Nurse Media Journal of Nursing, 10.
, 2020, 361-375 Available online at http://ejournal.
id/index.
php/medianers DOI: 10.
14710/nmjn.
The Effect of AuSELF-HELP PackagesAy on Post Stroke Depression among Ischemic Stroke Survivors Fitria Handayani1.
Setyowati Setyowati2.
Dwi Pudjonarko3,4.
Dian Ratna Sawitri5 Department of Nursing.
Faculty of Medicine.
Universitas Diponegoro.
Semarang.
Indonesia Department of Maternity and WomenAos Health.
Faculty of Nursing.
University of Indonesia.
Indonesia Departement of Neurology.
Faculty of Medicine.
Universitas Diponegoro.
Semarang.
Indonesia Kariadi General Hospital.
Semarang.
Indonesia Faculty of Psychology.
Universitas Diponegoro.
Semarang.
Indonesia Corresponding Author: Fitria Handayani .
handayani@fk.
Received: 19 June 2020
Revised: 16 December 2020
Accepted: 26 December 2020
ABSTRACT
Background: There are several factors that contribute to Post Stroke Depression (PSD).
Since a single intervention is proven ineffective to deal with PSD, an intervention which includes biological, psychological, social, and spiritual aspects (AuSELF-HELP PackagesA.
, therefore, needs to be established.
Purpose: The purpose of the study was to investigate the effect of AuSELF HELP PackagesAy intervention on PSD among ischemic stroke survivors after three months from onset and its effect after confounding variables were controlled.
Methods: This study was a pre and post quasi-experiment with a control group, involving 34 ischemic stroke survivors each group.
The inclusion criteria were survivors after three months from ischemic stroke, no aphasia, having a good hearing, and having Mini Mental Status Examination (MMSE) score of Ou22.
GRID-HAMD 17,
Multidimensional Scale of Perceived Social Support (MSPSS), and Barthel-Index were used to measure PSD, social support, and functional status respectively.
AuSELF-HELP PackagesAy intervention was delivered in three sessions, namely information delivery, discussion and activity.
Statistical analyses were conducted using McNemar test, chisquare and logistic regression.
Results: The result showed that AuSELF-HELP PackagesAy considerably decreased PSD in the intervention group .
=0.
There were also significant differences on PSD after the intervention between two groups .
=0.
Logistic regression showed that AoSELF-HELP PackageAy had no effect on PSD when other confounding variables were controlled .
=0.
OR=0.
288, 95% CI 0.
073 Ae 1.
Conclusion: SELF-HELP PackagesAy should be applied in providing the nursing intervention among stroke ischemic survivors in clinical setting.
A longer period of time for the intervention is recommended for the next study to obtain a more robust result.
Keywords: Ischemic stroke.
post stroke depression.
AuSELF-HELP PackagesAy How to Cite: Handayani.
Setyowati.
Pudjonarko.
, & Sawitri.
The effect of AuSELF-HELP packagesAy on post stroke depression among ischemic stroke Nurse Media Journal Nursing, 10.
, doi:10.
14710/nmjn.
Permalink/DOI: https://doi.
org/10.
14710/nmjn.
Copyright A 2020.
NMJN, p-ISSN 2087-7811, e-ISSN 2406-8799 Nurse Media Journal of Nursing, 10.
, 2020, 362
BACKGROUND
World Health Organization (WHO) stated that stroke is the fifth rank cause of mortality and contributes to different health status between males and females (World Health Organization, 2.
The prevalence of stroke in Central Java is 11 per miles in 2018 (Ministry of Health of the Republic of Indonesia, 2.
, while the number in Semarang City is also high, reaching for 8,808 cases (Health Office of Semarang City, 2.
This high prevalence of stroke should become more concern for management.
Stroke will impact many conditions, such as handicap, family and economic burden and Post Stroke Depression (PSD) (Donkor, 2.
The pattern of PSD is unique in which the incident increases at fourth week after onset and peaks at 14th week .
hree month.
after onset (Gbiri.
Akinpelu, & Odole, 2.
Furthermore.
PSD possibly continues up to six months, or more than one year after stroke onset (Chau et al.
, 2010.
De Wit et al.
