**7. Training of caregivers of survivors of stroke**

To help support survivors of stroke, stroke rehabilitation services should address caregiver issues and include practical training in nursing skills and counselling

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*Supporting Survivors of Stroke in Low Resource Settings DOI: http://dx.doi.org/10.5772/intechopen.86900*

facilitate patient recovery after stroke [131, 157].

vors may highlight the importance of this aspect of care.

on what to expect [42].

period [153].

caregivers [158, 159].

sessions, which will help in reducing the caregiver burden and improve stroke survivor recovery. Survivors of stroke spend most of their time with caregivers who therefore need to be trained and educated on how to take care of the survivor and

In high income countries, caregiver training consisting of basic skills of moving and handling, facilitation of activities of daily living and simple nursing tasks have been seen to reduce caregiver burden and improve quality of life [42, 101]; and was cost-effective [101]. Trained caregivers were also followed up over time in South Africa, and the structured caregiver training positively impacted on survivors' quality of life post discharge [98]. They recommended an exploration of different caregiver education programs to determine those that would produce the best outcomes in patients and caregivers so that they can be adopted regionally and internationally [98]. That education of caregivers reduce the burden of care and was also later reported in other studies on home-based care in HIV [32, 152]. The authors reported that those who received support from a nurse or community care worker had a lower caregiver burden and had more than twice the odds of wanting to care for another person living with HIV in the future [152]. Any training or educational program should start during the acute phase of rehabilitation to prepare patients and caregivers for the trajectory of problems they may face during the recovery

Education may benefit both the survivors of stroke and caregivers by preventing stroke. Education is defined as 'a planned experience that uses a combination of methods such as teaching, counselling and behaviour modification techniques to influence knowledge and behaviour' [154]. Various interventions have been developed and evaluated with the intention of supporting informal caregivers. However, there are conflicting reports on their effectiveness and even for those with positive outcomes, only modest effects are reported [155, 156]. Caregiver training is a non-pharmacological intervention to reduce the burden on informal caregivers and

Caregivers should receive information regarding stroke survivor handling, positioning and how to communicate with the stroke survivor [42, 101, 158]. These findings were supported by authors who reported that caregivers' training programs should mainly be focused on practical demonstrations on physical activities which they do whilst performing their roles to reduce physical strains among

Education should be given to family caregivers as this will benefit the community as they may relay the information to others for sustainability and improve quality of life of stroke survivors [42, 132]. They should be educated on how to look after the stroke survivor to prevent complications as well as recurrence [64, 160]. Training should cover self-efficacy and enable coping strategies like how to mobilise social support and also help the stroke survivor [123]. Training caregivers will also reduce adverse outcomes [145] However, the long-term impact of training on caregivers is not known in that they may end up thinking that the training is a qualification.

In Africa, about two thirds of caregivers of stroke survivors in rural areas receive no basic stroke education before discharge due to scarcity of rehabilitation services [6, 161]. On a positive note, educating the public and health care providers about prevention of stroke, warning signs and symptoms of the disease has been found to be useful when treating patients with hypertension [64, 162]. Lack of training is associated with high mortality among stroke survivors and severe forms of disabilities which could be minimised if training is done prior to discharge [161, 163]. Comparing the effects of training on the outcomes of caregivers and stroke survi*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

as cognitive, emotional and behavioural changes in the survivor have a negative influence on caregiver strain. On the other hand, high confidence knowledge about efficacy, high satisfaction with social support and frequent use of coping strategy confronting all had a positive influence [123]. They therefore concluded that caregiver support programs should include education about self-efficacy, stimulation of the use of the coping strategy confronting and training in mobilising social support in a way that is satisfactory to caregivers. Furthermore, support programs should be offered both to caregivers who recently started to take care of a survivor and to

caregivers who have been taking care of a patient for a longer time [123].

The mean age of caregivers ranged from 36 to 70 years [100, 142]. The most common informal caregivers are spouses and adult children or other relatives most of whom are poor [100, 116, 121, 143, 144]. Most of the caregivers are females [32, 100, 123, 142, 145]. In most cases there is no one else to carry out the caregiving task [146]. Female caregivers usually encounter more caregiving demands than male caregivers [147, 148]. This is because the female caregivers spend more time doing care giving tasks and other multiple family responsibilities [147, 149]. They are also the cornerstone for development and implementation of community care policies [141]. Further to this it was also found that 93% of men were cared for by women (their spouse in 73% of cases), while 55% of women were cared for by men [100]. Governments should make sure that poor people are educated on reduction of chronic diseases [150]. This is because they will end up caring for their sick

An attractive option is the use of formal caregivers, but they are expensive and for low resources settings like SSA, where accessibility to health settings is difficult [6, 109]. Home rehabilitation using informal caregivers is therefore the option of choice and if they receive support, may provide alternative cost-effective care compared to usual care [36, 151]. However, caregivers may end up giving up their jobs to care for the stroke survivor full time, give up their houses to stay with the stroke survivor and give up some social activities like going out with friends and going to church [38, 116, 138]. As discussed before, caregivers have not been made an integral part of the health care system [118], yet are responsible for the improvement of quality of life and survival of stroke survivors post discharge and suffer

