Essay Title: 

Developing an Information Communication Technology (ICT) Intervention for Adult Stroke Patients

March 24, 2016 | Author: | Posted in health and medicine, nursing

5 . The International Classification of Functioning Disability and Health

The International Classification of Functioning Disability and Health (ICF ) serves as a framework in disability studies as a means of achieving a common standard for comparing disability data . Disability data is an important statistic since it provides information regarding health service needs , utilization patterns , treatment outcomes and cost-effectiveness of medical interventions . Information using the ICF framework fills in the gap in information in the health sector in these areas . In the social sector , the classification supplied by the ICF framework provides a [banner_entry_middle]

solution in qualifying the disability of an individual which can be applied in dilemmas involving disability in law and labor (Kostanjsek 2004 . The standardization that is achieved using the ICF framework makes it also possible to predict health trends based on health indicators obtained through the ICF and compare them over time

5 .1 Disability data

Disability data is multidimensional . A disability data is an information of the impact of disability based on the degree of impairment as assessed by the basic functioning of body parts or organs , or the level of activity of a person as can be seen by the capacity of that person to do basic and complex actions or the extent by which person participates in the society or how the people and environment around that person is affected by a condition . Disability data can virtually be any symptom or illness of interest such as flu , myocardial infarction , paraplegia injury where there is a necessity to assess the impact of the condition on the person (Kostanjsek 2004

5 .2 ICF framework

The ICF framework helps define how an individual with a condition is classified according to disability . With the volume of complex health parameters and the number of diseases out there , a lot of health data would have been useless in terms of disability without the ICF framework because of lack of comparability . The implications of the lack of common and comprehensive language will result in the lack of adequate information which can be used to identity people with disabilities who needs the most medical attention or which functioning problem matter the most for people or develop effective interventions strategies for different health needs like assistance , treatment , rehabilitation and prevention . In addition , weak monitoring and evaluation of policies such as work discrimination . With all the various health data like mortality statistics , health survey data , disability survey data , registers , and hospital records , the work for comparative studies will be double just to reinterpret the data because of the lack of comparability . Adaptation of the ICF framework throughout all disability studies would mean data can be aggregated and disparate data can be integrated while language and sectoral barriers can be overcome by using the framework as an international standard (Kostanjsek 2004 . 6 . Stroke

Stroke is one of the leading causes of mortality and morbidity worldwide . For the European region , projections suggest that the proportion of the population over the age of 64 , in which most stroke events occur , will likely increase from 20 in 2000 to 35 in 2050 , and the median age will rise from 37 .7 years in 2000 to 47 .7 years in 2050 (World Population Prospects 2004 as cited by Truelsen Piechowski-Jo ?z ?wiak et al . 2006 ,

.5810] . Even if the incidence rates remain stable , the demographic changes in European countries will lead to a substantial increase in the number of stroke events from approximately 1 .1 million per year in 2000 to more than 1 .5 millions per year in 2025 (Truelsen , Piechowski-Jo ?z ?wiak et al . 2006 ,

.587 . In the UK , stroke ranks as the third biggest cause of death and the stands out as the largest single cause of severe disability (DOH n .d . In a South London stroke register , the 1 .24 /1000 population if age adjusted to the standard European population (Wolfe et al . 2002 . Since approximately half of all those who survive from stroke will have incomplete recovery while half of them will need assistance for their average daily activities , considerable fraction of all costs to stroke patients is spent on the long-term care rehabilitation , nursing , and lost production (Bonita et al . 1997 as cited by Truelsen , Piechowski-Jo ?z ?wiak et al . 2006 ,

.588 . A study in 1992 showed that stroke accounts for approximately 5 of the National Health Services expenditure in the UK (Isard and Forbes as cited by Hacke et al . 2000 ,

.607 . Recent data suggest that for each year , more than 110 ,000 people in England will suffer from a stroke which will costs the NHS over ?2 .8 billion (DOH n .d . Without a doubt , stroke is exacting a tremendous burden on the health care systems and on to society in general