Specific pattern of PSD is explained as a high prevalence of PSD after three month from onset, which ranges from 17.
7 to 47.
7 % (Handayani & Pudjonarko 2.
Post Stroke Depression after three months from onset will impact on functional status and handicap, continuous depression, suicidal thought, and fatigue (Bartoli.
Di Brita.
Crocamo.
Clerici, & Carryl, 2018.
Kang et al.
, 2018.
Lincoln et al.
, 2.
PSD leads to 5 year after stroke (Lerdal et al.
, 2.
, and low quality of life 5 years after stroke (Kielbergerova et al.
, 2.
PSD also contributes to mortality rate (Bartoli et al.
Hackett.
Kyhler.
OAoBrien, & Mead, 2.
Some medicines are prescribed to reduce PSD, namely deanxit, fluoxetine, setraline, paroxetine, and citalopram, and their effects will continue to six-eight weeks after treatment (Loubinoux et al.
, 2.
Although the patients consume medicines.
PSD will re-occur in three months to two years after stroke (Guiraud et al.
, 2016.
Kang et al.
, 2018.
Yuan et al.
, 2.
Two studies reported that some interventions could not significantly decrease PSD.
study which delivered high intensity of exercise among ischemic stroke patients had no impact on PSD (Holmgren.
Lindstrym.
Gosman-Hedstrym.
Nyberg, & Wester, 2.
Another intervention was cognitive rehabilitation among stroke patients in long term health care facilities which was reported to be significant to reduce Geriatric Depression Scale (GDS).
Nevertheless, the minimum number of participants in this study (Sakamoto et al.
, 2.
causing the generalization of the result could not be concluded.
These studies revealed that single interventions were not effective to reduce PSD.
Other studies using complex interventions, including aspects of biology, psychology, social, and spirituality show good outcomes.
Zimmermann et al.
, .
point out that a complex intervention which consists of biological, psychological, and social aspects, increases perceived self-efficacy and better clinical outcome of anxiety, depression or somatization symptoms.
Byrne et al.
claim that Ready to Reduce Risk .
R) complex intervention improves clinical lifestyles of the patients with cardiovascular The result of these studies supports the claim that complex interventions including biological, psychological, social and spiritual aspects have an opportunity to accomplish the modified behaviour and clinical improvements (Medical Research Council, 2.
Copyright A 2020.
NMJN, p-ISSN 2087-7811, e-ISSN 2406-8799 Nurse Media Journal of Nursing, 10.
, 2020, 363 Apart from the interventions to decrease PSD, several factors are reported to affect PSD, of which, in this study, are considered as the confounding factors.
A review concludes that a factor related to PSD after three months from stroke onset is social support (Handayani.
Setyowati.
Pudjonarko, & Sawitri, 2.
A study from Shi et al.
also shows that the predictors of PSD are cognitive aspects and stroke recurrent.
Furthermore, functional status is independently associated with PSD after three months from stroke onset (Ojagbemi & Owolabi, 2.
Another relating factor with PSD is Brain Derived Neurotropic Factor (BDNF).
Research showed that BDNF has an important role in maintaining neural function, plasticity and neurogenesis regulation (Silakarma & Sudewi, 2.
Specifically.
BDNF is related with PSD among ischemic stroke survivor after three months from onset (Li et al.
, 2.
Previous studies involving single interventions showed insignificant effect to decrease PSD.
On the other hand, complex interventions were reported to yield good outcomes in patients with psychological problems and cardiovascular diseases.
In addition, there are several factors contribute to PSD such as social or family support, cognitive functions, functional status and BDNF after three months from ischemic stroke onset.
Therefore, a complex intervention which consists biological, psychological, social, and spiritual aspects on ischemic stroke patients needs to be developed.
The AuSELF-HELP PackagesAy was a complex intervention, abbreviated of Smart.
Effort.
Wellness.
Feel.
Happy and Power, which might be effective to terminate the negative outcomes caused by stroke (Webber & Newby, 2015.
Wills, 2.
, one of which is PSD.
PURPOSE
The purpose of this study was to investigate the effect of AuSELF-HELP PackagesAy on PSD after three months from ischemic stroke onset and its effect after confounding variables were controlled.
