHmVD_ uO8C Rehabilitation definition. (2013). Retrieved from http://www.medical-dictionary. thefreedictionary.com/Rehabilitation Rettke, R., Geschwindner, H. M., & Heuvel, W. J. A. (2015). Assessment of patient participation in physical rehabilitation activities: An integrative review. Rehabilitation Nursing, 40, 209-223. Riewpaiboon, W. (2001). Process and outcomes study on rehabilitation service for hemiplegic patient causing by stroke at the Sirindhon National Medical Rehabilitation Center. Retrieved from http://www.Kb.hsri.or.th/dspace/ handle/11228/1811 Rimmer, J. H., Braunschweig, C., Silverman, K., Riley, B., Creviston, T., & Nicola, T. (2000). Effects of a short-term health promotion intervention for a predominantly African-American group of stroke survivors. American Journal of Preventive Medicine, 18(4), 332-338.

143 Rodgers, H., Atkinson, C., Bond, S., Suddes, M., Dobson, R., & Curless, R. (1999). Randomized controlled trial of a comprehensive stroke education program for patient and caregivers. Stroke, 30(12), 2585-91. Roopsawang, I., Aree-Ue, S., & Putwatana, P. (2001). A follow-up study of health status in patients with chronic low back pain before and after spinal surgery. Rama Nursing Journal, 15(3), 344-360. Rosenthal, S., Pituch, M., Greninger, L., & Metress, E. (1993). Perceived needs of wives of stroke patients. Rehabilitation Nursing, 18, 148-153. Roth, E. J., & Harvey, R. L. (1996). Rehabilitation of stroke syndromes. In R. M. Braddom, D. Buschbacher, E. Dumitru, W. Johnson, D. Mathews, & M. Sinaki (Eds.), Physical medicine rehabilitation (pp. 1053-1087). Philadelphia: W. B. Saunders. Royal College of Nursing [RCN]. (2007). Role of the rehabilitation nurse. London: 20 Cavendish Square. Ruangpowpun, S., Khuwatsamrit, K., Junda, T., & Kanogsunthrnrat, N. (2007). Health-related quality of life in burn patients. Rama Nursing Journal, 18(1), 134-151. Sacco, R. L., Adams, G., Alberts, J., Benavente, O., Furie, K., Goldstein, L. B., Philip Gorelick, P., Halperin, J., Harbaugh, R., Johnston, S. C., Katzan, I., Margaret Kelly-Hayes, M., Kenton, E. J., Marks, M., Schwamm, L. H., & Tomsick, T. (2006). Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: A statement for healthcare professionals from the American Heart Association/ American Stroke Association Council on Stroke: Co-sponsored by the Council on Cardiovascular Radiology and intervention: The American Academy of Neurology affirms the value of this guideline. Stroke, 37, 577-617. Sacco, R. L., Wolf, P. A., & Gorelick, P. B. (1999). Risk factors and their management for stroke prevention: Outcome for 1999 and beyond. Neurology, 53(4), 15-24. Sandin, K. J., & Mason, K. D. (1996). Manual of stroke rehabilitation. Massachusetts: Butterworth-Heinemann.

144 Saw, A., & Truax, D. (2007). Rehabilitation. In B. White, & D. Truax (Ed.), The nurse practitioner in long-term care: Guidelines for clinical practice (pp. 464-494). California: Jones and Bartlett publishers, Sipmue, N. (2009). Pharmacology: Principles and exercise. New York: Holistic. Sirikangwalkul, A. (2002). Influential factors on health-related quality of life in stroke patients. Bulletin of the Department of Medical Services, 27(6), 239-247. Sirilak, S. (2010). National health policy & health system. Nonthaburi: Health Policy and Health System Development Class. Skelton, D., Mcaloon, M., & Gray, L. (2011). Promoting physical activity with older people. In D. Tolson, J. Booth, & I. Schofield (Eds.), Evidence informed nursing with older people (pp. 121-136). New Dali: Blackwell. Songkhla, K., Tantirittisak, T., Hanchaiphiboolkul, S., & Wattanasen, Y. (2014). Relationship between the ischemic stroke subtypes and risk factors included clinical outcome from Prasat Neurological Institute stroke registry. Journal of Thai Stroke Society, 13(1-2), 3-12. Sornarkas, A., Deoisres, W., & Wacharasin, C. (2015). Factors influencing family caregiver’ rehabilitation behavior for stroke patients. Journal of Health Science Research, 9(2), 86-93. Sornarkas, A., Deoisres,W., & Wacharasin, C. (2015). Factors influencing family caregivers’ rehabilitation behavior for stroke patients. Journal of Health Science Research, 9(2)86-93. Srisoparb, W. (2007). Home-based physical program with family-centered approach for chronic stroke patients. Master’s thesis, Physical Therapy, Graduate Study, KhonKaen University. Srisupan, W., & Suchaxaya, P. (2001). Writing a research proposal. Nursing Newsletter, 28(2), 1-11. Sriwicha, K., Maprapo, L., & Jitaree, A. (2003). Quality of life of hemiplegic patients who lived in the community area of Buddhachinnaraj Hospital, Phitsanulok. Retrieved from http //www.med.nu.ac.th Statistic Canada. (2014). Perceived health of person. Retrieved from http://www.statcan.gc.ca/eng/concepts/definitions/health01

145 Stroke Association. (2012). Heart disease and stroke statistics—2012 Update. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4440543/ Studenski, S., Duncan, P. W., Perera, S., Reker, D., Lai, S. M., & Richards, L. (2005). Daily functioning and quality of life in a randomized controlled trial of therapeutic exercise for subacute stroke survivors. Stroke, 36(8), 1764-70. Sulter, G., Steen, C., & De Keyser, J. (1999). Use of the Barthel index and modified Rankin scale in acute stroke trials. Stroke, 30(8), 1538-1541. Supawong, C., Chunharas, S., Damrikarnled, L., Srivanichakorn, S., Wetsutthanon, K, & Sirilak, S. (2009). The service manual of tumbon health promoting hospital. Retreived from http//www.beid.ddc.moph.go.th/th/images/aw_ hospital.pdf Tabachnick, B. G., & Fidell, L. S. (1996). Using multivariate statistics analysis (3rd ed.). Boston: Allyn and Bacon. Taboonpong S. (2012). Care of a stroke survivor at home: A case study. Journal of Gerontology and Geriatric Medicine, 13(1), 61-71. Teasell, R., & Hussein, N. (2013). Background concepts in stroke rehabilitation. Retrieved from http://www.ebrsr.com/sites/default/files/Chapter3_ Background-Concepts_FINAL_16ed.pdf Teerata, W. (2010). Multidisciplinary patient care team experiences for stroke patient at a secondary hospital in center region. Master’s thesis, Adult Nursing, Graduate Study, Christian University. Thai Stroke Society. (2013). Stroke cost. Retrieved from http://thaistrokesociety.org/ purpose Thanh, D. T. (2013). Effectiveness of a diabetes self-management support intervention in Vietnamese adult with type 2 diabetes. Doctoral dissertation, Nursing Science, Faculty of Nursing, Burapha University. The New York Times. (2013). Health guide. Retrieved from http://www.nytimes.com/ health/guides/disease/stroke/ Thipsamning, T. (2000). Caregiving demands of stroke patients, patient-caregiver relationships, and caregivers’ life satisfaction. Master’s thesis, Adult Nursing, Graduate Study, Mahidol University.

146 Tsouna-Hadjis, E., Vemmos, K. N., Zakopoulos, N., & Stamatelopoulos, S. (2000). First-stroke recovery process: The role of family social support. Arch Phys Med Rehabil, 81, 881-7. United Kingdom Central Council for Nursing [UKCC]. (1994). The future of professional practice: The council’s standards for education and practice following registration. London: UKSS.

Van Mierlo, M. L., Schröder, C., Van Heugten, C. M., Post, M. W., De Kort, P. L., & Visser-Meily, J. M. (2013). The influence of psychological factors on healthrelated quality of life after stroke: A systematic review. Int J Stroke, 9(3), 341-8. Van S, J. C., Koudstaal, P. J., Visser, M. C., Schouten, H. J., & Van Gijn, J. (1988). Interobserver agreement for the assessment of handicap in stroke patients. Stroke, 19(5), 604-604-607. Van, P., R. P., Kwakkel, G., Wood-Dauphiness, S., Hendriks, H. J., Van der Wees, P. J., & Dekker, J. (2004). The impact of physical therapy on functional outcomes after stroke: what’s the evidence? Clinical Rehabilitation, 18(8), 833-862. Retrieved from http://www. ncbi.nlm.nih.gov/pubmed/24148550 Wade, D. T. (1994). Stroke (acute cerebrovascular disease). In A. Stevens, J. Raftery (Eds.), Health care needs assessments, vol. 1 (pp. 111-255). Oxford: Oxford Radcliffe Medical Press. Walden University. (2013). Information about registered nurse job duties and responsibilities. Retrieved from http://www.education-portal.com/ information_about_registered_nurse.html Ware, J. E., & Sherbourne, C. D. (1992). The mos 36-item short-form health survey (SF- 36). Medical Care, 30(6), 473-483. Ware, J. E., Snow, K. K., Kosinski, M., & Gandek, B. (1993). SF-36® health survey manual and interpretation guide. Boston, MA: New England Medical Center, The Health Institute. Wilkinson, P. R., Wolfe, C. D. A., Warburton, F. G., Rudd, A. G., Howard, R. S., & Ross-Russell, R. W. (1997). A long-term follow-up of stroke patient. Stroke, 28(3), 507-12.

147 Wilson, I. B., & Cleary, P. D. (1995). Linking clinical variables with health-related quality of life. A conceptual model of patient outcomes. The Journal of the American Medical Association, 273, 59-65. Wolfe, C. D. A. (2000). The impact of stroke. British Medical Bulletin, 56(2), 275-286. World Health Organization [WHO]. (1980). Categorizing disabilities. Retrieved from http://www.continuetolearn.uiowa.edu/nas1/07c187/Module%201/module_1 _p3.html World Health Organization [WHO]. (1996). Disability prevention and rehabilitation: A guide for strengthening the basic nursing curriculum. Retrieved from http://whqlibdoc.who.int/hq/1996/WHO_RHB_96.1.pdf World Health Organization [WHO]. (2004). Comprehensive community and homebased health care model. Retrieved from http://apps.searo.who.int/PDS_ DOCS/B0021.pdf?ua=1 World Health Organization [WHO]. (2012). Stroke, cerebrovascular accident. Retrieved from http://www.emro.who.int/health-topics/strokecerebrovascular-accident/ World Health Organization [WHO]. (2015). Cardiovascular diseases (CVDs): Fact sheet N°317. Retrieved from http://www.who.int/mediacentre/factsheets/ fs317/en/ Worldwide Stroke Organization [WSO]. (2010 a). What is stroke?. Retrieved from http://www.worldstrokecampaign.org/Facts/Pages/WhatisStroke.aspx Worldwide Stroke Organization [WSO]. (2010 b). Pain, depression, cognitive decline and spasticity after stroke. Retrieved fromhttp://www.worldstrokecampaign. org/Facts/Pages/Pain_Depression_Cognitive.aspx Yu, J., Hu, Y., Wu, Y., Chen, W., Zhu, Y., Cui, X., Lu, W., Qi.,Qi.,Qo,O., & Shen,X. (2009). The effects of community-based rehabilitation on stroke patients in China: A single-blind, randomized controlled multicentre trial. Clinical Rehabilitation, 23, 408-417.