6 .1 Management of Stroke

Governments in many countries strive to come up with improving practice guidelines for the management of stroke . In the UK , the Department of Health has recognized the importance of formulating better health care services for stroke by adapting specific milestones , targets and actions obtained from the National Service Framework (NSF ) for Older People which was launched in March 2001 (DOH n .d . From this , the UK government has recently announced an ongoing development of a health programme produce a national strategy which aims to modernize health service provisions and deliver the newest treatments for stroke . Through this strategy , the Government intends to reduce the death rate from stroke , CHD and related diseases in people under 75 by at least 40 by 2010 (DOH n .d . In the European context , the European Stroke Initiative (EUSI , the governing body on stroke-related activities within the European ederation of Neurological Societies (EFNS ) and the European Stroke Council (ESC , has formulated recommendations listing evidence-based management of stroke covering all areas related to stroke treatment . EUSI emphasized that these are recommendations rather than guidelines to accentuate the importance of individualized decision making despite these evidence-based recommendations (Hacke et al . 2000 br


6 .1 .1 Definitions for level of evidence

The recommendations that are approved by EUSI are listed according to levels of evidence which were pre-specified and modified based on several proposals in medical literature . The recommendations that are approved by EUSI are listed according to levels of evidence which were pre-specified and modified based on several proposals in medical literature . Level I is the highest level of evidence where the sources are from primary end-point from randomized , double-blind studies with adequate sample size and properly performed meta-analysis of qualitatively outstanding randomized trials . Level II is the intermediate level of evidence from randomized studies which are not blinded , secondary end-point from small randomized trials and predefined secondary end-points of large randomized trials . Level III has lower level of evidence based on prospective case series with concurrent or historical control while Level IV has undetermined level of evidence based on small case series without control , case reports or post hoc analyses . This level also includes commonly agreed practices despite the lack of medical evidence from controlled trials (Adams , 1994 as cited by Hacke et al . 2000 ,


6 .1 .2 Stroke as a medical emergency

The best treatment for stroke starts with identifying stroke as a medical emergency and should be treated as such , as suggested by the EUSI recommendations . Like an acute MI , successful stroke care begins by activating the emergency medical system (EMS ) as soon as possible . The underlying premise however is that patients and relatives are able to recognize the symptoms of stroke . This emphasizes the need for sustainable education program about the signs and symptoms of stroke as well as its risk factors

6 .1 .3 Diagnosis of stroke

There are several diagnostic tests which can be used in the diagnosis of stroke . These tests are not only important in diagnosing stroke but differentiate between acute types of stroke as week . The EUSI recommends computer assisted tomography (CAT /CT ) as the most important diagnostic test for stroke . Although magnetic resonance imaging or MRI provides better sensitivity , the test apparently has not attained widespread use in most centres to a level of a standard procedure . The same is true with modern MRI techniques such as magnetic resonance angiography (MRA and perfusion MRI which require major resources that are not readily available in most centres . Other test like electrocardiogram , Doppler sonography of extracranial cervical arteries , pulsoximetry , chest X-ray laboratory test such as blood analysis , hepatic and renal chemistry , and blood markers for infection may also be necessary , however , they should not delay any general or specific treatment for stroke (Hacke et al 2000 ,


6 .1 .4 General and specific stroke treatment

The recommendations for the general treatment of stroke includes pulmonary and airway protection , cardiac care , blood pressure management , blood glucose control , body temperature regulation , and fluid and electrolyte management . These entail close monitoring on the patient ‘s neurological status and vital functions , blood glucose and body temperature , and constant checking of airway compromise and disturbances in electrolyte balance . Specific stroke treatment includes pharmacotherapy with thrombolytic agents , defibrinogenating enzymes platelet inhibitors and neuroprotective agents . The level of evidence for these recommendations , however , is variable and clinical decision making should weigh in the practitioners individual assessment before any treatment option is considered (Hacke et al . 2000 ,


6 .2 Improving stroke services

The NHS through the Department of Health aims to transform stroke care services . They plan to achieve this through the current DOH policy on formulating and implementing a national strategy based on the National Service Network . Six project groups have been established for far which correspond to areas needed to develop a new national strategy for stroke . These are public awareness and prevention , TIA services emergency response , hospital stroke care , post hospital stroke care and workforce (Boyle 2006 . The NHS hopes that these are the first few steps taken in what will be a sustained and co-ordinated approach to improving stroke services