In most SSA countries, most of the caregivers are informal [36]. Due to the high HIV burden the occurrence of stroke in HIV positive patients causes a dual burden of care [10, 31, 32]. Lack of support systems in poor countries also pose challenges as most of those affected are poor and cannot afford outside support [6, 44]. It was further noted that caregivers in developing countries are usually family not educated about care and face challenges in dealing with patients' problems [32]. At the same time, they are expected to help lower the risk of stroke recurrence, reduce stroke related complications, improve function and subsequently improve community integration [42, 46, 47]. There is need to address the perceived needs of caregivers of stroke survivors to improve quality of life and reduce caregiver burden which may arise from long term caregiving. Caregiver training may be the best choice as these are available and will not need

To help support survivors of stroke, stroke rehabilitation services should address

caregiver issues and include practical training in nursing skills and counselling

**324**

payment.

relatives.

burnout themselves [38, 122].

**7. Training of caregivers of survivors of stroke**

sessions, which will help in reducing the caregiver burden and improve stroke survivor recovery. Survivors of stroke spend most of their time with caregivers who therefore need to be trained and educated on how to take care of the survivor and on what to expect [42].

In high income countries, caregiver training consisting of basic skills of moving and handling, facilitation of activities of daily living and simple nursing tasks have been seen to reduce caregiver burden and improve quality of life [42, 101]; and was cost-effective [101]. Trained caregivers were also followed up over time in South Africa, and the structured caregiver training positively impacted on survivors' quality of life post discharge [98]. They recommended an exploration of different caregiver education programs to determine those that would produce the best outcomes in patients and caregivers so that they can be adopted regionally and internationally [98]. That education of caregivers reduce the burden of care and was also later reported in other studies on home-based care in HIV [32, 152]. The authors reported that those who received support from a nurse or community care worker had a lower caregiver burden and had more than twice the odds of wanting to care for another person living with HIV in the future [152]. Any training or educational program should start during the acute phase of rehabilitation to prepare patients and caregivers for the trajectory of problems they may face during the recovery period [153].

Education may benefit both the survivors of stroke and caregivers by preventing stroke. Education is defined as 'a planned experience that uses a combination of methods such as teaching, counselling and behaviour modification techniques to influence knowledge and behaviour' [154]. Various interventions have been developed and evaluated with the intention of supporting informal caregivers. However, there are conflicting reports on their effectiveness and even for those with positive outcomes, only modest effects are reported [155, 156]. Caregiver training is a non-pharmacological intervention to reduce the burden on informal caregivers and facilitate patient recovery after stroke [131, 157].

Caregivers should receive information regarding stroke survivor handling, positioning and how to communicate with the stroke survivor [42, 101, 158]. These findings were supported by authors who reported that caregivers' training programs should mainly be focused on practical demonstrations on physical activities which they do whilst performing their roles to reduce physical strains among caregivers [158, 159].

Education should be given to family caregivers as this will benefit the community as they may relay the information to others for sustainability and improve quality of life of stroke survivors [42, 132]. They should be educated on how to look after the stroke survivor to prevent complications as well as recurrence [64, 160]. Training should cover self-efficacy and enable coping strategies like how to mobilise social support and also help the stroke survivor [123]. Training caregivers will also reduce adverse outcomes [145] However, the long-term impact of training on caregivers is not known in that they may end up thinking that the training is a qualification.

In Africa, about two thirds of caregivers of stroke survivors in rural areas receive no basic stroke education before discharge due to scarcity of rehabilitation services [6, 161]. On a positive note, educating the public and health care providers about prevention of stroke, warning signs and symptoms of the disease has been found to be useful when treating patients with hypertension [64, 162]. Lack of training is associated with high mortality among stroke survivors and severe forms of disabilities which could be minimised if training is done prior to discharge [161, 163]. Comparing the effects of training on the outcomes of caregivers and stroke survivors may highlight the importance of this aspect of care.

The training should not be generic, but tailor made or individually adapted for clients and include written information for caregivers given during the training session together with pictorial charts [156, 157, 164–166]. Stroke survivors should also be educated about their condition, treatment, prognosis and what they may need to do or not do and about hypertension as their knowledge was found to be suboptimal [64, 154, 160]. This finding strengthened findings from South Africa, which reported that 79% of hypertension and 64% of strokes said they did not know about the risk of stroke [167]. Development of a caregiver training programme that can be adapted to individual needs is important as any caregiver may receive this mode of support.

Any assistive devices used during training should be offered to them to take home to prevent regression of the stroke survivors' condition and difficulties in execution of the exercise programs [168]. Any training involving stroke survivors should be done after the acute phase, when they are less overwhelmed and able to comprehend the information [158, 169]. It is also important for stroke survivors and caregivers to be educated about the importance of incorporating the survivor back into the family [170]; although in some instances it may not result in improved perceived health status [171]. This is because education may improve carers' knowledge about stroke and its consequences but may fail to provide positive solutions to their problems hence lack of improvement in perceived health status [171]. It is therefore important for health workers to disseminate the training to other staff for sustenance of the training programme [172]. Training after the acute phase may be a challenge in situations where beds are required for other patients. In that case the caregivers may only receive training and later survivors of stroke may be included once they are ready.