148

APPENDICES

149

APPENDIX A Instrument for screening

150

แบบประเมินภาวะสมองเสื่ อม โดยแบบประเมินสภาพจิตจุฬา (Chula Mental Test: CMT) จานวน 13 ข้ อ คาถาม

บันทึกคาตอบ คะแนน

คาตอบ/ เกณฑ์ ให้ คะแนน

1. ปี นี้คุณอายุเท่าไหร่

ถูก = 1 ,ผิด = 0

2. ขณะนี้กี่โมง

ถูก = 1 ,ผิด = 0 (อาจคลาดเคลื่อนได้ 1 ชัว่ โมง

3. ผูป้ ระเมินพูดคาว่า “ร่ ม, กระทะ ประตู” ให้ฟังช้าๆชัดๆ 2 ครั้ง แล้ว บอกให้ผถู ้ ูกทดสอบทวนชื่ อทั้ง สามดังกล่าวทันที

-ไม่ถูก = 0 คะแนน -ถูก 1 ชื่อ = 1 คะแนน -ถูก 2 ชื่อ = 2 คะแนน -ถูก 3 ชื่อ = 3 คะแนน

4. เดือนนี้เดือนอะไร?

-ถูก = 1 ,ผิด = 0 (อาจตอบเป็ นเดือนไทยหรื อ เดือนสากลก็ได้) …………………………….. ……………………………. …………………………….

5. …………….. 6……………… 7……………… 8……………… 9……………… 10…………….. 11……………. 12…………… 13. บอกให้ผทู้ ดสอบนับเลข…… เปรี ยบเทียบกับเกณฑ์ ≤ 15 คะแนน หรื อ ต่ากว่า น่าจะมีความผิดปกติของ Cognitive function ≥ 16 คะแนน หรื อ มากกว่า Cognitive function ปกติ

151

แบบประเมินระดับความพิการของผู้ป่วยหลังเกิดโรคหลอดเลือดสมอง Modified Rankin Scale (MRS) Level and description of MRS 0 = No symptoms l 1 = No significant disability despite symptoms; able to carry out all usual duties and activities 2 = Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 = Moderate disability requiring some help, but able to walk without assistance 4 = Moderate severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 = Severe disability; bedridden, incontinent, and requiring constant nursing care and attention 6 = Dead

152

APPENDIX B Instrument for data collection

153

ฉบับที่......................... แบบสั มภาษณ์ ผ้ ปู ่ วยโรคหลอดเลือดสมองชนิดขาดเลือด ส่ วนที่ 1 แบบบันทึกข้อมูลทัว่ ไป คาชี้แจง โปรดใส่ เครื่ องหมายถูก (/) ลงในวงเล็บหน้าข้อความหรื อเติมข้อความในช่องว่างที่ตรง กับข้อมูลของท่านมากที่สุด 1. ปัจจุบนั อายุ ..............................ปี 2. เพศ ( ) ชาย ( ) หญิง 3. ระดับการศึกษาสู งสุ ด ( ) ไม่ได้รับการศึกษา ( ) ประถมศึกษา ( ) มัธยมศึกษา ( ) ปวช./ ปวส./ อนุปริ ญญา ( ) ปริ ญญาตรี ( ) สู งกว่าปริ ญญาตรี 4. อาชีพหลัก ( ) ไม่ได้ประกอบอาชีพ ( ) รับจ้าง ( ) ค้าขาย ( ) รับราชการ ( ) เกษตรกรรม ( ) อื่นๆ (ระบุ) 5. สถานภาพ ( ) สมรส ( ) โสด ( ) หม้าย/หย่า ( ) แยกกันอยู่ 6. ศาสนา ( ) พุทธ ( ) คริ สต์ ( ) อิสลาม ( ) อื่น ๆ......................... 7. รายได้ครอบครัว ................................................ บาท/ เดือน 8. ผูด้ ูแลรับผิดชอบหลักขณะป่ วยครั้งนี้ ........................................................................ 9. ประวัติการมีโรคประจาตัวของท่าน ( ) โรคความดันโลหิตสู ง ( ) โรคไขมันในเลือดสู ง ( ) โรคไต ( ) โรคหัวใจ ( ) โรคเบาหวาน ( ) อื่น ๆ ระบุ................................... 10. ยาที่ใช้ในปั จจุบนั (ได้มากกว่าหนึ่งข้อ) ( ) ยาลดความดันโลหิตสู ง ( ) ยาต้านการแข็งตัวของเกล็ดเลือด ( ) ยาลดไขมันในเส้นเลือด ( ) ยารักษาเบาหวาน ( ) อื่น ๆ ...............................................................................................

154

11. สถานบริ การสุ ขภาพที่ท่านรับยาที่รักษาโรคประจาตัวของท่าน ( ) โรงพยาบาลพหลพลพยุหเสนา ( ) โรงพยาบาลส่ งเสริ มสุ ขภาพตาบล ชื่อ............................................. ( ) อื่น ๆ ระบุ................................... 12. ประวัติการสู บบุหรี่ ( ) สู บ ระยะเวลา................................จานวน................................ ( ) ไม่สูบ 13. ประวัติการดื่มสุ รา ( ) ดื่ม ระยะเวลา................................จานวน................................ ( ) ไม่ดื่ม 14. การรักษาทางเลือกอื่นร่ วม ( ) มี ระบุ............................................... ( ) ไม่มี 15. สิ ทธิ ค่ารักษาพยาบาล ( ) เบิกจากหน่วยงานต้นสังกัด ( ) บัตรประกันสุ ขภาพถ้วนหน้า. ( ) ประกันสังคม. ( ) ประกันชีวติ ( ) จ่ายเอง

154

แบบประเมินการปฏิบัติกจิ วัตรประจาวันของผู้ป่วยโรคหลอดเลือดสมอง (Barthel Index) กิจกรรม/ คะแนน

1. Feeding (การรับประทานอาหารเมื่อเตรียมอาหารไว้ให้ เรียบร้ อยต่ อหน้ า) 0 = ไม่สามารถตักอาหารเข้าปากได้ตอ้ งมีคนป้ อนให้ 5 = ช่วยใช้ชอ้ นตักเตรี ยมไว้ให้หรื อตักให้เป็ นชิ้นเล็ก ๆ ไว้ล่วงหน้า 10 = ตักอาหารและช่วยตัวเองได้เป็ นปกติ 2. Transfer (ลุกนั่งจากทีน่ อนหรื อจากเตียงไปยังเก้ าอี)้ 0 = ไม่สามารถนัง่ ได้ (นัง่ แล้วจะล้มเสมอ) หรื อต้องใช้คนสองคนช่วยกันยกขึ้น 5 = ต้องการความช่วยเหลืออย่างมากจึงจะนัง่ ได้ เช่น ต้องใช้คนที่แข็งแรง หรื อมีทกั ษะ 1 คน หรื อใช้คน ทัว่ ไป 2 คน พยุงหรื อดันขึ้นมาจึงจะนัง่ อยูไ่ ด้ 10 = ต้องการความช่วยเหลือบ้าง เช่น บอกให้ทาตามหรื อช่วยพยุงเล็กน้อย หรื อต้องมีคนดูแลความปลอดภัย 15 = ทาเองได้ 3. Grooming (ล้างหน้ า หวีผม แปรงฟัน โกนหนวด) 0 = ต้องการความช่วยเหลือ 5 = ทาเองได้ (รวมทั้งที่ทาได้เองถ้าเตรี ยมอุปกรณ์ไว้ให้)

ID number........................ ครั้งที่ 1 ครั้งที่ 2 ครั้งที่ 3 ครั้งที่ 4 วันที่ วันที่ วันที่ วันที่ .............. ............. .............. ..............

155

4. Toilet Use 0 = ช่วยตัวเองไม่ได้ 5 = ทาเองได้บา้ ง (อย่างน้อยทาความสะอาดตัวเองได้หลังเสร็ จธุ ระ) แต่ตอ้ งการความช่วยเหลือในบางสิ่ ง 10 = ช่วยเหลือตัวเองได้ดี (ขึ้นนัง่ และลงจากโถส้วมได้เอง ทาความสะอาดได้เรี ยบร้อยหลังจากเสร็ จธุ ระแล้ว ใส่ เสื้ อผ้าได้เรี ยบร้อย) 9. Bowels (การกลั้นอุจจาระ) 0 = กลั้นไม่ได้ หรื อต้องการสวนอุจจาระอยูเ่ สมอ 5 = กลั้นไม่ได้เป็ นบางครั้ง (เป็ นน้อยกว่า 1 ครั้งต่อสัปดาห์) 10 = กลั้นได้เป็ นปกติ 10. Bladder (การกลั้นปัสสาวะ) 0 = กลั้นไม่ได้ หรื อใส่ สายสวนปั สสาวะแต่ไม่สามารถดูแลเองได้ 5 = กลั้นไม่ได้เป็ นบางครั้ง (เป็ นน้อยกว่า วันละ 1 ครั้ง) 10 = กลั้นได้เป็ นปกติ รวมคะแนน เซ็นชื่ อผู้ประเมิน ตาแหน่ ง

157

การแปลผล 0-20 หมายถึง ไม่สามารถปฏิบตั ิกิจวัตรประจาวันได้เลย 25-45 หมายถึง สามารถปฏิบตั ิกิจวัตรประจาวันได้เล็กน้อย 50-70 หมายถึง สามารถปฏิบตั ิกิจวัตรประจาวันได้ปานกลาง 75-95 หมายถึง สามารถประกอบกิจวัตรประจาวันได้มาก 100 หมายถึง สามารถประกอบกิจวัตรประจาวันได้ดว้ ยตนเองทั้งหมด