METHODS
Research design and samples This study was a quasi-experiment study using pre and post-test design with a control The samples were 68 stroke ischemic survivors after three months from onset, who were divided evenly into the intervention and control groups, with 34 respondents in each group.
The study was conducted in two government hospitals in Central Java.
Indonesia for three months in 2018.
The respondents in each group were separately recruited from different hospitals.
The inclusion criteria were ischemic stroke survivors after three months from ischemic stroke diagnosis, no aphasia, having a good hearing, having Mini Mental Status Examination (MMSE) score of Ou22.
The sampling technique used purposive sampling in which researchers relied on their own judgments to choose the respondents among stroke patients.
The sample selection is illustrated by Figure 1.
Measurements Post stroke depression was assessed using GRID-HAMD 17 questionnaire as the main instrument in this study, which consists of 17 questions (Williams et al.
, 2.
This instrument had interview guidelines for use to establish its validity during data collection (Patrick et al.
, 2.
The categories for the scores were divided to two.
patients with no PSD if the scores were O 7.
and second, patients with PSD if the scores Copyright A 2020.
NMJN, p-ISSN 2087-7811, e-ISSN 2406-8799 Nurse Media Journal of Nursing, 10.
, 2020, 364 were >7.
This instrument was translated to the Indonesian languages and then back translated to English using two independent translators.
Face validity then was carried out to find out any discrepancies and also any changes for every statement based on the Indonesian culture.
The reliability test yielded a CronbachAos alpha coefficient of 0.
There were four other instruments utilized to measure confounding factors in this study.
First.
Multidimensional Scale of Perceived Social Support (MSPSS) was used to measure respondentAos social supports.
This questionnaire had three categories and used Mean Standard Deviation to determine cut off points of the categories due to homogeneity of the data.
Language validity resulted in good agreement between translated and back-translated versions while reliability test yielded a CronbachAos alpha coefficient of 0.
Control Group 70 stroke ischemic visits in the outpatient unit Intervention Group 65 stroke ischemic visits in the outpatient unit Exclusion:
6 aphasia
7 MMSE < 22
2 recurrent stroke Exclusion:
5 aphasia
10 MMSE < 22
3 recurrent stroke 52 fulfill the informed consent 50 fulfill the informed consent 5 home was not found 7 resigned 1 was unable to meet 39 respondents Consented 6 home was not found 5 resigned 1 was unable to meet 39 respondents 5 did not complete the post data 34 respondents Population Data Baseline 1 Rested in peace 4 did not complete the post data 34 respondents Analysis Figure 1.
ParticipantsAo flowchart Second.
Mini Mental Status Examination (MMSE) was used to measure cognitive MMSE consisted of six subscales of orientation, registration, attention, calculation, recall, and language.
There were two categories of this questionnaire in which the scores were Ou 28 for no cognitive impairment and < 28 for cognitive A reliability test showed a CronbachAos Alpha coefficient of 0.
Third.
Barthel-Index was used to measure the respondentsAo functional status.
Barthel-Index five categories were transformed to two categories.
dependent category with the Copyright A 2020.
NMJN, p-ISSN 2087-7811, e-ISSN 2406-8799 Nurse Media Journal of Nursing, 10.
, 2020, 365 Barthel-index scores of < 90, and independent category with the Barthel-index scores of Ou 90.
The CronbachAos alpha coefficient of the Barthel-index was 0.
Fourth.
Enzyme-Linked Immunosorbent Assay (ELISA) was conducted using Emax Immunoassay System Kit (Promega.
Madison.
WI.
USA) (Promega, 2.
to analyse BDNF from patientAos blood samples.
The blood samples were taken and analysed in the same day.
Intervention The intervention of AuSELF-HELP PackagesAy consisted of three activities which covered health education, discussion and independent activities (Aranda, 2.
AuSELF-HELP PackagesAy were delivered in four sessions with one week apart between sessions, each of which lasted for 60-90 minutes.
Prior to the data collection, eight registered nurses were recruited and trained for two days to deliver the intervention.
During the intervention, booklet and self-monitoring chart were provided to the respondents while a SELF-HELP module was given to the nurses to guide them delivering the intervention.
A flip chart was also used to help nurses deliver the health education.
The activities in the AuSELF-HELP PackagesAy can be seen in Table 1.