7 . Self-management

Health programs to improve patient care for people with chronic diseases are being implemented throughout different countries . Patient self-care has gained a lot of interest because of its cost-effectiveness and its practicality . It also offers government health agencies a remedy to relieve budget deficits from acute care and other health care services This emphasis on consumer responsibility for health however necessitates better understanding , development , and testing of efficacy on interventions which aims to enhance self-management in people with chronic conditions . There are several studies that have evaluated the effectiveness of self-management interventions on the outcomes of chronic conditions . Unfortunately , for the specific approaches for the self-management of stroke , there has been a paucity of studies regarding this subject . Nevertheless , it helps to analyze the findings of studies on self-management interventions on chronic conditions in general so that strategies are assessed for their use in the self-care management to stroke patients when applicable

7 .1 Defining self-management and self-efficacy

The concept of self-management and its practice is dynamic and arbitrary . However , some authors have provided their opinions on how self-management can be defined . According to Fawcett , self-management is defined as the cluster of daily behaviors that individuals (and their families ) perform to manage (a condition (1984 as cited by Grey , Knafl McCorkle 2006 ,

.279 . It serves as the means of maximizing the patient ‘s health rather than the mere compliance and submission to prescribed s . In contrast to of compliance and adherence self-management considers the complexity of living with a condition and suggests the necessary interventions needed to attain an acceptable condition in the context of average daily living (Schilling , Knafl Grey 2002 as cited by Grey , Knafl McCorkle 2006 ,

.279 . According to Barlow et al , self-management refers to the ability of the individual to manage the symptoms , treatment , physical and psychosocial consequences , and lifestyle changes which are inherent to living with a chronic condition (2002 as cited by Sol et al . 2006 . On the other hand self-efficacy is defined as a person ‘s confidence to carry out behavior that is necessary to reach a desired goal . It is an important precondition for successful self-management and behavior change (Bandura , 1998 as cited by Sol et al . 2006 . Indeed , studies have shown that there may be a correlation between the recovery of a person from a wide range of traumas and the perceived self-efficacy of that person which provides an enabling and protective function of belief in one ‘s capability to exercise some measure of control over traumatic adversity (Benight Bandura 2004 . In addition , there is a growing body of evidence which show that , compared to patients without any intervention such as standard care self-management approaches can provide benefits for participants in terms of knowledge , adoption of self-management behaviors , self-efficacy and aspects of health status (Barlow et al 2002 ,


7 .2 Approaches to Self-Management

The review conducted by Barlow on self-management strategies identified several approaches employed in obtaining the active participation of individuals who are living with chronic conditions (2002 ,

.178 . These are designed to allow people to manage symptoms , carry out treatment regimens or adapt behavior and lifestyle modifications which are necessary for improving the outcome of their condition

7 .2 .1 Target population

Studies on self-management for chronic conditions have several different populations whom the interventions are focused . It helps to recognize the demography of the people which the self-management interventions will be targeted to so that these interventions are well suited to the target population . According to the review by Barlow , most self-management interventions target adults although there are few which focus on children and older participants (Barlow 2002 ,

.178 . A study by Deakin et al . reviewed 53 studies on self-management programs on older people (2006 ,

.55 . Accordingly , most of people recruited in the studies were 65 years old and older and of the studies included subjects under 50 . Some interventions have been adapted to include a particular culture or race especially when they are predisposed to the chronic condition of interest . This may also be done incidentally when a prevalence of certain race groups is identified in the target population . A study by Rimmer et al . on the effects of a short-term health promotion intervention involved a predominantly African-American population (2000 ,

.332 . Individuals with chronic conditions are not the only subjects for self-management interventions . There are also studies which focus self-management programs on caregivers and parents of patients as well . Van den Heuvel et al . conducted a study on the short-term effects of a group support program and an individual support program for caregivers of stroke patients while Mant el at . evaluated the effects of family support for stroke patients and carers (2000 br

.109 2005 ,


7 .2 .2 Delivery location

Self-management studies have variable settings where the interventions are delivered . Two of the most common locations for self-management programs are hospitals and home-based environment (Barlow 2002 ,

.178 The advantages of each approach is not clear . Zarnke et al compared patient-directed hypertension management strategy with usual office-based care and found that although patient-directed management achieved better BP control , it was associated with more frequent physician visits than the office-based management (1997 ,