158

แบบสอบถามสุ ขภาพทัว่ ไป (Thai GHQ-12) คาชี้แจง แบบสอบถามนี้มีวตั ถุประสงค์เพื่อต้องการทราบถึงสภาวะสุ ขภาพของท่าน ในระยะสองถึงสามสัปดาห์ที่ผา่ นมาเป็ นอย่างไรบ้าง กรุ ณาตอบคาถามต่อไปนี้ โดยเขียน เครื่ องหมายวงกลมรอบคาตอบที่ใกล้เคียงกับสภาพของท่านในปั จจุบนั หรื อในช่วงสามสัปดาห์ที่ ผ่านมามากที่สุด โดยไม่รวมถึงปั ญหาที่ท่านเคยมีในอดีต และกรุ ณาตอบคาถาม ทุกข้อ ในระยะสองถึงสามสั ปดาห์ ที่ผ่านมานีท้ ่าน 1) สามารถมีสมาธิ จดจ่อกับสิ่ งที่กาลังทาอยูไ่ ด้ ก. ดีกว่าปกติ ข. เหมือนปกติ ค. น้อยกว่าปกติ ง. น้อยกว่าปกติมาก 2) นอนไม่หลับเพราะกังวลใจ ก. ไม่เลย ข. ไม่มากกว่าปกติ ค. ค่อนข้างมากกว่าปกติง. มากกว่าปกติมาก 3) รู ้สึกว่าได้ทาตัวให้เป็ นประโยชน์ในเรื่ องต่าง ๆ ก. มากกว่าปกติ ข. เหมือนปกติ ค. น้อยกว่าปกติ ง. น้อยกว่าปกติมาก 4) รู ้สึกว่าสามารถตัดสิ นใจในเรื่ องต่าง ๆ ได้ ก. มากกว่าปกติ ข. เหมือนปกติ ค. น้อยกว่าปกติ ง. น้อยกว่าปกติมาก 5) รู ้สึกตึงเครี ยดอยูต่ ลอดเวลา ก. ไม่เลย ข. ไม่มากกว่าปกติ ค. ค่อนข้างมากกว่าปกติ ง. มากกว่าปกติมาก 6) รู้สึกว่าไม่สามารถที่จะเอาชนะความยากลาบากต่าง ๆ ได้ ก. ไม่เลย ข. ไม่มากกว่าปกติ ค. ค่อนข้างมากกว่าปกติ ง. มากกว่าปกติมาก 7) ……………………………………………………………… 8) ……………………………………………………………… 9)……………………………………………………………… 10)…………………………………………………………….. 11)…………………………………………………………….. 12) รู้สึกมีความสุ ขดี ตามสมควร เมื่อดูโดยรวม ๆ ก. มากกว่าปกติ ข. เท่า ๆ ปกติ ค. น้อยกว่าปกติ ง. น้อยกว่าปกติ

159

แบบสอบถามเกีย่ วกับระดับคุณภาพชี วติ อันเป็ นผลมาจากการเจ็บป่ วยด้ วยโรคหลอดเลือดสมอง จากแบบวัดคุณภาพชี วติ SF-36 ID No…… วัตถุประสงค์ ของแบบสอบถามฉบับนี้เพื่อประเมินผลกระทบของโรคหลอดเลือดสมองที่มีผลต่อ สุ ขภาพและชีวติ ของท่าน ผูว้ ิจยั ต้องการทราบ ความคิดเห็นของท่าน ว่าโรคนี้มีผลกระทบต่อท่าน อย่างไร คาชี้แจง กรุ ณากาเครื่ องหมาย / ลงในช่องที่ใกล้เคียงความรู ้สึกของท่านมากที่สุด 1.ท่านคิดว่าสุ ขภาพของท่านโดยทัว่ ไปเป็ นอย่างไร ดีเยีย่ ม ดีมาก ดี พอใช้ ไม่ดี 5 4 3 2 1 2.ท่านคิดว่าสุ ขภาพของท่านในขณะนี้เป็ นอย่างไร เมื่อเปรี ยบเทียบกับปี ที่แล้ว ดีข้ ึนกว่า ดีข้ ึนกว่าปี ที่แล้ว พอ ๆ กับปี ที่แล้ว แย่กว่าปี ที่แล้ว แย่กว่าปี ที่ บ้างเล็กน้อย บ้างเล็กน้อย แล้วมาก 5 4 3 2 1 3.ท่านคิดว่าในขณะนี้ท่านสามารถทากิจกรรมต่าง ๆ ต่อไปนี้ได้มากน้อยแค่ไหน ข้ อความ ทาได้ ตามปกติ ทาได้ เล็กน้ อย 1. กิจกรรมที่ตอ้ งออกแรงมาก เช่น วิง่ ยกของ หนัก เล่นกีฬาที่ใช้กาลังมาก เช่น แบดมินตัน 2. กิจกรรมที่ออกแรงปานกลาง เช่น เคลื่อนย้ายโต๊ะ-เก้าอี้ กวาดถูบา้ น 3. ยกของหรื อหิ้วของเวลาไปจ่ายตลาด 4. ขึ้นบันไดมากกว่า 2 ชั้น เช่น เดินขึ้น บันไดจากชั้น 1 ไปชั้น 3 5. ขึ้นบันได 1 ขั้น (จากชั้น 1 ไปชั้น 2) 6. ก้มหยิบของหรื อคุกเข่า 7. เดินระยะทางมากกว่า 1 กิโลเมตร 8. เดินระยะทางประมาณ 1 กิโลเมตร หรื อ ประมาณ 2-3 ป้ ายรถเมล์

ทาไม่ ได้ เลย

160

4………………………………………………………………………………………………….. 5. …………………………………………………………………………………………………. 6. …………………………………………………………………………………………………. 7. …………………………………………………………………………………………………. 8. …………………………………………………………………………………………………. 9. …………………………………………………………………………………………………. 10. ในช่วง 1 เดือนที่ผา่ นมา ปั ญหาทางด้านร่ างกายหรื อจิตใจมีผลทาให้ท่านไม่สามารถไปร่ วมงาน สังคม เช่น ไปพบปะเพื่อนฝูงหรื อญาติพี่นอ้ ง ตลอดเวลา บ่อยครั้ง บางครั้ง น้อยครั้ง ไม่เลย 1 2 3 4 5 11. เลือกคาตอบที่ตรงกับท่านมากที่สุด ข้ อความ เห็นด้ วย เห็น ไม่ ไม่ เห็น ไม่ เห็นด้ วย อย่างยิง่ ด้ วย ทราบ ด้ วย อย่างยิง่ 1. ท่านรู ้สึกว่าจะเจ็บป่ วยง่ายกว่าคน อื่นทัว่ ไป 2. ท่านมีสุขภาพดีเหมือนกับคนอื่น ๆ 3. ท่านคาดว่าสุ ขภาพตัวเองจะแย่ ลง กว่าเดิม 4. ท่านมีสุขภาพดีเยีย่ ม

161

APPENDIX C The instruments for intervention

162

163

164

165

166

167

168

169

170

171

172

โปรแกรมการพยาบาลในการฟื้ นฟูสมรรถภาพทีบ่ ้ านสาหรับผู้ป่วยโรคหลอดเลือดสมองตีบ โปรแกรมการพยาบาลในการฟื้ นฟูสมรรถภาพที่บา้ นสาหรับผูป้ ่ วยโรคหลอดเลือดสมองตีบ คือแนวทางดาเนินการปฏิบตั ิการเพื่อส่ งเสริ มการฟื้ นฟู สมรรถภาพสาหรับผูป้ ่ วยโรคหลอดเลือดสมองที่รอดชีวิตฝึ กทาที่บา้ น โดยผูว้ จิ ยั พัฒนาขึ้นจากแนวคิดคุณภาพชีวิตที่เกี่ยวข้องกับสุ ขภาพ ของ Wilson and Cleary (1995) ร่ วมกับแนวคิดการพยาบาลในการฟื้ นฟูสมรรถภาพของ Association of Rehabilitation Nurses [ARN] (2014) และการทบทวนวรรณกรรมที่เกี่ยวข้องเป็ นแนวทางใน การจัดกิจกรรม โดยใช้วธิ ีการติดตามดูแลเมื่อผูป้ ่ วยจาหน่ายกลับไปอยูบ่ า้ น และมีการสร้างทีมจากบุคลากรทางสุ ขภาพซึ่งเป็ นตัวแทนของโรงพยาบาลและ หน่วยบริ การสุ ขภาพในชุมชน เพื่อติดตามดูแลผูป้ ่ วยรายบุคคลที่บา้ น โดยประสานขอความร่ วมมือในการติดตามดูแลต่อเนื่องที่บา้ น มีการทาความเข้าใจให้ ตรงกัน และกาหนดบทบาทและหน้าที่ของแต่ละบุคคลในทีม ทั้งการเยีย่ มบ้านและการติดตามเยีย่ มทางโทรศัพท์ตามความเหมาะสม เพื่อดาเนินการตาม โปรแกรมฯที่สร้างขึ้น และผลลัพธ์ที่คาดหวังคือมีการปฏิบตั ิหน้าที่ การรับรู ้สุขภาพทัว่ ไปและมีคุณภาพชีวติ ที่เกี่ยวข้องกับสุ ขภาพดีข้ ึน ผูว้ ิจยั ดาเนินการตาม โปรแกรมฯ อย่างมีข้ นั ตอนและเป็ นระบบตามแผนที่วางไว้ เนื้อหาในโปรแกรม ฯ มีท้ งั หมด 3 ระยะ ได้แก่ ระยะที่1 เป็ นการประเมินความต้องการของบุคคลอย่างครอบคลุมเพื่อนามาสู่ การวางแผนการตอบสนองของบุคคลและกาหนดเป้ าหมายร่ วมกัน ระยะที่ 2 เป็ นการให้ความรู้และฝึ กทักษะเพื่อพัฒนาความรู้และทักษะในการช่วยเหลือตนเองของผูป้ ่ วยโรคหลอดเลือดสมอง ซึ่ งมีกิจกรรมหลักๆ คือ กิจกรรมการสอนให้ความรู้ เรื่ องโรคหลอดเลือดสมอง การรับประทานอาหารที่เหมาะสมกับโรค การปรับเปลี่ยนพฤติกรรมที่เหมาะสม การฝึ กการออกกาลัง กายและการฝึ กปฏิบตั ิกิจวัตรประจาวันที่บกพร่ องให้สามารถช่วยเหลือตนเองให้ได้มากที่สุดเท่าที่จะทาได้ ระยะที่ 3 เป็ นการติดตามดูแลต่อเนื่ องอย่างครอบคลุม เพื่อติดตามและส่ งเสริ มการฟื้ นฟูสมรรถภาพที่เหมาะสมโดยกระตุน้ ให้มีการฝึ กการออกกาลัง กายอย่างต่อเนื่อง โดยการส่ งเสริ มสุ ขภาพจิตให้ผปู้ ่ วยและครอบครัว โดยทีมจะทาหน้าที่ในการติดตามสนับสนุนอย่างต่อเนื่อง ทั้งการเยีย่ มบ้านและการใช้ โทรศัพท์ตามความเหมาะสม วัตถุประสงค์ หลัก เพื่อส่ งเสริ มให้ผปู ้ ่ วยโรคหลอดเลือดสมองตีบ มีการฟื้ นฟูสมรรถภาพที่เหมาะสมนาไปสู่ การปฏิบตั ิหน้าที่ดีข้ ึนการรับรู ้สุขภาพทัว่ ไปดีข้ ึน และมีคุณภาพชีวติ ที่เกี่ยวข้องกับสุ ขภาพที่ดีข้ ึน

วัตถุประสงค์ ทวั่ ไป เพื่อให้ผปู้ ่ วยโรคหลอดเลือดสมองตีบมีพฤติกรรมดังนี้ 1. มีความรู ้เกี่ยวกับโรคหลอดเลือดสมอง ยา พฤติกรรมการบริ โภคอาหารเฉพาะโรคและการปรับเปลี่ยนพฤติกรรมที่เหมาะสมถูกต้อง 2. มีทกั ษะการปฏิบตั ิตนเกี่ยวกับการออกกาลังกายเพื่อฟื้ นฟูสมรรถภาพอย่างเหมาะสมและช่วยเหลือตนเองในการปฏิบตั ิกิจวัตรประจาวันได้ กลุ่มเป้าหมาย ผูป้ ่ วยโรคหลอดเลือดสมองชนิดตีบ จานวน 34 คน ระยะเวลาในการดาเนินการในโปรแกรม 12 สัปดาห์ ผู้ดาเนินการโปรแกรม ผูว้ จิ ยั วิธีปฏิบัติ ผูว้ จิ ยั สรุ ปการดาเนินการตามโปรแกรม ทั้ง 3 ระยะ ดังนี้ ระยะ ระยะที่ 1