Once the intervention group completed the packages, the post-tests were measured one week after the fourth session.
On the other hand, the control group received standard interventions according to the hospitals and the post-tests were done on the fifth week.
Table 1.
The activities of the AuSELF-HELP PackagesAy Session First session Activities Media Focusing on the biological and psychological aspects - Involving health education, demonstration and Booklets and discussion of biological aspect such as knowledge Flipcharts of stroke, life styles to prevent stroke, hypertension diet, ranged of motion (ROM), mobilization and transfer.
- Facilitating for patientsAo acceptance and Booklets and commitment through acceptance and Flipcharts (ACT) rehabilitations and treatments of stroke as a part of psychological aspects.
Second Session - Independent activities of the patients during a week to the next meeting.
Focusing on the social and spiritual aspects - Discussing and encouraging the social aspects, such as family support, social gathering and social activities of the patients during the post stroke period.
- Discussing spiritual values of the patients and religion activities, such as prayer.
and developing patientAos spiritual competences - Independent activities of the patients during a week to the next meeting.
Copyright A 2020.
NMJN, p-ISSN 2087-7811, e-ISSN 2406-8799 Booklets and selfmonitoring charts Booklets and Flipcharts Booklets and Flipcharts Booklets and selfmonitoring charts Nurse Media Journal of Nursing, 10.
, 2020, 366 Table 1.
(Continue.
Session Third Session Fourth Session Activities Focusing on evaluation of the patientAos achievements and progresses along previous weeks - Evaluating and discussing any skill improvements on each aspect.
When no improvement was made, another contract would be made to accomplish the skills according to the patientAos agreement.
- Independent activities of the patients during a week to the next meeting.
Conducting independent activities for the patients under text messaging aids for controlling Media Self-monitoring Booklets and selfmonitoring charts Booklets and selfmonitoring charts Data analysis McNemar test.
Chi-square and logistic regression were employed to analysed the data.
McNemar test was used to determine the differences on dichotomous dependent variables while Chi-square test was conducted to compare PSD between groups.
The logistic regression was finally utilized to measure the effect of AuSELF-HELP PackagesAy on PSD after other confounding variables were controlled.
Ethical considerations Ethical clearance was gained from the Health Research Ethic Committee of the Faculty of Medicine.
Universitas Diponegoro (No.
596/EC/FK-RSDK/X/2.
Informed consents were obtained from all respondents before the data collection.
The patients and their families were well-informed about the study before consenting their participation.
RESULTS
Characteristics of respondents The result showed that the characteristics of respondents between intervention and control groups were homogenous (Table .
Table 2.
Characteristics of respondents .
Characteristics Gender
Male
Female Age
O 60
> 60
Employment Employed Unemployed Monthly income Low High Control group .
Intervention group .
Copyright A 2020.
NMJN, p-ISSN 2087-7811, e-ISSN 2406-8799 Nurse Media Journal of Nursing, 10.
, 2020, 367 Table 2.
(Continue.
Characteristics Education Low
High
PSD
No PSD
PSD
Control group .
Intervention group .
The effect of AuSELF-HELP PackagesAy on PSD in the intervention group The result showed that the number of respondents who had no PSD increased from 2% to 68% while the number of respondents who had PSD decreased from 58.
8% to 32% after AuSELF-HELP PackagesAy intervention.
It was shown that the intervention reduced the PSD in the intervention group .
=0.
(Table .
Table 3.
Differences on PSD in the intervention group .
Intervention Group
Pre-test
Post-test
No PSD
PSD
*Mc-Nemar The effect of AuSELF-HELP PackagesAy on PSD between groups As seen in Table 4, there was a significant difference in the number of PSD and No PSD at post-tests between the intervention and control group .
=0.
It can be concluded that AuSELF-HELP PackagesAy had a significant effect on decreasing PSD.
Table 4.
Differences on PSD between the intervention and control group .
Groups Intervention .
Control .
no PSD
PSD
*Chi square The effect of AuSELF-HELP PackagesAy on PSD after controlling the confounding Logistic regression showed that AoSELF-HELP PackageAy had no effect on PSD when other confounding variables were controlled .
=0.
OR=0.
288, 95% CI 0.
073Ae1.
