The effect of self-management program on perceived social support of family caregivers of stroke patients

Background and aims: Stroke is the first leading cause of disability in adults. Long-term disability after stroke necessitates long-term caregiving by family members. The family caregivers (FCGs) of patients with stroke (PWS) experience different problems and hence, require self-management (SM) skills. The aim of this study was to assess the effects of an SM program based on Strauss and Corbin’s SM model on perceived social support (PSS) among the FCGs of PWS. Methods: This quasi-experimental study was conducted in 2019–2020. Participants were eighty FCGs of PWS who were hospitalized in Kashani hospital, Shahrekord, Iran. They were purposefullyrecruited and randomly allocated to a control and an intervention group. An SM program based on Strauss and Corbin’s SM model was implemented in six ninety-minute sessions for participants in the intervention group. The Multidimensional Scale of PSS was used for PSS assessment before, immediately after, and two months after the intervention. Data were analyzed using the SPSS software (v. 16.0). Results: There was no significant difference between the groups in terms of the pretest mean score of PSS (P = 0.76), while the mean score of PSS in the intervention group was significantly greater than the control group at both posttests (P < 0.05). Moreover, the mean score of PSS in the control group did not significantly change across the three measurement time points (P > 0.05), but significantly increased in the intervention group (P < 0.05). Conclusion: SM program based on Strauss and Corbin’s SM model is effective in significantly improving PSS among the FCGs of PWS. Therefore, nurses and other healthcare providers can use this program for the FCGs of PWS.


Introduction
Stroke is the second leading cause of death with a death rate of 11.3% and the first leading cause of disability among adults in the world (1). The prevalence of stroke is predicted to increase with the growing increase of the population of people over sixty which is estimated to double by 2050 and triple by 2100 (2).
Almost 50% of patients with stroke (PWS) suffer from permanent problems in balance, standing, and walking, as well as disability in doing the activities of daily living such as changing clothes, eating, and bathing (3). Therefore, family caregivers (FCGs) play significant role in caregiving to PWS. As stroke occurs suddenly, family members of PWS should assume caregiving responsibility without adequate preparation (4).
Caregivers are individuals who are mostly involved in caregiving to patients in the course of a disease or disability in order to help them cope with or manage their conditions. There are two main types of caregivers, namely formal and informal. Formal caregivers are trained caregivers, have professional competencies for delivering different care services, and receive payment for their services. However, informal caregivers, including spouses, children, and friends, may not receive regular payment (5). The role of caregivers is more important when PWS need long-term care (6). Currently, PWS have short hospital stay due to the heavy costs of hospital services and hence, the major part of caregiving to these patients is with their FCGs (7).
During caregiving, FCGs usually face different physical, psychological, and social challenges which predispose them to physical and mental health problems (such as depression and anxiety), financial problems, social isolation, role conflicts, change of goals, and low quality of life (8). Most FCGs report caregiving problems and low quality of life due to limited social and financial support, lack of educational programs, exposure to their patients' physical and mental problems, and limited access to rehabilitation services for their patients (9). Therefore, support systems in societies need to assess their needs and take appropriate measures to provide them with adequate help and support (10). Social support is associated with different positive outcomes, such as improved self-confidence, sense of competence and productivity, and better quality of life, while limited social support is associated with mental problems and poor health status (11). As an emotion-focused coping strategy, social support can prevent the occurrence of stressful conditions, and thereby, protects individuals and helps them evaluate and manage stressful conditions to reduce their effects (12).
There are two main types of social support, namely received social support and perceived social support (PSS). Received social support refers to the amount of received support, while PSS refers to individuals' perceptions of the availability of support in emergencies. PSS is measurable and is a criterion for self-evaluation (13). Compared with received social support, PSS has more important role in reducing psychological strains (14). PSS can reduce the problems of FCGs, particularly the FCGs of patients with chronic conditions. Moreover, adequate PSS among FCGs has positive effects on patient outcomes. A study reported that limited social and informational support for FCGs was associated with problems in caregiving to PWS and adherence to rehabilitation programs (15). Another study showed that family education and support positively affected patients' self-efficacy and self-management (SM) (16).
SM is a factor with potential effects on PSS among the FCGs of PWS. SM plays significant role in empowering individuals to manage their personal and organizational behaviors, improve their productivity, and modify their lifestyle (17). SM is a dynamic and ongoing interactive process which helps individuals reinforce a positive behavior or skill or reduce the incidence of an inappropriate behavior. Successful SM is associated with greater sense of responsibility towards personal behaviors and greater senses of control and self-efficacy (18). The core of SM is an individual who wants to start SM and extend it to society (19). SM skills include problem solving, decision making, using resources, therapeutic relationship with healthcare providers, and taking action (20). Chronic disease SM was first introduced by Anselm Strauss and Juliet Corbin. They noted that chronic disease SM is based on knowledge and skills for several sets of assignments. The first set of assignments pertains to the medical management of disease and pain and includes regular medical visits, appropriate use of medications, awareness of medical treatments, and adherence to dietary regimen. The second set of assignments pertains to the management of roles and daily activities such as interaction with friends and family members, occupational activities, and habits. The third set of assignments pertains to the management of the emotional consequences of affliction by a chronic disease such as depression and anxiety (21). A study reported that the implementation of SM program was associated with stronger social support for the FCGs of PWS (22).
To the best of our knowledge, most previous studies into the effects of SM interventions on perceived support were conducted on patients and hence, there is limited information about the effects of such interventions on the FCGs of PWS (23). Therefore, further studies are needed to narrow this gap. The present study aimed at assessing the effects of an SM program based on Strauss and Corbin's SM model on PSS among the FCGs of PWS.