ชื่อหัวเรื่อง comprehensive individual need assessment and planning การประเมินความ ต้องการของบุคคล

วัตถุประสงค์ เป็ นการประเมินความ ต้องการของบุคคลอย่าง ครอบคลุมเพื่อนามาสู่ การวาง แผนการตอบสนองของ บุคคลและกาหนดเป้ าหมาย และวางแผน

กิจกรรม 1. ผูว้ จิ ยั พบผูป้ ่ วยโรคหลอดเลือดสมองเป็ นรายบุคคลและ ครอบครัว/ผูด้ ูแลที่คลินิกโรคหลอดเลือดสมอง 2. ผูว้ จิ ยั ใช้วธิ ีการประเมินภาวะสุ ขภาพอย่างครอบคลุม โดยมี ข้อมูลพื้นฐานของผูป้ ่ วยประกอบ ผูว้ จิ ยั ตรวจร่ างกายตามระบบ เบื้องต้นและวัดสัญญาณชีพเพื่อประเมินปั ญหาสุ ขภาพ การสื่ อสาร และการสัมภาษณ์ที่ดี โดยใช้ทกั ษะการดู ฟัง เคาะ คลา การตรวจ ประเมินทางระบบประสาท และเทคนิคการพูดคุยสอบถามสังเกต และรับฟัง

สื่ อ -อุปกรณ์การวัด สัญญาณชีพ -ข้อมูลของผูป้ ่ วย ( แบบสอบถาม ข้อมูลทัว่ ไปของ ผูป้ ่ วยโรคหลอด เลือดสมอง

ระยะ

ระยะที่ 2

ชื่อหัวเรื่อง อย่างครอบคลุมและ วางแผน

วัตถุประสงค์ กิจกรรมต่างๆร่ วมกัน ระหว่างผูว้ จิ ยั และผูป้ ่ วย

กิจกรรม 3. การตั้งเป้ าหมาย และวางแผนดาเนินการกิจกรรมต่าง ๆ ร่ วมกัน เพื่อให้เป็ นไปตามเป้ าหมายที่ต้ งั ไว้ 4. หลังจากได้ขอ้ มูลจากผูป้ ่ วย ผูว้ จิ ยั วิเคราะห์ปัญหาของผูป้ ่ วยทุก มิติหากมีปัญหาที่ซบั ซ้อน หรื อความต้องการกายอุปกรณ์ช่วยเหลือ ผูว้ จิ ยั จะประสานงานกับบุคลากรทางสุ ขภาพวิชาชีพอื่น ผูว้ จิ ยั จะ ประสานงานกับพยาบาลที่เป็ นตัวแทนจากโรงพยาบาลพหลพล พยุหเสนา เพื่อประสานขอความช่วยเหลือในปั ญหาสุ ขภาพที่ ซับซ้อนอื่น ๆ เช่น นักกายภาพบาบัด นักโภชนาการ เภสัชกร นัก สังคมสงเคราะห์ เป็ นต้น Individualized home- เป็ นการให้ความรู้และฝึ ก ดาเนินการตามเป้ าหมายที่ต้ งั ไว้ ซึ่ งมีกิจกรรมหลักๆ ดังนี้ based rehabilitation ทักษะรายบุคคลเพื่อให้ผปู้ ่ วย 1 กิจกรรมให้ความรู ้ เรื่ องโรคหลอดเลือดสมอง การรักษา การ การฝึ กการฟื้ นฟู พัฒนาความรู้และทักษะใน รับประทานอาหารที่เหมาะสมกับโรค ป้ องกันการกลับเป็ นซ้ า การ สมรรถภาพรายบุคคล การช่วยเหลือตนเอง ซึ่ งมี ปรับเปลี่ยนพฤติกรรมที่เหมาะสม ฝึ กทาที่บา้ น กิจกรรมหลักๆ ดังนี้ 2 การฝึ กทักษะการออกกาลังกายอย่างต่อเนื่อง และฝึ กปฏิบตั ิ 1.กิจกรรมให้ความรู ้เรื่ อง กิจวัตรประจาวัน เพื่อฟื้ นฟูสมรรถภาพในด้านที่อ่อนแรง และฝึ ก โรคหลอดเลือดสมอง การ ความแข็งแรงในด้านปกติ และส่ งเสริ มการช่วยเหลือตนเองในการ รับประทานอาหารที่ ดูแลกิจวัตรประจาวัน

สื่ อ แบบคัดกรอง กลุ่มตัวอย่างเข้า สู่ วจิ ยั (แบบ ประเมินระดับ ความพิการ, แบบทดสอบ สภาพสมอง เสื่ อม) -อุปกรณ์การวัด สัญญาณชีพ -คู่มือโรคหลอด เลือดสมอง สาหรับ ประชาชน, แผน พับโรคเลือด สมองและโรค อื่น ๆ

ระยะ

ระยะที่ 3

ชื่อหัวเรื่อง

Continuing comprehensive care การติดตามดูแล ต่อเนื่องอย่าง ครอบคลุม

วัตถุประสงค์

กิจกรรม

สื่ อ

เหมาะสมกับโรค การ ปรับเปลี่ยน พฤติกรรมที่เหมาะสม 2. การฝึ กทักษะการออก กาลังกายและการฝึ กปฏิบตั ิ กิจวัตรประจาวันที่บกพร่ อง ให้สามารถช่วยเหลือตนเอง ให้ได้มากที่สุดเท่าที่จะทาได้

-โดยผูว้ ิจยั ดาเนินการที่ให้ความรู ้และติดตามให้ความรู ้เพิ่มเติมและ ฝึ กทักษะที่บา้ นของผูป้ ่ วย จานวนทั้งหมด 7 ครั้ง ใน 6 สัปดาห์ -ในกิจกรรมสอนให้ความรู ้ ผูว้ จิ ยั มอบสิ่ งสนับสนุนต่างๆ เพิ่มการ เรี ยนรู ้ ได้แก่ คู่มือโรคหลอดเลือดสมองสาหรับประชาชน,แผนพับ โรคเลือดสมองและโรคอื่นๆ วีดีทศั น์เรื่ อง โรคหลอดเลือดสมอง สาหรับประชาชน ของสถาบันประสาทวิทยา เพื่อให้ผปู้ ่ วยและ ญาติที่ดูแลสามารถทบทวนได้ตลอดเวลา และแบบบันทึกการฝึ ก การออกกาลังกายรายวันและแบบติดตามเฝ้ าระวังการเกิด ภาวะแทรกซ้อน เพื่อเป็ นการบันทึกและติดตามความก้าวหน้าของ โปรแกรมฯ

- แบบบันทึกการ ฝึ กการออกกาลัง กายรายวันและ แบบติดตามเฝ้ า ระวังการเกิด ภาวะแทรกซ้อน -วีดีทศั น์โรค หลอดเลือดสมอง สาหรับประชาชน (สถาบันประสาท)

เป็ นการติดตามดูแลต่อเนื่ อง อย่างครอบคลุม เพื่อติดตาม และส่ งเสริ มการฟื้ นฟู สมรรถภาพที่เหมาะสมโดย กระตุน้ ให้มีการฝึ กการออก กาลังกายอย่างต่อเนื่ อง โดย การส่ งเสริ มสุ ขภาพจิตให้

1. ผูว้ จิ ยั เป็ นผูส้ นับสนุนให้ทีม ทาหน้าที่ในการติดตามเยีย่ มเพื่อ สนับสนุนอย่างต่อเนื่ อง ทั้งการเยีย่ มบ้านและการใช้โทรศัพท์ตาม ความเหมาะสม โดยกาหนดจานวนครั้งของการเยีย่ มบ้านและ โทรศัพท์ มีดงั นี้ กิจกรรมเยีย่ มบ้าน ทีมเยีย่ มบ้านซึ่ งได้แก่ พยาบาลตัวแทนจากโรงพยาบาลพหล พลพยุหเสนา 1-2 คนร่ วมกับพยาบาลชุมชน1-2 คนในเขตพื้นที่ที่ รับผิดชอบ ได้แก่โรงพยาบาลส่ งเสริ มสุ ขภาพตาบลเขาคุราง

- แบบบันทึกการ ฝึ กการออกกาลัง กายรายวันและ แบบติดตามเฝ้ า ระวังการเกิด ภาวะแทรกซ้อน

ระยะ

ชื่อหัวเรื่อง

วัตถุประสงค์ ผูป้ ่ วยและครอบครัว

กิจกรรม อ.เมือง จ.กาญจนบุรี เยีย่ มบ้านอย่างน้อย 2 สัปดาห์ต่อ 1 ครั้ง รวม 3 ครั้ง ในการเยีย่ มแต่ละครั้งดาเนินการกิจกรรมดังนี้ 1.1 ทีมเยีย่ มบ้านส่ งเสริ มให้ครอบครัว/ญาติที่ดูแลมีส่วนร่ วมใน การดูแลและประคับประคองด้านจิตใจผูป้ ่ วย 1.2 ทีมเยีย่ มบ้านให้คาปรึ กษาด้านจิตใจอย่างเหมาะสมแก่ผปู ้ ่ วย และครอบครัว/ญาติที่ดูแล 1.3 ทีมเยีย่ มบ้านให้การแก้ไขปั ญหาเฉพาะบุคคล เช่น ภาวะ ซึมเศร้า 1.4 หากพบปั ญหาทางด้านร่ างกายและจิตใจที่ซบั ซ้อน ให้ทีม ปรึ กษาและประสานกับเจ้าหน้าที่อื่น ๆ ของโรงพยาบาลพหลพล พยุหเสนาเพื่อให้ผปู ้ ่ วยได้รับการดูแลอย่างเหมาะสม กิจกรรมการเยีย่ มทางโทรศัพท์ ดังนี้ ทีมเยีย่ มบ้านให้คาปรึ กษาเป็ นระยะ ๆ โดยการพูดคุยทางโทรศัพท์ อย่างน้อย 2 สัปดาห์ต่อ 1 ครั้ง รวม 3 ครั้ง

สื่ อ

ครั้งที่ 1 (สั ปดาห์ ที่ 1) ทีโ่ รงพยาบาลพหลพลพยุหเสนา ขณะทีผ่ ้ ปู ่ วยมาตรวจตามนัดทีค่ ลินิกโรคหลอดเลือดสมอง ใช้ เวลา 60 นาที วัตถุประสงค์ 1. สร้างสัมพันธภาพ ระหว่างผูว้ ิจยั กับ ผูป้ ่ วยและครอบครัว ประเมินปัญหาและ ความของต้องการ ของผูป้ ่ วยอย่าง ครอบคลุม กาหนด เป้ าหมายและ วางแผนร่ วมกัน