.58 . The choice where the interventions are conducted appear to be affected by a number of factors which include the use of medical equipment and other resources , the availability of qualified trainers and health professionals and the type of target population such as in-patients out-patients in rehabilitation centers , and home-based patients According to Barlow , hospitals , home environment , school , work site home for the psychiatric patients , primary care , research and rehabilitation centres were among those reported in self-management studies (2002 ,


7 .2 .3 Self-management tutors

The range of self-management tutors also varied from health care professionals to trained lay tutors with chronic condition . Tutors reported in the studies reviewed by Barlow included dieticians /nutritionists , doctors , educators , nurses , occupational therapists , pharmacists , physiotherapists /physical therapist psychologists , researchers /social scientists , social workers , and speech and language therapists (2002 , p179 . The complexity of the interventions and the level of medical background and specialization necessary in formulating the interventions influences the type of tutors required to deliver the interventions . A study by Scholz et al . which evaluated the long-term effects of a self-management intervention on the physical activity and depressive symptoms in patients undergoing cardiac rehabilitation used interventions which are prescribed by physicians (2006 ,

.3111 . In contrast , Fu et al , conducted a qualitative evaluation of chronic disease management program led by lay persons who were trained at helping participants develop a range of skills and confidence to deal more effectively with their chronic conditions (2006 br


7 .2 .4 Mode and format

There were also several approaches in the way the mode and the format of self-management interventions were carried out . Self-management approaches were either done in groups , in single individual or in combination of both . The mode of how the self-management interventions were delivered influenced the form of the interventions that were given such as in the form of lectures , role play , booklets and manuals . Gebert et al compared the use of family-oriented clinical training program against regular medical treatment based on international practice guidelines for efficacy in the treatment of asthma . The training included health education lectures , interactive learning , video films practical exercises , and roleplay . Social activities were done including a field trip and a party , while physiotherapy and sports (swimming ) were also integrated into the course (Gebert et al . 1998 ,


7 .2 .5 Content

A review by Barlow et al on the self-management approaches for people with chronic conditions recognized that there is diverse range of components in these self-management interventions such as pain and fatigue management , relaxation and breathing exercises , self-monitoring and sleep management . Barlow classified these components as (1 )health information for health promotion and education (2 )drug management for interventions focused on improving drug compliance (3 )symptom management such as emergency treatment (4 )psychological management like disease acceptance , anger and stress therapy (5 )lifestyle modifications such as exercise , nutritional diet and leisure activities (6 )social support and (7 )communication (2002 ,


7 .3 Components of Self-Management

The content of self-management interventions can be classified into distinct components as previously described . Most of their interventions are drawn on social , cognitive , and behavioral theories during their development . Therefore , the contents of each intervention is based on what type of component of self-management the intervention aims to achieve whether it symptom management , lifestyle modification or any other component for that matter

p 7 .3 .1 Health Information

This component of self-management includes interventions aimed at analyzing and improving the patient ‘s and their carer ‘s understanding about the condition and its treatment . This approach utilizes the tenets of self-efficacy theory where the content is based around providing the participants with information from a persuasive and credible source . A study illustrated the importance of this intervention in the assessment of the control of cardiovascular risk factors (CVRF ) in patients with stroke . The results showed that the control is not optimal and is inversely related to the patient ‘s awareness and knowledge if the condition (Croquelois Bogousslavsky , 2006 ,

.726 . The results further indicate that older patients and patients with excellent recovery are at particular risk because for poor awareness and CVRF control . This lack of awareness of the facts about their condition lead to the lack of self-efficacy in these patients based on the poor control of the risk factors for stroke . Since self-management is built around the behavioral change as a result of good self-efficacy , this intervention of providing information to patients and carers is essential for any self-management program

7 .3 .2 Drug Management

Components of self-management approaches which focus primarily with drugs obviously need to be disease-specific as drugs have very specific indications . Therefore , drug interventions for a particular chronic condition may not be applicable to other conditions . Nevertheless , the rationale behind self-management interventions for drug management is basically the same , which is to provide an alternative from the conventional management