However, functional status was shown to be the most affecting factor on PSD .
=0.
OR=0.
34 95% CI 0.
083Ae0.
Copyright A 2020.
NMJN, p-ISSN 2087-7811, e-ISSN 2406-8799 Nurse Media Journal of Nursing, 10.
, 2020, 368 Table 5.
Effects of AuSELF-HELP PackagesAy on PSD after controlling the confounding factors .
Interventions /Factors AuSELF-HELP PackagesAy Social Support
Functional State
Cognitive BDNF
Constant
Wald
95 % CI
073Ae1.
097Ae1.
083Ae0.
130Ae2.
Nagelkerke R Square=0.
p=0.
DISCUSSION
This study aimed to analysed the effect of AuSELF-HELP PackagesAy on PSD among ischemic stroke survivors after three months from onset.
The result showed that AuSELFHELP PackagesAy had a significant effect on reducing PSD after three months from This result was similar with the result of a study that developed complex interventions which included support psychotherapeutic treatment, information about disease, developing daily activity schedules, coping with daily hassles, using problemsolving skills, engaging in social networks and community activities, learning relaxation techniques and community based psychosocial services (Zimmermann et al.
, 2.
Another study also found that a complex, nurse-led intervention, which was implemented as a collaborative care model, increased perceived self-efficacy and better clinical outcome of anxiety, depression or somatization symptoms (Zimmermann et al.
Other studies also showed similar results with this study.
Mayo et al.
reported that exercise and project-based activities promoting learning, leisure, and social activities among stroke showed a great gain of stroke-specific health-related quality of Evans-Hudnall et al.
revealed that multi-intervention increased the efforts of stroke survivors to control the secondary risk factors of stroke.
Stroke survivor who has been showing a good adaptation with their life, will gain a good quality of life although with a handicap (Dharma, 2.
A study by Byrne et al.
also found that a complex intervention, consisting of medication adherence to statins, lifestyle behaviours and cardiovascular risk and delivered by health education session, massage and phone call, resulted in good outcomes in patients with coronary vascular diseases.
The AuSELF HELP PackagesAy consists of biological, psychological, social and spiritual The biological aspect, which includes life style behaviour in stroke preventions, hypertension diets, range of motion (ROM), mobilization and transfer, facilitates stroke survivors to adapt in their new stroke life and reduce the risk factors of stroke (Dharma et al.
, 2.
Stroke knowledge .
isk factors, causes, diets, treatments, and medication.
, daily activities, mobilization, transfer and range of motion are also claimed as parts of the biological aspects (Ebert et al.
, 2.
The psychological aspect of the packages includes acceptance and commitment therapy (ACT).
A study found that ACT was more likely to reduce depression (Majumdar & Morris, 2.
Acceptance and commitment intervention leads the individual to a Copyright A 2020.
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, 2020, 369 psychological flexibility.
The ACT has become the protocol for chronic illness (Karekla.
Karademas, & Gloster, 2.
The flexibility leads the individuals to the adaptive process.
ACT should be trained, so that the patients feel safe and comfort, and blend with present moments .
ACT helps the patient in organizing the negative emotions, achieving the coping adaptive, and considering the stressor as the positive The actions in ACT guide the personal to step forward in thoughts.
Regarding the natural emotion in responding illness, individuals cannot avoid the negative Individuals practice in organizing the negative thoughts with stopping spontaneous reactions such as crying, feeling sad and hopeless (Khashouei.
Ghorbani, & Tabatabaei, 2.
ACT is effective in a wide range of population, such as breast cancer, (Mahdavi et al.
, 2.
DM type-II (Gregg.
Callaghan.
Hayes, & GlennLawson, 2007.
Lindholm-Olinder et al.
, 2.
, and multiple sclerosis (Bach.
Hayes, & Gallop, 2.
The social aspect of AuSELF-HELP PackagesAy endorses the patientsAo motivation to involve in the social activities and the familiesAo motivation to be an informational, emotional, and instrumental support.
Social supports facilitate stroke survivors to adapt with post stroke activity daily living (Dharma et al.
, 2.
A qualitative study stated that family caregivers are playing an important role in caring for their relatives who have suffered from strokes (Agianto, 2.
