Social Work - Theses
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ItemConsumer centred care in nephrology social work: understanding the psychosocial experiences of adult patients living with chronic kidney disease and their carer( 2015)Introduction Chronic Kidney Disease (CKD) imposes a substantial burden on individuals and communities. It can have a profound impact on the wellbeing and quality of life of the individual diagnosed with the disease and also on their family. CKD is associated with complex psychosocial problems in both patients and their primary carer. Individual quality of life can be compromised through the experience of anxiety and depression, a reduced sense of hope, limited coping strategies and reduced social supports. The complex nature of CKD can result in a reduction in quality of life and can affect dyadic adjustment and lead to the development of learned helplessness in both the patient and their carer. Aim The aim of this longitudinal study was to explore the contextual and complex nature of the psychosocial experiences and implications of illness on both adult patients experiencing CKD and their carers. This was done to provide insight and understanding into the individual patient’s experience of CKD including the impact on their quality of life and the psychological experiences of the disease including hope, depression and anxiety, social support, coping. It also aimed to provide insight into the implications of the illness on dyadic adjustment and learned helplessness and into the psychosocial impact of CKD on carers. Method This is a case series study exploring a number of identified issues relevant to the renal population. It used previously validated tools over a 12 month period to explore the research questions presented in the thesis. "Controls" were not used as the published data already showed what the “norm” was or what the expected responses would be within a similar underlying population. The goal was to compare the current group of participants against the established norms and the patient scores against their carer’s scores. The number of participants were chosen by looking at other published studies exploring a similar question in a similar population. To support this methodology, minimal clinically important differences (MCID) were reported for the tools where a pre-established MCID had been reported in the literature. Findings This study has shown that: • Quality of life was compromised in the current patient participants. In particular the symptoms and problems of kidney disease, effects of kidney disease and physical component summary subscales of the KDQoL were the most compromised subscales in this population. These results are reflective of those previously reported in the literature. • In relation to carer perceptions of quality of life in patients, there was a lack of agreement between patient and carer perceptions of the patient’s quality of life. • In the overall participants, hope was not significant and did not correspond to high levels of quality of life. The participants reporting high levels of hope, however, also reported above average quality of life scores. • Anxiety and depression were not significant factors for the overall population, although higher levels of anxiety were reported by both patients and carers when compared to depression. This finding contradicts the previously reported literature. • The participants in this study used more emotion-focused coping strategies and fewer problem-focused coping strategies and this assisted them to develop coping strategies for dealing with illness intrusiveness. • Social support was high in the participants and in particular perceived support from family and significant others were the most frequently reported sources of social support. This high degree of support was reflected in normal to mild anxiety and depression scores for both patients and carers, thus supporting a limited number of studies in the literature. • Learned helplessness was not significant in the current study participants. Depression and anxiety were not significant in the minimal number of patients and carers who reported high levels of learned helplessness. • Dyadic adjustment was reported in fifty percent of the participating dyads in this study. Overall dyadic adjustment and in particular dyadic cohesion and affectional expression resulted in lower incidence of depression and anxiety and higher reported levels of hope. Conclusion In conclusion, this thesis offers a comprehensive, detailed and deeper understanding about the psychosocial experiences of patients across all stages of CKD and their nominated carer from an Australian perspective. CKD has a profound impact on patients’ and caregivers’ physical, mental and emotional wellbeing, relationships with family and friends, lifestyle, and roles and responsibilities. Despite facing the continuous and overwhelming challenges of CKD, the patients and caregivers in this study used an array of emotion-focused coping strategies, and formal and informal social supports to maintain a reasonable quality of life. Suggestions for future research and implications for social work practice are made.
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ItemEvaluation of a goal-based intervention to reduce depression post-stroke( 2014)The main contentions of this thesis revolve around the multi-factorial concept of recovery after stroke. Stroke is a focal cerebrovascular event that remains a worldwide leading cause of death and permanent disability. Although the incidence of stroke is reducing, its overall prevalence is increasing due to an ageing demographic. Also, despite improvements in acute care management (resulting in reduced mortality rates and less severe levels of impairments), the event of a stroke still often results in complex sequelae, which may present across the spectrum of enduring body structure and function changes, activity limitations, and participation restrictions. The majority of people who have had a stroke will return to reside in the community, however, many of these people will continue to have a level of disability that necessitates ongoing assistance from their families, social networks, and formal community services in order to achieve daily tasks and engage in valued activities. Historically, post-stroke rehabilitation programs have essentially focussed on the amelioration of basic mobility and self-care deficits, with the subsequent published literature abundantly reporting these outcomes. However, over recent decades there has also been greater emergence of publications reporting more ‘holistic’ post-stroke outcomes, demonstrating that the event of a stroke may also frequently result in mood disorders, reduced participation status, gradual functional decline, a diminished quality of life, adverse carer outcomes, and lifestyle adjustment issues. In particular, about one third of people who have had a stroke will also have symptoms of depression, which may impede the recovery process and adversely affect post-stroke outcomes, including failure to resume previous activities. Many of these post-stroke complications and adverse sequelae may be potentially modifiable by targeted interventions. There are many theoretical models and frameworks that exist to try to inform rehabilitation practice. Within these models it is espoused that goal setting is a key component. However, to date, relatively little research has investigated the effectiveness of facilitating the pursuit of individualised goals on the ‘holistic’ outcomes. The first area of work in this thesis assessed the published body of literature that pertained to the effectiveness of community-based rehabilitation programmes on the specific post-stroke outcomes of interest - depression, participation status, and perception of health-related quality of life. Overall, there was evidence to support some community-based interventions in affecting the outcomes of participation and health-related quality of life post-stroke, especially when incorporating management strategies that specifically target participation and leisure domains. In addition, certain exercise programs were shown to have been of benefit in the reduction of post-stroke depressive symptoms The second area of work in this thesis aimed to investigate the effectiveness of a person-centred, integrated approach to facilitating goal achievement and recovery in the community in the first year post-stroke – via a randomised controlled trial. This main study incorporated a multi-modal protocol that used resources that were predominantly available within the existing community-based rehabilitation framework. The intervention included collaborative goal setting, review of goal achievement levels, written information provision, and further referral to relevant health services as required. Intermittent telephone contacts and face-to-face reviews via home visits enabled the clinical researcher to screen for the occurrence of adverse post-stroke sequelae and monitor the participants’ progress throughout the first year after the event – and implement further management options as required With respect to the study’s primary outcome variable, there was a significant difference between the two groups regarding the rates of depression at twelve months post-stroke – with the rate of depression in the intervention group being significantly lower than the rate of depression in the control group. Additionally, the intervention group achieved a higher level of attainment of the collaborative goals that were devised at discharge from inpatient rehabilitation – in both total number of goals, and goals rated to be in the participation domain. No significant group differences were identified for the quality of life outcomes, but interestingly, there was a difference identified between the groups for self-care self-efficacy - perhaps indicating that the intervention may have also altered the participants’ perception of their ability to adopt sufficient coping mechanisms, manage their stress, and deal with arising situations post-stroke. In addition, these results further support the contention that mood status may have an association with self-care self-efficacy after stroke. Learnings from the studies in this thesis suggest that positive effects can be achieved in the more ‘holistic’ post-stroke outcomes when they are specifically targeted. The interventions utilised in this study are readily applicable to community-based clinical practice, and the next challenge lies in how to successfully translate this evidence into routine post-stroke management strategies.