**8. Patient and caregiver outcomes after training**

Several studies were carried out to determine effect of training on the outcomes of survivors of stroke and their caregivers. Most of the studies compared intervention and control groups. Most studies that found better outcomes in the intervention group were from developed countries and looked at functional status of patients and physical/emotional health of family caregivers, quality of life, caregiver optimism, task difficulties and use of intervention [42, 101, 173–176]. In some instances, 89% of the control group was functionally independent at 3 months compared to 93% in the intervention group. At 6 months, this was 86 and 89% respectively. Similarly, Foster and colleagues found a significant difference in two of the satisfaction questions on satisfaction with hospital services [177].

The differences found between the intervention and control group were largely attributed to extended training time and longer call durations in the intervention group [175]. Effects of the intervention can persist over a long-term period as the intervention can sustain home care by reducing institutionalisation and mortality as well as improve clinical outcomes for caregivers [173, 175]. On the other hand, some findings showed no difference in outcomes between the control and intervention groups and in other cases are contrasting [42, 175, 177, 178]. These authors found no statistically significant difference between groups in functional Barthel Index score or functional independence at 6 months among patients. They did not give caregiver outcomes. No significant differences in patient activities of daily living or functioning or in caregiver emotional distress, anxiety, depression and strain were also reported [177]. On the other hand, the intervention group had more patients

**327**

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

be of value to offer support to stroke survivors and caregivers.

the curriculum development is based on the following six steps [8]: Step 1. Problem identification and general needs assessment

This begins with identification and analysis of health care needs. A general analysis of the current approach to address the identified needs is done. The difference between the ideal approach and the current approach represents a general needs assessment. This helps identify the gaps that exist in the care of stroke survivors. There is need to assess how other countries are dealing with training issues and compare outcomes of the stroke survivors and those in one's country. In most cases key informant interviews are carried out and other training programmes are assessed for adaptability. The observed gaps help in coming up with a targeted needs analysis.

This involves assessing the needs of the targeted group of caregivers and stroke survivors which may be different from their needs in general. A

Education of caregivers is important [32, 42, 47, 101, 158]. However any developed training programme should be repeatable [8]. To come up with a training programme that is relevant, objective and feasible, it is important to consider the cultural and socio-economic context in which it will be used. The Kern model of curriculum development for medical education a six-step approach that links health needs to the education process was used to develop a caregiver training programme. The process does not usually proceed in sequence but is rather an interactive and dynamic one and can be adapted for low resource settings. According to Kern et al.,

**9. Developing a caregiver training programme**

Step 2. Targeted needs analysis

found positive results.

referred for depression in one study [178]; although stroke recurrence was similar in both groups. It was therefore concluded that there was no evidence of a clinically significant benefit of the intervention to both patients and caregivers [177]. However it is important to consider the differences in this study with those that

Studies that involved caregivers only were carried out in other places [176, 178]. One study in the rural areas in the United States found that all caregivers were satisfied with the intervention and were willing and able to use the intervention [178]. The intervention helped the caregivers make informed decisions about health care needs of stroke survivors thus reducing stress. This was further supported when the caregiver training program was found to have a positive impact on the functional status, post stroke depression and caregivers' knowledge and practices [179]. Caregivers were trained alone or in some instances together with the stroke survivor [42]. In other instances, both the caregivers and patients were trained [101, 176]. However different findings were reported in that some found the intervention to improve quality of life in both caregivers and patients [42] On the other hand, improvement in quality of life among the caregivers was found but not in the other outcomes [101]. No significant differences in survivors' activities of daily living or functioning or in caregiver emotional distress, anxiety, depression and strain were found in other studies [177]. On the other hand, in South Africa, improvement in quality of life, mobility and reduction in caregiver burden were found in the intervention group [98]. When training caregivers it is important to take into account other factors that may confound the outcomes such as culture and level of education. All the results point towards a trend for caregiver targeted interventions having some value, but there is need for further research to confirm this and improve generalizability [155]. A caregiver training programme in low resource settings may

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

mode of support.

once they are ready.

hospital services [177].

