LECTURA DE IMÁGENES

Depression: Depressive symptoms were reported to be related to poor functional status

and quality of life in stroke patients (Altindag et al., 2008; Haacke et al., 2006). A study by Berg et al reported that male stroke survivors had significantly more depressive symptoms (p<0.001) at more than 18 months after stroke (Berg et al., 2003). Some studies have consistently found significant relationships with female survivors reporting more depressive symptoms (Carod-Artal et al., 2009; Cassidy et al., 2004; Chiu et al., 2005; Leentjens et al., 2006). At 1 year post stroke, variables associated with depression were status as a housewife, female sex, incapable to work owing to disability, and reduced social activity (p<0.0001) (Carod-Artal et al., 2000). A study by Kwok revealed that depressive mood had a fundamental and broad adverse effect on QOL between 3 months to 1 year post stroke (Kwok et al., 2007). Carod-Artal et al (2009) found mood disturbance to be a stronger and independent predictor of HRQOL among Brazilian

55 stroke survivors. In addition, post-stroke depression was associated with female sex, disability, and lower cognitive functioning (p<0.001). Motor impairment, disability, and mood disturbances (depression) were consistently reported as independent predictors of HRQOL (Carod-Artal et al., 2009; Carod-Artal et al., 2000; Sturm et al., 2004).

Comorbidities: Nichols-Larsenet al (2005b) found that stroke survivors with more comorbidities reported poorer HRQOL in the area of memory and thinking at 3-9 months post stroke. Other studies have also reported comorbities as determinant of quality of life in stroke survivors (Carod-Artal et al., 2009; Hopman & Verner, 2003;

Owolabi, 2008). Suenkeler et al (2002) reported that absence of diabetes at 3 and 6 months after stroke was identified as a predictor of favourable QOL at 1 year post stroke (p<0.05). Stroke survivors with comorbidities who were restricted in their physical and cognitive functions were more likely to report worse mental health (Clarke et al., 2002). In their study of clinical determinants of QOL after stroke, Patel et al (2007) reported that at 1 year after stroke, diabetics were worse than non-diabetics (p<0.001). Side of stroke: Decreased QOL especially the communication domain have been observed among stroke survivors with left hemispheric lesion (right sided hemiplegia) (Barker-Collo, 2007; Carod-Artal et al., 2009; Kamel et al., 2010 ; Moon et al., 2004; Nichols-Larsen et al., 2005b; Patel et al., 2007). Findings by Barker-Collo (2007) suggested that individuals with left hemisphere lesions may be particularly at risk of developing depression and anxiety after stroke. Younger individuals are also at heightened risk of depression during the 3 months post stroke. Moon et al (2004) found that at 2 months following stroke, severe sub cortical gray matter lesion and depressive symptoms in the acute phase of stroke were of significance in predicting low QOL.

Type of stroke: Kauhanen et al (2000) found that QOL was poorer for patients with mild to moderate impairement 3 months poststroke caused by brain infarction . Azita et al (2001) found subarachnoid haemorrhage survivors fare as well as or better than

56 intracerebral haemorrhage survivors at 6 months after stroke. Functional status: Carod-Artal (2000) identified functional status as a predictor of quality of life at 1 year post stroke. Clarke et al (2000) found that an improvement in motor disability was found to be related to progress in quality of life throughout the first year of recovery. However, Robinson-Smith et al (2000) found that functional independence and quality of life to be improved over time, while depression was reduced. Functional independence was sufficiently correlated with quality of life at 6 months following stroke, but not at 1 month after stroke. Bosworth et al (2000) discovered that the patients’ evaluations of their health status during the early first year after stroke were very steady over time, with only slight progress at 6 months, followed by an insignificant decline at 12 months.