Gebert et al . compared the efficacy of drug management interventions against regular treatment in a population of children with asthma . The children and their family were enrolled in a five-day standardized family-oriented clinical asthma training program which included a field trip to practice the children in taking their medicine in public (1998 br

.215 . This was designed to empower the children to take responsibility for their condition in daily life activities . The results showed that the children who underwent self-management training benefit most with respect to active asthma self-management than the children in the control group . Although there were other self-management components other than drug management , the empowerment of the children to take their own medicine with proper guidance may have played a significant factor in the outcome . Another study compared also compared drug management intervention against conventional drug therapy . Christensen et al . evaluated the efficacy and safety of self-management of oral anticoagulant therapy for patients on long-term oral anticoagulant therapy using a systematic review and meta-analysis of randomized controlled trials with highly selected patients and compared self-management of oral anticoagulant therapy with conventional treatment (2006 ,

.1 . The results showed that after considering all trials , self-management was found to be associated with a reduced risk of death and major complications . These studies demonstrated that self-management interventions provide additional advantages than the regular medical treatment of chronic conditions such as asthma

7 .3 .3 Symptom management

Symptom management includes several interventions which focus on emergency treatment especially in asthma and prevention of symptoms such as breathing problems and management of cognitive symptoms using visualization , distraction , guided imagery . Interventions on fatigue management , relaxation , sleeping management , pain management and self monitoring are included in this category (Barlow et al 2002 ,

.180 Symptom management plays is an important self-management intervention because is saves the patient from unnecessary hospital visits or undue worries on symptoms which may be easily treated and managed . On the other hand , symptom management interventions may also rescue patients from potentially fatal acute symptoms which needs to be remedied immediately otherwise any delay of treatment may lead to irreversible disability or even death . A study by Ghosh et al . on the reduction of hospital use by self management training for chronic asthmatics assessed the impact of such asthma training on the health status and resource use of patients with chronic asthma (1998 ,

.1087 . The study used a control group of patients who received the usual treatment for asthma , which included administration of bronchodilator drugs (orally or by inhalers and prophylactic anti-inflammatory drugs . Patients in the intervention group , however , received asthma self-management training in addition to the regular treatment . The training included sessions where patients were trained to adjust the dose of the treatment promptly , appropriately and safely depending on the severity of the disease . The assessment of severity was aided by instructions on how to properly interpret peak flow estimation . From on PEFR measurements , asthmatic episodes were graded as mild , moderate and severe . After detailed and demonstration of the normal range of PEFR and the significance of its variations , patients were given precise written instructions regarding drug administration depending on the severity of attack as judged by PEFR measurements based on accepted guidelines for the management of asthma in adults . The results showed statistically significant improvement of health outcome measures in the intervention group in relation to the control group . The effects of the intervention on resource use measures were also generally statistically significant since the intervention group had a 53 .2 reduction in days hospitalized overall , and the likelihood of a patient having any hospitalization was reduced to about 26 . Furthermore , among patients hospitalized , the average length in hospital stay for patients in the intervention group was only 22 days compared to 38 days for the control group . The intervention group also experienced a 46 .7 reduction in emergency room visits while their likelihood of having any emergency visits fell by 14 . Cost analysis of direct and indirect costs indicated that the intervention group incurred 48 less indirect costs while the direct costs were 16 lower compared to the control group (Ghosh et al .1998 br

.1091 . This study illustrates that self-management not only relieves patient of the burden of morbidity from their condition but also help reduce the cost of their illness

7 .3 .4 Management of psychological symptoms

Psychological symptom management helps patients through their stress anger , and in dealing with depression and emotions , and disease acceptance . A comparative study found a similarly high incidence of depression after stroke and myocardial infarction during the first year (Aben et al 2003 ,

.581 . Studies have also shown that depression is a significant predictor of impaired psychological and functional QOL which emphasizes the importance of psychological interventions in self-management programs (Jaracz et al . 2002 ,

.219 Pohjasvaara et al 2001 ,

.315 . Therefore it is necessary for self-management interventions to address this symptom in patients with these chronic conditions . Scholz et al studied the long-term effects of self-management interventions on the physical activity and depressive symptoms after cardiac rehabilitation (2006 ,