**8. Patient and caregiver outcomes after training**

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

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

Several studies were carried out to determine effect of training on the outcomes of survivors of stroke and their caregivers. Most of the studies compared intervention and control groups. Most studies that found better outcomes in the intervention group were from developed countries and looked at functional status of patients and physical/emotional health of family caregivers, quality of life, caregiver optimism, task difficulties and use of intervention [42, 101, 173–176]. In some instances, 89% of the control group was functionally independent at 3 months compared to 93% in the intervention group. At 6 months, this was 86 and 89% respectively. Similarly, Foster and colleagues found a significant difference in two of the satisfaction questions on satisfaction with

The differences found between the intervention and control group were largely attributed to extended training time and longer call durations in the intervention group [175]. Effects of the intervention can persist over a long-term period as the intervention can sustain home care by reducing institutionalisation and mortality as well as improve clinical outcomes for caregivers [173, 175]. On the other hand, some findings showed no difference in outcomes between the control and intervention groups and in other cases are contrasting [42, 175, 177, 178]. These authors found no statistically significant difference between groups in functional Barthel Index score or functional independence at 6 months among patients. They did not give caregiver outcomes. No significant differences in patient activities of daily living or functioning or in caregiver emotional distress, anxiety, depression and strain were also reported [177]. On the other hand, the intervention group had more patients

**326**

referred for depression in one study [178]; although stroke recurrence was similar in both groups. It was therefore concluded that there was no evidence of a clinically significant benefit of the intervention to both patients and caregivers [177]. However it is important to consider the differences in this study with those that found positive results.

Studies that involved caregivers only were carried out in other places [176, 178]. One study in the rural areas in the United States found that all caregivers were satisfied with the intervention and were willing and able to use the intervention [178]. The intervention helped the caregivers make informed decisions about health care needs of stroke survivors thus reducing stress. This was further supported when the caregiver training program was found to have a positive impact on the functional status, post stroke depression and caregivers' knowledge and practices [179].

Caregivers were trained alone or in some instances together with the stroke survivor [42]. In other instances, both the caregivers and patients were trained [101, 176]. However different findings were reported in that some found the intervention to improve quality of life in both caregivers and patients [42] On the other hand, improvement in quality of life among the caregivers was found but not in the other outcomes [101]. No significant differences in survivors' activities of daily living or functioning or in caregiver emotional distress, anxiety, depression and strain were found in other studies [177]. On the other hand, in South Africa, improvement in quality of life, mobility and reduction in caregiver burden were found in the intervention group [98]. When training caregivers it is important to take into account other factors that may confound the outcomes such as culture and level of education.

All the results point towards a trend for caregiver targeted interventions having some value, but there is need for further research to confirm this and improve generalizability [155]. A caregiver training programme in low resource settings may be of value to offer support to stroke survivors and caregivers.

## **9. Developing a caregiver training programme**

Education of caregivers is important [32, 42, 47, 101, 158]. However any developed training programme should be repeatable [8]. To come up with a training programme that is relevant, objective and feasible, it is important to consider the cultural and socio-economic context in which it will be used. The Kern model of curriculum development for medical education a six-step approach that links health needs to the education process was used to develop a caregiver training programme. The process does not usually proceed in sequence but is rather an interactive and dynamic one and can be adapted for low resource settings. According to Kern et al., the curriculum development is based on the following six steps [8]:

Step 1. Problem identification and general needs assessment

This begins with identification and analysis of health care needs. A general analysis of the current approach to address the identified needs is done. The difference between the ideal approach and the current approach represents a general needs assessment. This helps identify the gaps that exist in the care of stroke survivors. There is need to assess how other countries are dealing with training issues and compare outcomes of the stroke survivors and those in one's country. In most cases key informant interviews are carried out and other training programmes are assessed for adaptability. The observed gaps help in coming up with a targeted needs analysis.

Step 2. Targeted needs analysis

This involves assessing the needs of the targeted group of caregivers and stroke survivors which may be different from their needs in general. A triangulation of methodologies is used to come up with their needs and challenges that they face. This should be done among those that are likely to have faced challenges, meaning that they have experienced the challenges for a certain length of time.