Carod-Artal (2000) reported that post stroke disability was a stronger predictor of low QOL than post stroke depression 1 year after stroke. Patients with severe/moderate disability reported lower QOL than depressed patients. It was reported that poor mental health and physical and cognitive difficulties were associated with reduced sense of QOL (Hopman & Verner, 2003; Patel et al., 2007). Lanaguage impairement: An indirect relationship with QOL - difficulty with aphasia is associated with lower QOL or life satisfaction in stroke survivors (King, 1996; Patel et al., 2007). The ability to communicate was rated as a highly important predictor of QOL after stroke (King, 2006; Kwok et al., 2007). Communication impairement was perceived as devastating and was a source of stress leading to loneliness (Michallet et al., 2003; Natterlund, 2010). Aphasia affected the biopsychosocial wellbeing of the stroke survivors including their participation in activities of daily living, in social activities, the ability to work, and their emotional status leading to development of depressive symptoms (LaPoint, 2005; Pound et al., 2001). Dependency at Discharge: Robinson-Smith et al (2000) found functional independence to be reasonably associated with quality of life at 6 months after stroke, but not at 1 month after stroke. Other studies had also reported that

57 vigorous rehabilitation enhanced functional outcome, and consequently influence depression positively (Appelros & Viitanen, 2004; Clarke et al., 2000). Hopeman and Verner (2003) discovered that significant gains in HRQOL during inpatient stroke rehabilitation may be followed by equally considerable decrease in the 6 months following discharge. Lee et al (2009) et al reported that length of hospital stay after admission for stroke was identified to have an independent effect on QOL at 6 months after stroke. Disability: as measured with Barthel Index (BI) was a predictor of HRQOL for all SIS 3.0’ physical and social participations domain (Carod-Artal et al., 2009). On the contrary, Moon et al (2004) found that the level of neurological dysfunction, as measured by BI was not associated with the QOL status 2 months after stroke. In another study, Kwok et al (2007) found that there was substantial progress in BI, but QOL pertaining to social relationships and environment diminished between 3 and 12 months after stroke. Researcher also found improvement in functional status, between 3 and 12 months after first stroke, but QOL deteriorated considerably in terms of psychological health, social relationships, and perceived living environment (Kwok et al., 2007). Carod-Artal (2000) reported that women had a lower BI score both on admission and at 1 year after stroke and reported a reduced QOL. In a follow-up study at 6 and 12 months after stroke, Kwok et al (2007) reported that despite significant improvement in the BI score, the QOL in terms of cognitive function increased but social relationship and environment decreased. In their study of clinical determinants of QOL after stroke, Patel et al (2007) reported that at 1 year after stroke, patients with pre-morbid BI <15 were worse than those with BI 15-20 (p<0.021). Modified Rankin Scale (mRS) was found to be substantially correlated (−0.65 < r −0.42, P < 0.001) to the physical, psychological, intellectual and social domains of the QOL (Owolabi, 2008).

Carod-Artal (2009) also reported that the mean scores of the SIS 3.0 domains were significantly higher in the patients more affected by stroke as accessed by mRS.

58 Appelros and Viitanen (2004) found that a low functional outcome as measured by mRS predicts depression, which also has a major impact on life satisfaction one year after a stroke. Social environment: In stroke survivors, social support is believed to affect the quality of patient care and disease outcome, as well as patient’s physical and psychosocial well-being (Lyncha et al., 1999; Tsouna-Hadjis et al., 2000). Apart from disability, psychosocial factors such as emotional responses and social support determine HRQOL in stroke survivors (Owolabi, 2008; Yu et al., 2013). Studies have consistently demonstrated a link between low levels of social support and poor mental and physical health outcomes and have subsequently fuelled the development and evaluation of interventions designed to improve social support for those deprived of this resource (Brenda et al., 2002; Bruwer et al., 2008; Katherine et al., 2010; Lyncha et al., 1999). Living alone, being institutionalized, reduced physical function, and depression were independently linked to lower levels of patient’s satisfaction over time (Bosworth et al., 2000). Social supports and educational resources moderate the impact of functional status on well-being (Clarke et al., 2002). In a study of QOL among Chinese patients, Kwok et al (2006) reported a decrease in environmental and social interaction HRQOL after 1 year of stroke.

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CHAPTER THREE: RESEARCH METHODOLOGY

This chapter describes and explain the methodology of the mixed-method research study and methods used. Methodology implies to the philosophical framework, while method is the research techniques and procedures for conducting the research (Wilkins

& Woodgate, 2008). The subtopics in this chapter describe the study area, mixed-method research design and the rationale for using it. Next, the topics describe the research design and research procedures in accordance with the individual phases of the study. Phase I is the instruments validation phase; Phase II, is the quantitative component and; Phase III is the qualitative component. Finally, sampling methods, research instruments and statistical methods used are described where appropriate.