กิจกรรมผู้วจิ ยั 1. หลังจากทาบทามกลุ่มตัวอย่างเข้าสู่การวิจยั ผูว้ ิจยั เริ่ มต้นเข้าสู่ โปรแกรมฯ โดยพบผูป้ ่ วยและญาติที่ดูแลที่บา้ น 1.1 ผูว้ ิจยั แนะนาตนเองอีกครั้งกับผูป้ ่ วยและญาติที่ดูแลเพื่อสร้าง ความคุน้ เคยพร้อมทั้งได้ตรวจสอบข้อมูลจากแบบสอบถามข้อมูล ทัว่ ไปของผูป้ ่ วยและแบบประเมินกิจวัตรประจาวัน (จาก แบบสอบถาม) 1.2 ผูว้ ิจยั อธิ บายวัตถุประสงค์ของการวิจยั และวิธีการดาเนินการตาม โปรแกรมฯ เพื่อเป็ นการกาหนดข้อตกลงร่ วมกัน 1.3 ผูว้ ิจยั อธิ บายรายละเอียดขั้นตอนของโปรแกรมฯซึ่ งผูว้ ิจยั จะมาที่ บ้านของผูป้ ่ วยและญาติที่ดูแลเพื่อดาเนินโปรแกรมฯ รวมครั้งนี้ดว้ ย เป็ นจานวน 7 ครั้ง ดังนี้ ครั้งที่ 1 ในสัปดาห์ที่ 1 ที่บา้ น ใช้เวลา 60 นาที ครั้งที่ 2 ในสัปดาห์ที่ 1 ที่บา้ น 2-3วันต่อมา ใช้เวลา 60-90 นาที ครั้งที่ 3 ในสัปดาห์ที่ 1 ที่บา้ น 2-3วันต่อมา ใช้เวลา 60-90 นาที ครั้งที่ 4 ในสัปดาห์ที่ 2 ที่บา้ น ใช้เวลา 60-90 นาที

สื่ ออุปกรณ์ ระยะเวลา เหตุผลเชิงทฤษฎี - แบบสอบถาม 5 นาที -การสร้างสัมพันธภาพ เพื่อให้เกิด ข้อมูลทัว่ ไปของ ความเป็ นกันเอง พูดคุยกับผูว้ ิจยั ได้ ผูป้ ่ วยโรคหลอด อย่างเต็มที่ จะทาให้ผปู ้ ่ วย หรื อญาติ เลือดสมอง พร้อมที่จะเปิ ดเผย กล่าวถึงการ -แบบคัดกรองกลุ่ม เจ็บป่ วย ตลอดจนปัญหาอื่นๆ แต่ ตัวอย่างเข้าสู่วิจยั ก่อนการสร้างสัมพันธภาพกับผูป้ ่ วย (แบบประเมินระดับ ผูว้ ิจยั ควรรู ้ประวัติ หรื อปัญหาของ ความพิการ, ผูป้ ่ วยจากแบบสอบถามข้อมูล แบบทดสอบสภาพ ทัว่ ไปของผูป้ ่ วย เพื่อจะได้ประเมิน สมองเสื่ อม) สภาพปัญหาของผูป้ ่ วยอย่างคร่ าวๆ -อุปกรณ์การ 15 นาที ได้ ตรวจวัดสัญญาณชีพ - การอธิ บายรายละเอียดช่วยให้ ผูป้ ่ วยและญาติที่ดูแลเข้าใจถึง วัตถุประสงค์ ขั้นตอนและ ประโยชน์ของการเข้าร่ วมกิจกรรม ที่จะได้รับ และเพื่อเป็ นการกาหนด ข้อตกลงร่ วมกัน

วัตถุประสงค์

กิจกรรมผู้วจิ ยั ครั้งที่ 5ในสัปดาห์ที่ 3 ที่บา้ น ใช้เวลา 60-90 นาที ครั้งที่ 6ในสัปดาห์ที่ 4 ที่บา้ น ใช้เวลา 60-90 นาที ครั้งที่ 7ในสัปดาห์ที่ 6 ที่บา้ น ใช้เวลา 60-90 นาที 1.4 หลังจากนั้นผูว้ ิจยั ดาเนินการตามโปรแกรมฯ ในครั้งที่ 1 โดยผูว้ ิจยั ตรวจร่ างกายและสนทนาซักถามข้อมูลต่าง ๆ ของผูป้ ่ วยและจากญาติที่ ดูแล เพื่อประเมินสภาพและความต้องการอย่างครอบคลุม ในการพูดคุย ผูว้ ิจยั ให้ผดู ้ ูแลหลักเข้ามามีส่วนร่ วม เพื่อประเมินความสามารถของ ครอบครัวในการตอบสนองความต้องการของครอบครัว 1.5 ผูว้ ิจยั ประเมินอย่างครอบคลุม โดยจะประเมินให้ครอบคลุมทั้ง 5 ด้าน ได้แก่ดา้ นร่ ายกาย ด้านจิตใจ ด้านการคิด สิ่ งสนับสนุนทางสังคม และความสามารถในการทาหน้าที่ ตัวอย่างเช่น ผูว้ ิจยั ประเมินสุ ขภาพด้านร่ างกายโดยการซักประวัติต่าง ๆ ประวัติ ความเจ็บป่ วยในปัจจุบนั ประวัติความเจ็บป่ วยในอดีต ประวัติส่วนตัว ประวัติการส่ งเสริ มสุ ขภาพและป้ องกัน, ผูว้ ิจยั ตรวจร่ างกายตามระบบ - ผูว้ ิจยั ประเมินสุ ขภาพด้านจิตใจ เพื่อคัดกรองสภาวะทางจิต จากการ พูดคุย - ผูว้ ิจยั ประเมินด้านสติปัญหา ซึ่ งได้จากการสังเกตจากสภาพทัว่ ไป สติปัญญาการรู ้คิด การพูด การรับรู ้ และการแปลความหมาย

สื่ ออุปกรณ์

ระยะเวลา

เหตุผลเชิงทฤษฎี เพื่อเตรี ยมวางแผนดาเนิ นการตาม โปรแกรมฯ

30 นาที

เมื่อผูป้ ระเมินได้ขอ้ มูลที่ครบถ้วน ถูกต้อง จะสามารถวินิจฉัยปัญหาได้ ครอบคลุมและทาให้มีการวางแผนได้ อย่างเหมาะสม โดยใช้วิธีการต่าง ๆ เช่น การให้คาปรึ กษา การให้คาแนะนา การให้คาปรึ กษาเพื่อเสริ มศักยภาพ เพื่อ ตอบสนองความต้องการของ ผูร้ ับบริ การเป็ นระยะๆ -ขณะซักประวัติและตรวจร่ างกาย ผูว้ ิจยั ใช้เทคนิคการสื่ อสารและ สัมภาษณ์ คือ พูดชัดเจน ระดับเสี ยงดัง พอควร ใช้คาถามที่ส้ นั เข้าใจง่าย ตั้งใจ รับฟัง และเทคนิคการสะท้อนกลับเพื่อ ทบทวนข้อสรุ ป หลีกเลี่ยงอคติโดยสรุ ป เรื่ องราวที่ได้ยินตามความคิดของ ผูส้ มั ภาษณ์และระยะเวลาการ

วัตถุประสงค์

กิจกรรมผู้วจิ ยั - ผูว้ ิจยั ประเมินด้านสังคมและสิ่ งแวดล้อม จากความสัมพันธ์ภายใน ครอบครัว เศรษฐกิจ ถามถึงลักษณะของเพื่อนบ้าน ลักษณะบ้านที่อยู่ อาศัย ความปลอดภัย เป็ นต้น - ผูว้ ิจยั ประเมินระบบสนับสนุนทางสังคม โดยถามถึงแหล่งประโยชน์ ในสังคม การสนับสนุนช่วยเหลือดูแล หรื อชื่อบุคคลเป็ นต้น - ผูว้ ิจยั ประเมินความสามารถในการทาหน้าที่ โดยซักถามผูป้ ่ วยถึงการ รับรู ้ภาวะสุ ขภาพของตนเองว่ามีสุขภาพดีหรื อไม่ 1.6 ผูว้ ิจยั พูดคุยซักถามถึงครอบครัวดั้งเดิมของครอบครัวปั จจุบนั เพื่อ ความเข้าใจความสัมพันธ์และลักษณะปฏิสมั พันธ์ที่เกิดในปัจจุบนั 1.7 หลังจากนั้น ผูป้ ่ วยและผูว้ ิจยั มีการตั้งเป้ าหมาย และวางแผนกิจกรรม ร่ วมกัน (ตัวอย่าง เช่น ช่วยกันร่ วมวิเคราะห์และพูดคุยเกี่ยวกับปัญหา ของผูป้ ่ วย ในปัจจุบนั ที่บกพร่ องภายหลังจากเป็ นโรคหลอดเลือดสมอง ตีบ เพื่อเป็ นการประเมินปัญหาและวางแผนดูแล) เพื่อนามาสู่ การวาง แผนการตอบสนองของบุคคลและกาหนดเป้ าหมายร่ วมกัน ผูว้ ิจยั นัด ครั้งต่อไปที่บา้ นของผูป้ ่ วยอีก 2-3 วัน 1.8 ผูว้ ิจยั กลับมาวิเคราะห์ปัญหาของผูป้ ่ วย หากผูป้ ่ วยมีปัญหาทาง สุ ขภาพที่ซบั ซ้อน ผูว้ ิจยั จะประสานงานกับทีมบุคลากรทางสุ ขภาพ อื่น ๆ

สื่ ออุปกรณ์

ระยะเวลา

10 นาที

เหตุผลเชิงทฤษฎี สัมภาษณ์ไม่ควรเกิน 30นาที -การประเมินปั จจัยที่มีผลต่อคุณภาพ ชีวิต เช่น ปัจจัยส่ วนบุคคล และปัจจัย สิ่ งแวดล้อม จะทาให้ทราบมิติของ คุณภาพชีวิตอย่างครอบคลุม ถึงภาวะ อาการ ภาวการณ์ทาหน้าที่ การรับรู ้ สุ ขภาพโดยทัว่ ไปและโดยรวม (Wilson, & Cleary, 1995) -การประเมินอย่างครอบคลุม เป็ น เครื่ องมือสาคัญที่ช่วยค้นหาปั ญหาที่ หลากหลายของผูป้ ่ วยและสามารถ วิเคราะห์แก้ไขปัญหาตามความต้องการ ได้

แบบบันทึกการฝึ กการออกกาลังกายรายวัน *ให้ลงบันทึกเฉพาะกิจกรรมการออกกาลังกายที่ต่อเนื่ องมากกว่า30 นาที วันที่เริ่ ม วันที่ ...........................เดือน...........................................ปี ...................... ออกกาลังกาย