A meta-analysis concluded that social supports in chronic illness reduce depression (Vallury.
Jones, & Gray, 2.
The spiritual aspect of the packages leads the stroke survivors to have spiritual values which are gained by accepting the illness condition and by religious activities, such as prayer and praying.
Spiritual wellness gained the benefits to support stroke rehabilitation (Mundle, 2015.
The Joanna Briggs Institute, 2.
Another study supports that spirituality affects the quality of life (Moon & Kim, 2.
and reduces depression among acute coronary and heart disease patients (Abdi.
Soufinia.
Borji, & Tarjoman, 2019.
Warber et al.
, 2.
Spiritual values indicate that the patients are having hope in illness (Warber et al.
, 2.
Furthermore, spirituality decreases the mortality risk of 18 % in chronic illness (Lucchetti.
Lucchetti, & Koenig, 2.
The AuSELF-HELP PackagesAy in this study was delivered by health education, discussions and activities.
Health education facilitated stroke survivors to meet with the new information about stroke that they need.
Stroke survivors need an access to the health information, which can help them respond more quickly to health problems.
comprehend their disease and treatment interventions.
obtain good recovery.
and reduce the chance of a new stroke (Du.
Ma, & Li, 2.
Discussion and activities help the stroke survivors adapt the new daily living (Dharma et al.
, 2.
Health education also contributes to the functional status of stroke (Ning & Te, 2.
, self-satisfaction, participation in treatment and rehabilitation, as well as emotional function (Lin.
Yih.
Shih, & Chu, 2019.
Sabariego et al.
, 2.
The AuSELF-HELP PackageAy is a nursing intervention derived from AuRoy Adaptation ModelAy nursing theory.
Post stroke depression is the negative result of adaptation in dealing with stimuli (Handayani & Pudjonarko 2015.
Hubbard & Workman, 1998.
Philip & Harris, 2.
The result of this study would improve the nursing intervention Copyright A 2020.
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, 2020, 370 protocols toward PSD among stroke survivors after three months from onset, both in the hospital and the community.
However, after the confounding factors were controlled, the result found that the AuSELF-HELP PackagesAy had no significant effect on PSD.
The confounding factors included social support, functional status, cognitive function and BDNF.
It was assumed that the intervention should be conducted in a long period to achieve an impactful result.
This assumption is supported by Byrne et al.
and Medical Research Council .
Mayo & Scott .
also points out that it may not be a good idea to evaluate a complex intervention though a single outcome.
Stroke patientsAo needs have wide spread and person-varying effects which may not be best represented by the changes on a single outcome variable.
Future studies require a longer period of time for the intervention and to investigate more than one outcomes.
The result of the study claimed that functional status was the most affecting factors on PSD.
This result is in line with the other studies which state that functional status significantly affect the PSD (Lincoln et al.
, 2013.
Ojagbemi & Owolabi 2013.
Stein et , 2015.
Zhang et al.
, 2.
A meta-analysis shows that the functional status is the risk factor of PSD after three and six months from onset (Shi.
Yang.
Zeng, & Wu.
Any variations in the functional status need to be controlled in gaining the clear effect of the intervention on PSD.
Functional status should be homogenous at the same This study has several limitations.
First, there was no randomization in sample.
There was only one group intervention and one group control.
Thus, the effect of intervention could not be compared with other interventions.
Second, there was no follow-up to evaluate the long-term effects.
Nevertheless, this study showed a good estimate in the effect of AuSELF-HELP PackagesAy, a complex intervention, on PSD in ischemic stroke survivors after three months from onset.
CONCLUSION
The study concluded that AuSELF-HELP PackagesAy significantly decreased PSD.
Therefore, it is recommended for nurses to apply the AuSELF-HELP PackagesAy in delivering nursing intervention.
Future research is recommended to involve a larger size of sample with randomized controlled trial design in order to be able to generalize the The homogeneity should be achieved in the variable of functional status, as this is the strongest affecting factor of PSD.
A longer period of time for the intervention is also recommended in order to obtain a more robust result.
ACKNOWLEDGMENT
The study was funded by the Ministry of Research.
Technology and Higher Education.
Indonesia.
CONFLICT OF INTEREST
No conflict of interest was declared by the authors.
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