Design
This two-group quasi-experimental study was conducted in an eight-month period from September 2019 to May 2020.

Participants and setting
Study population consisted of the FCGs of PWS whose patients were hospitalized in Kashani hospital, Shahrekord, Iran. Eligibility criteria were an age of 18-65 years, ability to read and speak Persian, significant role in caregiving, close kinship with patient, and receiving no payment for caregiving. Exclusion criteria were irregular participation in the intervention sessions and patient death during the study.
Based on the findings of previous studies (16,20,22) sample size was determined to be 35 FCGs per group. Nonetheless, sample size was expanded to forty per group in order to compensate probable withdrawals from the study. Participants were purposefully selected and randomly allocated to a control and an intervention group through a table of random numbers.

Intervention
Participants in the intervention group received SM program based on Strauss and Corbin's model in six ninety-minute sessions. Table 1 shows the details of the program. Participants in the control group did not receive any SM intervention. PSS was assessed in both groups before, immediately after, and two months after the intervention.

Instrument
PSS was assessed using the twelve-item Multidimensional Scale of PSS. Zimet et al introduced this instrument in 1988 for assessing PSS by family members (4 items), friends (4 items), and significant others (4 items). The items of this scale are scored on a five-point Likert scale from 1 to 5 (24,25), resulting in a possible total score of 12-60. The total score of this sale is interpreted as follows: scores 12-20: limited PSS; scores 20-40: moderate PSS; and scores 40-60: strong PSS. A former study in Iran confirmed the validity and reliability of this scale through respectively the factor analysis and internal consistency methods and reported that the Cronbach's alpha values of its dimensions were 0.86, 0.86, and 0.82, respectively (26). Another study in Iran reported that the Cronbach's alpha values of the dimensions of this scale were 0.76-0.89 (27).
Investigating the effect of self-management program on family caregivers of stroke patients

Results
Age mean was 43.37 years in the intervention group and 44.22 years in the control group. Most participants in these groups were female (65% vs. 57.5%), married (85% vs. 90%), and employed (65% vs. 55%). Moreover, 37.5% of participants in the intervention group and 47.5% of participants in the control group had secondary diploma. There were no significant differences between the groups in terms of participants' gender, marital status, employment status, and educational level (P > 0.05; Table 2).
The repeated measures analysis of variance showed that in the control group, the mean score of PSS did not significantly change across the three measurement time points (P > 0.05), while this mean score significantly increased in the intervention group (P < 0.05). The independent-sample t test indicated no significant difference between the groups regarding the pretest mean score of PSS (P = 0.76). However, the mean score of PSS in the intervention group was significantly greater than the control group at both posttests (P < 0.05) ( Table 3).

Discussion
Most participants of the study were married (85% in the intervention group and 90% in the control group). This is in line with the findings of several previous studies (28)(29)(30). Moreover, most participants were female (65% in the intervention group and 57.5% in the control group). Several former studies also reported that most FCGs were female (9,29,31). In addition, a large percent of participants had secondary diploma (37.5% in the intervention group and 47.5% in the control group). This agrees with the findings of a former study (32).
Study findings revealed that the mean score of PSS in the intervention group significantly increased after the implementation of the SM program. A previous study also found the positive effects of rehabilitation services on PSS and caregiver burden among the caregivers of PWS (33). Another comparative study into the effects of an SM program and a standard educational program also revealed that the SM program was associated with higher PSS among FCGs of PWS (22). Similarly, a study reported that group and family support helped maintain the level of PSS among the FCGs of PWS (34). A study on the FCGs of patients with dementia also showed the positive effects of SM on PSS (35). Moreover, a study found that health education programs significantly improved social health among the FCGs of PWS (36). PSS among the FCGs of patients with epilepsy and PWS has significant direct relationships with their SM ability, quality of life (35), and mental health (37).

Conclusion
This study concludes that the SM program based on Strauss and Corbin's SM model is effective in significantly improving PSS among the FCGs of PWS. Higher levels of PSS among these FCGs can improve their ability to more effectively perform their roles and manage their problems. Given the effectiveness and simplicity of the SM program, nurses are recommended to use it for improving PSS among FCGs.