วันจันทร์

วันอังคาร

วันพุธ

วันพฤหัส

วันศุกร์

วันเสาร์

วันอาทิตย์

แบบการติดตามเฝ้ าระวังการเกิดภาวะแทรกซ้ อน วันทีพ่ บ ภาวะแทรกซ้ อน

ภาวะแทรกซ้ อน

วิธีการแก้ปัญหา/ช่ วยเหลือ

วันทีป่ ัญหาหมดไป

หมายเหตุ

APPENDIX D Institutional review board

174

175

176

APPENDIX E Participant information and consent form

177

ใบยินยอมเข้ าร่ วมการวิจัย

-----------------------หัวข้ อวิทยานิพนธ์ เรื่ องประสิ ทธิ ผลของโปรแกรมการพยาบาลในการฟื้ นฟูสมรรถภาพที่ บ้านสาหรับผูป้ ่ วยโรคหลอดเลือดสมองตีบต่อการทาหน้าที่ การรับรู ้ภาวะสุ ขภาพและคุณภาพชีวติ ที่เกี่ยวข้องกับสุ ขภาพ วันให้คายินยอม วันที่ ………… เดือน…………………พ.ศ. ………………. ก่อนที่จะลงนามในใบยินยอมเข้าร่ วมการวิจยั นี้ ข้าพเจ้าได้รับการอธิ บายจากผูว้ จิ ยั ถึง วัตถุประสงค์ของการวิจยั วิธีการวิจยั ประโยชน์ที่จะเกิดขึ้นจากการวิจยั อย่างละเอียดและมีความ เข้าใจดีแล้ว ข้าพเจ้ายินดีเข้าร่ วมโครงการวิจยั นี้ ดว้ ยความสมัครใจ และข้าพเจ้ามีสิทธิ ที่จะบอกเลิก การเข้าร่ วมในโครงการวิจยั นี้เมื่อใดก็ได้และการบอกเลิกการเข้าร่ วมการวิจยั นี้จะไม่มีผลกระทบ ใด ๆ ต่อข้าพเจ้า ผูว้ จิ ยั รับรองว่าจะตอบคาถามต่าง ๆ ที่ขา้ พเจ้าสงสัยด้วยความเต็มใจ ไม่ปิดบัง ซ่อนเร้น จนข้าพเจ้าพอใจ ข้อมูลเฉพาะเกี่ยวกับตัวข้าพเจ้าจะถูกเก็บเป็ นความลับและจะเปิ ดเผยในภาพรวม ที่เป็ นการสรุ ปผลการวิจยั ข้าพเจ้าได้อ่านข้อความข้างต้นแล้ว และมีความเข้าใจดีทุกประการ และได้ลงนามใน ใบยินยอมนี้ดว้ ยความเต็มใจ ลงนาม…….…………..……………………………ผูย้ นิ ยอม (………………………………………………) ลงนาม………………………………………………พยาน (………………………………………………) ลงนาม………………………………………………ผูว้ จิ ยั (………………………………………………)

178

ข้าพเจ้าไม่สามารถอ่านหนังสื อได้ แต่ผวู ้ ิจยั ได้อา่ นข้อความในใบยินยอมนี้ให้ขา้ พเจ้า ฟังจนข้าพเจ้าเข้าใจดีแล้ว ข้าพเจ้าจึงลงนามหรื อประทับลายนิ้วหัวแม่มือของข้าพเจ้าในใบยินยอมนี้ ด้วยความเต็มใจ ลงนาม…….…………..……………………………ผูย้ นิ ยอม (………………………………………………) ลงนาม………………………………………………พยาน (………………………………………………) ลงนาม………………………………………………พยาน (………………………………………………) ลงนาม………………………………………………ผูว้ จิ ยั (………………………………………………)

179

เอกสารชี้แจงผู้เข้ าร่ วมการวิจัย (สาหรับกลุ่มควบคุม) การวิจัยเรื่องเรื่ องประสิ ทธิ ผลของโปรแกรมการพยาบาลในการฟื้ นฟูสมรรถภาพที่บา้ น สาหรับผูป้ ่ วยโรคหลอดเลือดสมองตีบต่อการทาหน้าที่ การรับรู ้ภาวะสุ ขภาพและคุณภาพชีวติ ที่ เกี่ยวข้องกับสุ ขภาพ รหัสจริยธรรมการวิจัย 10-09-2558 ชื่ อผู้วจิ ัย นางสาวบรรณฑวรรณ หิ รัญเคราะห์ การวิจยั ครั้งนี้ทาขึ้นเพื่อศึกษาผลของโปรแกรมการพยาบาลในการฟื้ นฟูสมรรถภาพที่ บ้านสาหรับผูป้ ่ วยโรคหลอดเลือดสมองตีบต่อการทาหน้าที่ การรับรู ้ภาวะสุ ขภาพและคุณภาพชีวติ ที่เกี่ยวข้องกับสุ ขภาพ ท่านได้รับเชิ ญให้เข้าร่ วมการวิจยั ครั้งนี้เนื่องจากท่านเป็ นผูท้ ี่มีคุณสมบัติตรง กับการศึกษาครั้งนี้คือ เป็ นผูท้ ี่มีอายุระหว่าง 35-65 ปี มีความบกพร่ องในการช่วยเหลือตัวเองระดับ ปานกลางถึงเล็กน้อย มีความสามารถในการสื่ อสารภาษาไทยได้ดี และยินดีเข้าร่ วมการวิจยั ในการ วิจยั ครั้งนี้มีจานวนผูป้ ่ วยที่รอดชีวติ จากโรคหลอดเลือดสมองเข้าร่ วมกลุ่มวิจยั ทั้งหมด 48 ท่านการ วิจยั นี้ใช้เวลาทั้งสิ้ น 12 สัปดาห์ เมื่อท่านเข้าร่ วมการวิจยั แล้วสิ่ งที่ท่านจะต้องปฏิบตั ิคือตอบคือตอบ แบบสัมภาษณ์ขอ้ มูลส่ วนบุคคลของผูป้ ่ วยโรคหลอดเลือดสมองชนิดขาดเลือด แบบประเมินการ ปฏิบตั ิกิจวัตรประจาวันของผูป้ ่ วยโรคหลอดเลือดสมอง แบบสอบถามสุ ขภาพทัว่ ไป และ แบบสอบถามเกี่ยวกับคุณภาพชีวติ โดยสัปดาห์ที่ 1 ผูว้ จิ ยั จะพบกับท่านที่แผนกผูป้ ่ วยนอก โรงพยาบาลพหลพลพยุหเสนาในวันที่ท่านมาพบแพทย์ เพื่อเก็บข้อมูล ท่านจะได้รับการตรวจ ตามปกติ และตอบแบบประเมินการปฏิบตั ิกิจวัตรประจาวันของผูป้ ่ วยโรคหลอดเลือดสมอง แบบสอบถามสุ ขภาพทัว่ ไป และแบบสอบถามเกี่ยวกับคุณภาพชีวติ ในสัปดาห์ที่ 4, 8 และ 12 ใน วันที่ท่านมาพบแพทย์ ท่านจะได้รับการตรวจสุ ขภาพเช่นเดียวกับสัปดาห์ที่ 1 อีกครั้ง ณ แผนกผูป้ ่ วย นอก โรงพยาบาลพหลพลพยุหเสนา ใช้เวลาประมาณ 30 นาที ประโยชน์ที่จะได้รับในการวิจยั ครั้งนี้คือท่านจะได้รับความรู ้เรื่ องโรคหลอดเลือดสมอง การวิจยั ครั้งนี้ไม่มีความเสี่ ยง หรื อความไม่สบายที่อาจเกิดขึ้นจากการวิจยั

180

การเข้าร่ วมการวิจยั ของท่านครั้งนี้เป็ นไปด้วยความสมัครใจท่านมีสิทธิ์ ที่จะยกเลิกหรื อ ถอนตัวออกจาก การวิจยั เมื่อใดก็ได้ตามที่ท่านต้องการโดยไม่มีผลกระทบต่อการดูแลรักษาที่ท่าน จะได้รับจากแพทย์ ประการสาคัญที่ท่านควรทราบคือ ผูว้ จิ ยั รับรองว่าจะเก็บข้อมูลเฉพาะที่เกี่ยวกับท่านเป็ นความลับโดยใช้รหัสเลขที่ของ แบบสอบถามเป็ น รหัสแทนชื่อ-นามสกุล ของกลุ่มตัวอย่างและนามาใช้ตามวัตถุประสงค์ในการ วิจยั ครั้งนี้ เท่านั้นการเสนอหรื ออภิปรายข้อมูลในการรายงานการวิจยั จะเสนอในภาพรวมของกลุ่ม ตัวอย่างทั้งหมดและไม่มีการแพร่ งพรายสู่ สารณชน ขอรับรองว่าจะไม่มีการเปิ ดเผยชื่อของท่านตาม กฎหมาย และข้อมูลทั้งหมดจะถูกเก็บไว้ในเครื่ องคอมพิวเตอร์ และถูกทาลาย ภายใน 1 ปี หากมี ข้อมูลเพิ่มเติมทั้งด้านประโยชน์และโทษที่เกี่ยวข้องกับการวิจยั นี้ ผูว้ จิ ยั จะแจ้งให้ท่านทราบ โดย รวดเร็ ว ไม่ปิดบัง หากท่านมีปัญหาหรื อข้อสงสัยประการใดสามารถสอบถามได้โดยตรงจากผูว้ ิจยั ใน วันทาการเก็บรวบรวมข้อมูลหรื อสามารถติดต่อสอบถามเกี่ยวกับการวิจยั ครั้งนี้ได้ตลอดเวลาที่ นางสาวบรรณฑวรรณ หิ รัญเคราะห์ ผูว้ จิ ยั หมายเลขโทรศัพท์ 086-336-2824 หรื อที่ ผูช้ ่วยศาสตราจารย์ ดร.สุ ภาภรณ์ ด้วงแพง อาจารย์ที่ปรึ กษาหลักหมายเลขโทรศัพท์ 081-8143913 ขอขอบพระคุณในความร่ วมมือของท่านมา ณ ที่น้ ี นางสาวบรรณฑวรรณ หิ รัญเคราะห์ ผูว้ จิ ยั