.3109 . The interventions included guided exercise sessions for at least three to four times a week , such as bicycle ergometer training or power walking , with intensity levels individualized as prescribed by a physician . After being discharged , the patients were advised to engage in long-term exercise similar to the exercise intensity level during rehabilitation The results showed that there was as reduction of depressive symptoms and that perceived attainment of exercise goals , but not physical exercise itself , emerged as a mediator between the intervention and favorable treatment outcome . The rationale behind this effect was suggested to be secondary to the association of goal attainment and depressive symptoms . Perceived failures in goal attainment are often related to depressive symptoms and negative affect (Carver Scheier 1990 as cited by Scholz et al 2006 ,

.3110 . Conversely , the success in goal attainment has been correlated to subject well-being or to the absence of depressive symptoms (Brunstein 1993 as cited by Scholz et al 2006 ,

.3110 . The investigators concluded that since the attainment of personal goals appeared to be play a significant role in lowering depressive symptoms during health-behavior change , thus , self-management strategies to help patients attain their goals should be part of rehabilitation programs (Scholz et al . 2006 ,


7 .3 .5 Life style interventions

Aside from the positive effect of exercise on depressive symptoms , there are other goals in maintaining a good exercise regimen and other healthy life style adjustments . Rimmer et al studied the effects of short-term health promotions interventions in stroke survivors by using a health program which consisted of fitness instruction and exercise , nutrition education , and health behavior changes (2000 ,

.333 . The results showed that the treatment group showed significant gains over the control group in terms of reduced

fitness , increased

strength , increased flexibility , increased life satisfaction and ability to manage

self-care needs , and decreased social isolation . The challenge in introducing life style interventions not only includes overcoming barriers to exercise and diet adherence but also getting rid of unhealthy habits smoking and drinking . However , as shown by Rimmer et al , the outcome is worth it

7 .3 .6 Social support

It has been recognized that stroke has a significant impact on patients as well as to their carers . In the United Kingdom , services such as Stroke Association family

support have been developed to provide information and emotional support along with other services (Mant et al .2006 ,

.1006 . The service maintains contact by home and hospital visits and telephone calls . A study on the effects of the family support showed that the service was associated with significantly improved quality of life of

carers at follow up six months after the stroke (Mant , Carter Wade 2000 ,p .808

However , there were no significant effects on patients even on follow up studies (Mant et al .2006 ,

.1006 . The investigators concluded that family support is effective for carers , but different approaches somehow need to be considered to remedy the psychosocial problems of stroke patients (Mant et al .2006 ,

.1006 . Interestingly , van Heuvel et al found no significant effects on caregivers both through group program and home visits (2000 ,

.109 . Even interventions on perceived self efficacy only have minimal effects . This implies that more studies on social support intervention programs are needed to improve the psychological support for patients and theirs carers

7 .3 .7 Communication

According to Barlow et al , self-management programs also include interventions which focus on improving patient ‘s assertiveness and communication strategies such as talking with doctors (2002 ,

.180 . It has been shown that stroke patients rehabilitating in nursing homes experience an increase in their autonomy , particularly in self-determination , independence and self-care during the last weeks before discharge (Proot et al . 2000 ,

.275 . The change in autonomy was found to be related to regained abilities and self-confidence , and to patients ‘ strategies such as taking initiative and being assertive . It is therefore helpful that lines of communication between patients and health care professionals during rehabilitation should be maintain beyond the patient ‘s discharge to ensure a smooth transition as the patients regains autonomy


Stroke is one of the leading cause of death in the UK and the largest single cause of severe disability . Self-management offers to alleviate the burden of stroke on the health care systems and on the society by giving stroke survivors the ability to manage the symptoms , treatment physical and psychosocial consequences , and lifestyle changes which are inherent to living with a chronic condition . However , despite the abundance of self-management programs for chronic conditions , there is a paucity of studies on the utility of interventions following stroke Fortunately , there is strong evidence to support the use of self-management programmes and their effect on self-efficacy and associated health outcomes for stroke survivors (Jones 2006 ,

.841 Although there certainly are some differences in the nature of each chronic condition , there are also similarities in the core competencies required for self-management . Thus , many effective strategies for other chronic conditions could be incorporated into stroke targeted self-management interventions . Additional studies , however , are necessary to ensure the efficacy and safety of these interventions


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