Social Work - Theses
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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.