181

เอกสารชี้แจงผู้เข้ าร่ วมการวิจัย (สาหรับกลุ่มทดลอง) การวิจัยเรื่อง เรื่ องประสิ ทธิ ผลของโปรแกรมการพยาบาลในการฟื้ นฟูสมรรถภาพที่บา้ น สาหรับผูป้ ่ วยโรคหลอดเลือดสมองตีบต่อการทาหน้าที่ การรับรู ้ภาวะสุ ขภาพและคุณภาพชีวติ ที่ เกี่ยวข้องกับสุ ขภาพ รหัสจริยธรรมการวิจัย 10-09-2558 ชื่ อผู้วจิ ัย นางสาวบรรณฑวรรณ หิ รัญเคราะห์ การวิจัยครั้งนี้ทาขึน้ เพือ่ ศึกษาผลของโปรแกรมการพยาบาลในการฟื้ นฟูสมรรถภาพที่ บ้านสาหรับผูป้ ่ วยโรคหลอดเลือดสมองตีบ ท่านได้ รับเชิญให้ เข้ าร่ วมการวิจัยครั้งนี้เนื่องจากท่านเป็ นผูท้ ี่มีคุณสมบัติตรงกับ การศึกษาครั้งนี้คือ เป็ นผูท้ ี่มีอายุระหว่าง 35-65 ปี มีความบกพร่ องในการช่วยเหลือตัวเองระดับปาน กลางถึงเล็กน้อย มีความสามารถในการสื่ อสารภาษาไทยได้ดี และยินดีเข้าร่ วมการวิจยั ในการวิจยั ครั้งนี้จานวนผูป้ ่ วยที่รอดชีวิตจากโรคหลอดเลือดสมองเข้าร่ วมกลุ่มวิจยั ทั้งหมด 48 ท่านการวิจยั นี้ ใช้เวลาทั้งสิ้ น 12 สัปดาห์ เมื่อท่านเข้ าร่ วมการวิจัยแล้วสิ่ งทีท่ ่านจะต้ องปฏิบัติคือตอบแบบสัมภาษณ์ขอ้ มูลส่ วน บุคคลของผูป้ ่ วยโรคหลอดเลือดสมองชนิดขาดเลือด แบบประเมินการปฏิบตั ิกิจวัตรประจาวันของ ผูป้ ่ วยโรคหลอดเลือดสมอง แบบสอบถามสุ ขภาพทัว่ ไป และแบบสอบถามเกี่ยวกับคุณภาพชีวติ และระยะเวลาของโปรแกรมฯ ทั้งหมด 12 สัปดาห์ รวมเป็ นจานวน7 ครั้งดังนี้ครั้งที่ 1 ในสัปดาห์ที่ 1 ที่โรงพยาบาลใช้เวลาโดยประมาณ 60 นาที ครั้งที่ 2 ในสัปดาห์ที่ 1 ที่บา้ น 2-3 วันต่อมาใช้เวลา 60-90 นาทีครั้งที่ 3 ในสัปดาห์ที่ 1 ที่บา้ น 2-3วันต่อมาใช้เวลา 60-90 นาทีครั้งที่ 4 ในสัปดาห์ที่ 2 ที่ บ้านใช้เวลา 60-90 นาทีครั้งที่ 5 ในสัปดาห์ที่ 3 ที่บา้ นใช้เวลา 60-90 นาทีครั้งที่ 6 ในสัปดาห์ที่ 4 ที่ บ้านใช้เวลา 60-90 นาทีครั้งที่ 7 ในสัปดาห์ที่ 6 ที่บา้ นใช้เวลา 60-90 นาที หรื อแบ่งเป็ นระยะทั้งหมด 3 ระยะ คือ ระยะที่ 1 เป็ นการประเมินความต้องการของบุคคลอย่างครอบคลุมเพื่อนามาสู่ การวาง แผนการตอบสนองของบุคคลและกาหนดเป้ าหมายร่ วมกัน ระยะที่ 2 เป็ นการให้ความรู้และฝึ ก

182

ทักษะเพื่อพัฒนาความรู ้และทักษะในการช่วยเหลือตนเองของผูป้ ่ วยโรคหลอดเลือดสมองซึ่ งมี กิจกรรมหลัก ๆ คือ กิจกรรมการสอนให้ความรู ้เพิ่มเติมใน เรื่ องโรคหลอดเลือดสมอง การ รับประทานอาหารที่เหมาะสมกับโรค การปรับเปลี่ยนพฤติกรรมที่เหมาะสม การฝึ กการออกกาลัง กายและการฝึ กปฏิบตั ิกิจวัตรประจาวันที่บกพร่ องให้สามารถช่วยเหลือตนเองให้ได้มากที่สุดเท่าที่ จะทาได้และระยะที่3เป็ นการติดตามดูแลต่อเนื่ องอย่างครอบคลุม เพื่อติดตามและส่ งเสริ มการฟื้ นฟู สมรรถภาพที่เหมาะสม โดยกระตุน้ ให้มีการฝึ กการออกกาลังกายอย่างต่อเนื่ อง โดยการส่ งเสริ ม สุ ขภาพจิตให้ผปู้ ่ วยและครอบครัว โดยทีมผูว้ จิ ยั จะทาหน้าที่ในการติดตามสนับสนุนอย่างต่อเนื่ อง ทั้งการเยีย่ มบ้านและการใช้โทรศัพท์ตามความเหมาะสม ประโยชน์ที่จะได้รับในการวิจยั ครั้งนี้คือ หลังจากที่ท่านได้รับกิจกรรมต่าง ๆ ตาม โปรแกรมฯที่ผวู้ จิ ยั พัฒนาขึ้น ท่านจะมีความรู ้ความเข้าใจโรคหลอดเลือดสมอง ส่ งผลให้ท่านจะมี การพฤติกรรมสุ ขภาพที่ดีข้ ึนปรับเปลี่ยนพฤติกรรมในเรื่ องการรับประทานอาหารที่ถูกต้อง เหมาะสม กับโรค การมีกิจกรรมทางกายและการออกกาลังกายที่ถูกต้องเหมาะสมกับท่านและเมื่อท่านมีสุขภาพ ที่ดีข้ ึน จะส่ งผลให้ท่านรู ้สึกพึงพอใจกับสุ ขภาพที่ดีข้ ึนจากการที่สามารถช่วยเหลือตนเองได้ มี การ วิจยั ครั้งนี้ไม่มีความเสี่ ยง หรื อความไม่สบายที่อาจเกิดขึ้นจากการวิจยั การเข้าร่ วมการวิจยั ของท่านครั้งนี้เป็ นไปด้วยความสมัครใจท่านมีสิทธิ์ ที่จะยกเลิกหรื อ ถอนตัวออกจากการวิจยั เมื่อใดก็ได้ตามที่ท่านต้องการโดยไม่กระทบต่อการดูแลรักษาที่ท่านจะ ได้รับจากแพทย์ ผูว้ จิ ยั รับรองว่าจะเก็บข้อมูลเฉพาะที่เกี่ยวกับท่านเป็ นความลับโดยใช้รหัสเลขที่ของ แบบสอบถามเป็ นรหัสแทนชื่อ-นามสกุล ของกลุ่มตัวอย่างและนามาใช้ตามวัตถุประสงค์ในการวิจยั ครั้งนี้เท่านั้นการเสนอหรื ออภิปรายข้อมูลในการรายงานการวิจยั จะเสนอในภาพรวมของกลุ่ม ตัวอย่างทั้งหมดข้อมูลทั้งหมดจะถูกทาลาย ภายใน 1 ปี หากมีขอ้ มูลเพิม่ เติมทั้งด้านประโยชน์และโทษที่เกี่ยวข้องกับการวิจยั นี้ ผูว้ ิจยั จะแจ้งให้ ท่านทราบโดยรวดเร็ ว ไม่ปิดบัง หากท่านมีปัญหาหรื อข้อสงสัยประการใดสามารถสอบถามได้โดยตรงจากผูว้ ิจยั ใน วันทาการเก็บรวบรวมข้อมูลหรื อสามารถติดต่อสอบถามเกี่ยวกับการวิจยั ครั้งนี้ได้ตลอดเวลาที่ นางสาวบรรณฑวรรณ หิ รัญเคราะห์ ผูว้ จิ ยั หมายเลขโทรศัพท์086-336-2824หรื อที่ ผูช้ ่วยศาสตราจารย์ ดร.สุ ภาภรณ์ ด้วงแพง อาจารย์ที่ปรึ กษาหลักหมายเลขโทรศัพท์ 081-814-3913 ขอขอบพระคุณในความร่ วมมือของท่านมา ณ ที่น้ ี นางสาวบรรณฑวรรณ หิ รัญเคราะห์ ผูว้ จิ ยั

183

เอกสารชี้แจงผู้เข้ าร่ วมการวิจัย (สาหรับผู้ช่วยวิจัย) การวิจัยเรื่อง เรื่ องประสิ ทธิ ผลของโปรแกรมการพยาบาลในการฟื้ นฟูสมรรถภาพที่บา้ น สาหรับผูป้ ่ วยโรคหลอดเลือดสมองตีบต่อการทาหน้าที่ การรับรู ้ภาวะสุ ขภาพและคุณภาพชีวติ ที่ เกี่ยวข้องกับสุ ขภาพ รหัสจริยธรรมการวิจัย 10-09-2558 ชื่ อผู้วจิ ัย นางสาวบรรณฑวรรณ หิ รัญเคราะห์ การวิจัยครั้งนี้ทาขึน้ เพือ่ ศึกษาผลของโปรแกรมการพยาบาลในการฟื้ นฟูสมรรถภาพที่ บ้านสาหรับผูป้ ่ วยโรคหลอดเลือดสมองตีบ ท่านได้ รับเชิญให้ เข้ าร่ วมการวิจัยครั้งนี้เนื่องจากท่านเป็ นผูท้ ี่มีคุณสมบัติตรงกับ การศึกษาครั้งนี้คือ เป็ นเป็ นบุคลากรทางสาธารณสุ ข ในการปฏิบตั ิงานดูแลผูป้ ่ วย ที่มีประสบการณ์ การทางานมากกว่า 1 ปี และยินดีเข้าร่ วมการวิจยั ในการวิจยั ครั้งนี้ คือ เป็ นผูช้ ่วยวิจยั ในการ ช่วยเหลือผูว้ ิจยั ในการศึกษาประสิ ทธิ ผลของโปรแกรมฯนี้ โดยผูว้ ิจยั ได้อบรมเกี่ยวกับจริ ยธรรมการ วิจยั ในมนุษย์ให้แก่ผชู ้ ่วยวิจยั ได้มีความรู ้ ความเข้าใจเรี ยบร้อยแล้ว เมื่อท่านเข้ าร่ วมการวิจัยแล้วสิ่ งทีท่ ่านจะต้ องปฏิบัติคือ ช่วยเหลือผูว้ ิจยั ในการตรวจสอบ คุณสมบัติของกล่มตัวอย่าง และชี้แจงวัตถุประสงค์การวิจยั ขั้นตอนและวิธีการเก็บรวบรวมข้อมูล ให้กบั ผูป้ ่ วยโรคหลอดเลือดสมองตีบและญาติที่ดูแล ชี้แจงให้ทราบถึงสิ ทธิ ในการตอบรับหรื อ ปฏิเสธ การตอบคาถามและข้อมูลทุกอย่าง และการช่วยผูว้ ิจยั ในการสอบถามแบบสัมภาษณ์ขอ้ มูล ส่ วนบุคคลของผูป้ ่ วยโรคหลอดเลือดสมองชนิดขาดเลือดหรื อตีบ แบบประเมินเบื้องต้น และ เครื่ องมือที่ใช้ในการวิจยั ได้แก่ แบบประเมินการปฏิบตั ิกิจวัตรประจาวันของผูป้ ่ วยโรคหลอดเลือด สมอง แบบสอบถามสุ ขภาพทัว่ ไป และแบบสอบถามเกี่ยวกับคุณภาพชีวติ ผูช้ ่วยวิจยั ช่วยผูว้ จิ ยั รวบรวมข้อมูล จานวน 4 ครั้ง ดังนี้ ครั้งที่ 1 ในสัปดาห์ที่ 1 ที่โรงพยาบาล ครั้งที่ 2 ในสัปดาห์ที่ 4 ที่ บ้าน ครั้งที่ 3 ในสัปดาห์ที่ 8 ที่บา้ น และครั้งที่ 4 ในสัปดาห์ที่ 12 ที่บา้ น (หากเป็ นไปได้) ประโยชน์ ที่จะได้รับในการวิจยั ครั้งนี้คือ ผูว้ จิ ยั เชื่ อว่าหลังจากที่ท่านได้เข้าร่ วมเป็ นผูช้ ่วยวิจยั กับผูว้ จิ ยั ผลดีจะ

184

เกิดกับผูร้ ับบริ การ และในอนาคต โปรแกรมฯที่ผวู ้ ิจยั พัฒนาขึ้นนี้ อาจทาให้จานวนผูป้ ่ วยโรคหลอด เลือดสมองตีบ ในความดูแลของโรงพยาบาลและในชุมชน จ.กาญจนบุรี มีคุณภาพชีวิตที่ดีข้ ึน และ การลดจานวนเข้ารับบริ การในโรงพยาบาลจากการเกิดภาวะแทรกซ้อนต่าง ๆ การวิจยั ครั้งนี้ไม่มี ความเสี่ ยงร้ายแรงที่อาจเกิดขึ้นจากการวิจยั การเข้าร่ วมการวิจยั ของท่านครั้งนี้เป็ นไปด้วยความสมัครใจท่านมีสิทธิ์ ที่จะยกเลิกหรื อ ถอนตัวออกจากการวิจยั เมื่อใดก็ได้ตามที่ท่านต้องการโดยไม่กระทบต่อการทางานประจาของท่าน ประการสาคัญที่ท่านควรทราบคือ ผูช้ ่วยวิจยั ต้องเก็บข้อมูลที่เกี่ยวข้องกับกลุ่มตัวยอย่างที่ใช้ในการทดลองการวิจยั ครั้งนี้เป็ น ความลับ หากท่านมีปัญหาหรื อข้อสงสัยประการใดสามารถสอบถามได้โดยตรงจากผูว้ ิจยั ใน วันทาการเก็บรวบรวมข้อมูลหรื อสามารถติดต่อสอบถามเกี่ยวกับการวิจยั ครั้งนี้ได้ตลอดเวลาที่ นางสาวบรรณฑวรรณ หิ รัญเคราะห์ ผูว้ จิ ยั หมายเลขโทรศัพท์ 086-336-2824 หรื อที่ ผูช้ ่วยศาสตราจารย์ ดร.สุ ภาภรณ์ ด้วงแพง อาจารย์ที่ปรึ กษาหลักหมายเลขโทรศัพท์ 081-814-3913 ขอขอบพระคุณในความร่ วมมือของท่านมา ณ ที่น้ ี นางสาวบรรณฑวรรณ หิ รัญเคราะห์ ผูว้ จิ ยั

185

APPENDIX F Permission instrument

186

APPENDIX G Content validators

188

Content validators 1. Dr.Saridetcharoenchai

Director of Khaosukim Hospital

2. Assistant Professor Dr.TotsapornKhampolsiri

Faculty of Nursing, Chiangmai University

3.Mrs.LamipornLohityotin

Head of cluster of nursing Sirindhon National Medical Rehabilitation Institute Medical Department

4. Dr.SukjaiChalernsuk

Director of Chakriraj College Nursing

189

APPENDIX H Additional analysis

190 1.Outlier

Descriptives

BITOT

Group = 1 (FILTER)

Statistic Std. Error

Selected Mean

3.3875E2 13.87786

95% Confidence

Lower Bound

3.1004E2

Interval for Mean

Upper Bound

3.6746E2

5% Trimmed Mean

3.4597E2

Median

3.6250E2

Variance

4.622E3

Std. Deviation

6.79874E 1

Minimum

135.00

Maximum

400.00

Range

265.00

Interquartile Range

57.50

Skewness

-1.788

.472

Kurtosis

2.623

.918

1.8854

.33749

GHQTO Selected Mean T

95% Confidence

Lower Bound

1.1873

Interval for Mean

Upper Bound

2.5836

5% Trimmed Mean

1.7778

Median

1.6250

Variance

2.734

Std. Deviation Minimum

1.65335 .00

191

SFTOT

Maximum

6.00

Range

6.00

Interquartile Range

2.69

Skewness

.763

.472

Kurtosis

-.106

.918

1.0192E2

2.00321

Selected Mean 95% Confidence

Lower Bound

97.7727

Interval for Mean

Upper Bound

1.0606E2

5% Trimmed Mean

1.0175E2

Median

1.0225E2

Variance Std. Deviation

96.308 9.81366

Minimum

86.50

Maximum

120.25

Range

33.75

Interquartile Range

18.81

Skewness

.121

.472

Kurtosis

-.960

.918

192 2. Normality Tests of Normality Kolmogorov-Smirnova Statistic

Df

Shapiro-Wilk

Sig.

Statistic

df

Sig.

BITOT

.192

48

.000

.830

48

.000

GHQTOT

.172

48

.001

.905

48

.001

SFTOT

.069

48

.200*

.975

48

.381

a. Lilliefors Significance Correction *. This is a lower bound of the true significance.

193

3. Independence of observation Model Summaryb Std. R Model

R 1

Adjuste

Square

d R Square

.12

.01

a

6

7

-.005

Error of the Estimate 64.1942 5

a. Predictors: (Constant), Group b. Dependent Variable: BITOT Model Summary Std. R

Adjuste

Model

R

Square

d R Square

1

.59

.35

3a

2

a. Predictors: (Constant), Group b. Dependent Variable: GHQTOT

.338

Error of the Estimate 2.50596

194 Model Summaryb

Model 1

R .733a

R Square

Adjusted R

Std. Error of

Square

the Estimate

.537

.527

12.11645

a. Predictors: (Constant), Group b. Dependent Variable: SFTOT

4. Randomness

Runs Test GHQTO BITOT Test Valuea

T

SFTOT

357.50

2.88

88.75

24

24

24

24

24

24

Total Cases

48

48

48

Number of Runs

24

22

8

-.146

-.729

-4.815

.884

.466

.000

Cases < Test Value Cases >= Test Value

Z Asymp. Sig. (2tailed) a. Median

195 5. Homoginity of variance Box's Test of Equality of Covariance Matricesa Box's M F

301.257 2.774

df1

78

df2

6.682E3

Sig.

.000

Multivariate Testsb

Effect Between Subjects

Intercept

Group

Within Subjects

time

Value

Hypothesis df

Error df

Sig.

Partial Eta Squared

Pillai's Trace

.990

1.481E3a

3.000

44.000

.000

.990

Wilks' Lambda

.010

1.481E3a

3.000

44.000

.000

.990

Hotelling's Trace

100.977

1.481E3a

3.000

44.000

.000

.990

Roy's Largest Root

100.977

1.481E3a

3.000

44.000

.000

.990

Pillai's Trace

.562

18.842a

3.000

44.000

.000

.562

Wilks' Lambda

.438

18.842a

3.000

44.000

.000

.562

Hotelling's Trace

1.285

18.842a

3.000

44.000

.000

.562

Roy's Largest Root

1.285

18.842a

3.000

44.000

.000

.562

.962

a

9.000

38.000

.000

.962

a

9.000

38.000

.000

.962

a

9.000

38.000

.000

.962

a

9.000

38.000

.000

.962

20.538

a

9.000

38.000

.000

.829

20.538

a

9.000

38.000

.000

.829

20.538

a

9.000

38.000

.000

.829

20.538

a

9.000

38.000

.000

.829

Pillai's Trace Wilks' Lambda Hotelling's Trace Roy's Largest Root

time * Group

F

.038 25.633 25.633

Pillai's Trace

.829

Wilks' Lambda Hotelling's Trace Roy's Largest Root

.171 4.864 4.864

a. Exact statistic, b. Design: Intercept + Group Within Subjects Design: time

1.082E2 1.082E2 1.082E2 1.082E2

APPENDIX I Sample size determination

198

Sample size determination To determine sample size in this study, based on previous studied of Chalermwannapong, Panuthai, Srisuphan, Panya, and Ostwald (2010) that examined the effect of transitional care program on functional ability and quality of life of stoke survivors. The result showed that the mean score of functional ability in the experimental group was 33.77, SD = 5.02, and in the control group showed the mean score was 27.79, SD = 9.97 Hedger’1982 formula d = XE-XC SDpool d = effect size XE = mean score of functional ability in the experimental group XC = mean score of functional ability in the control group SDpool= total mean of the standard deviation

d = 33.77-27.79 9.97+5.02/2

=

5.98 7.495

d = 0.798

Hence, the criteria of the significant level of .05, power of .80, and effect size of .80 were used; the required need sample size was 25 persons per group or all sample size 50 persons (25*2=50) (Polit&Hungler, 1987).

199

BIOGRAPHY Name

Ms BuntawanHirunkhro

Date of birth

September 12, 1977

Address to contact:

Boromarajonani College of Nursing, Chakriraj 99 M 3 Ladbuakaw subdistrict, Banpong district, Ratchaburi, Thailand, 70110

Position held 2000-2016

Nursing Instructor Borommarajjonani College of Nursing, Chakriraj, Ratchaburi province, Thailand. Praboromarajchanok Institute, Ministry of Public Health, Thailand

Education 1996

Diploma in Nursing Science (Equivalent to Bachelor of Science in Nursing), Boromarajonani College of Nursing, Ratchaburi, Thailand

2004

Master of Nursing (Adult Nursing), Faculty of Nursing, Chiang Mai University, Thailand

2016

Doctor of Philosophy (Nursing Science) International Program, Burapha University

Awards or Grants 2010-2013

Research grant Praboromarajchanok Institute, Ministry of Public Health, Thailand

2015

Research grant from Burapha University

Loading...

effectiveness of home-based rehabilitation nursing program on

EFFECTIVENESS OF HOME-BASED REHABILITATION NURSING PROGRAM ON FUNCTIONAL STATUS HEALTH PERCEPTIONS AND HEALTH-RELATED QUALITY OF LIFE AMONG ISCHEMIC S...

4MB Sizes 10 Downloads 77 Views

Recommend Documents

Masters of Rehabilitation Counseling Program Student - AState.edu
Mission. The MRC program is committed to ensuring that people with disabilities, regardless of their race, ethnicity, se

the effectiveness of implementing the expanded program on
21 May 2004 - (สาธารณสุขศาสตร ) สาขาเอกบริหารสาธารณสุข. คณะกรรมการควบคุมวิทยานิพนธ : ป ยธิดา ตรีเดช ส.ด., พีระ ครึกคร

Yorkton Nursing Program - USASK Nursing - University of
22 Feb 2016 - In September 2014, the College of Nursing, in partnership with Parkland College and. Sunrise Health Region

Cost-Effectiveness Analysis of Rehabilitation Services for Stroke
(ADL) 5 years after stroke for mildly to moderately. Barthel-level impaired patients.(15) In developed coun- .... was th

The Effectiveness of the Raskin Program - eaber
National Family Planning Coordinating Board. BPK. : State Audit Agency. BPKP. : Financial and Development Supervisory Bo

Nursing Program @ KCTCS - Discussion on Topix
98% of the people who want to do nursing do it simply because they think it will offer the biggest paycheck with the lea

13 best ECTC: Nursing Program images on Pinterest | Nursing
Explore ✨Kenzi Ann 's board "ECTC: Nursing Program" on Pinterest. | See more ideas about Nursing schools, Nursing car

Evaluation of effectiveness of training of nursing professionals: a
In: Borges-Andrade JE. Abbad GS, Mourão L. Treinamento, desenvolvimento e educação em organizações e trabalho: fundament

Lake City Nursing and Rehabilitation Center, LLC
Lake City Nursing and Rehabilitation Center is a Medicare Certified, Medicaid Approved skilled nursing center in Lake Ci

Pediatric Rehabilitation Service - Intech Rehab & Nursing Center
Children who are at another hospital or institution can be referred to us by faxing pertinent clinical and insurance inf