Psychosocial interventions for carers of survivors of stroke: a systematic review of interventions based on psychological principles and theoretical frameworks

Authors:
ELDRED Clare, SYKES Catherine
Journal article citation:
British Journal of Health Psychology, 13(3), September 2008, pp.563-581.
Publisher:
Wiley

Most stroke survivors are cared for at home by informal carers, usually their partners or children. The chronic burden of meeting these care needs can have a significant impact on the psychological well-being of the carer. The aim of this review is to analyse interventions that target psychosocial functioning in carers of stroke survivors to understand how such interventions can reduce the burden of caring. Seven studies that reported on randomized controlled trials of psychosocial interventions for informal adult carers of a survivor of stroke, which reported validated measures of psychological health outcome and met a satisfactory rating of quality were included in this systematic review. A forest plot of two studies that used education and counselling as the intervention for patients and spouses indicate a more favourable outcome for the intervention on the global family functioning scale. The Clarke, Rubenach, and Winsor (2003) study showed that patients were more likely to benefit from an intervention consisting of counselling and education than spouses. It is noted that there are relatively few studies investigating the impact of psychologically based interventions for carers of stroke survivors and the quality of evidence is varied. However, there is evidence of good quality to show that stroke patients benefit from a counselling combined with education intervention. The clinical implications of this review suggests, according to current available evidence, that those working with survivors of stroke and their families should consider providing counselling and education interventions to patients in the first instance. More research is needed to determine the effectiveness of interventions aimed at improving the psychosocial functioning of carers of survivors of stroke.

Extended abstract:
Author

ELDRED Clare; SYKES Catherine;

Psychosocial interventions for carers of survivors of stroke: a systematic review of interventions based on psychological principles and theoretical frameworks.

Journal citation/publication details

British Journal of Health Psychology, 13(3), September 2008, pp.563-581.

Summary

Seven randomised controlled trials (RCTs) are reviewed and suggest that counselling combined with education can be effective in improving outcomes for the informal carers of stroke survivors. The evidence base is limited and in some respects contradictory, and more research is needed. However, short term interventions provided by telephone on a group basis, and that combine counselling and education with a focus on problem solving and coping with stress, are worth consideration by practitioners.

Context

Most stroke survivors are cared for at home by family members whose psychological well-being can suffer significantly as a result of the burden imposed by dealing with mobility and self care needs, communication difficulties, cognitive impairment, depression and personality changes. Interventions have focused on education and information and/or psychosocial support and counselling. While information and education alone may be ineffective, past reviews suggest that the provision of psychosocial support can be beneficial.

Methods

The review followed the guidelines of the Centre for Reviews and Dissemination (2001).

What sources were used?
The following databases were searched: CINAHL (Cumulative Index to Nursing and Allied Health Literature); the Cochrane Controlled Trials Register; EMBASE (Excerpta Medica); Medline; and PsycINFO. Conference Papers, Dissertation Abstracts and the National Research Register were searched for unpublished literature, and eight named journals were hand searched. The reference lists of relevant primary research and review papers were checked and ‘key researchers and practitioners’ in the field were contacted.

What search terms/strategies were used?
The strategy (with the asterisk is used as a truncation device to pick up variant word endings) appears to be:
stroke
AND (carer OR family)
AND (counselling OR psych* OR cognitive behaviour OR cognitive behavioural OR behaviour management OR psychotherapy OR support)
AND (intervention OR randomized controlled trial)

The text indicates that US spellings of behaviour and behavioural (but not counselling or randomized) were also used. The sensitivity of the search strategy was tested in relation to two previous reviews, and picked up all the studies contained within them.

What criteria were used to decide on which studies to include?
Eligible studies were RCTs that examined explicitly theory-based psychosocial interventions for informal carers (aged 16 and above) of stroke victims living in the community. Outcomes of interest included psychological health, physical health, quality of life or perceived burden where measured using established and validated assessment tools.

Who decided on their relevance and quality?
The searches delivered 80 studies of which 22 were based on RCTs and were read in full for detailed assessment against the inclusion criteria. Responsibility for this process is not reported. Quality assessment was based on a specially designed tool, which is available on request, with both authors coding each study independently and resolving disagreements through consensus.

How many studies were included and where were they from?
Seven RCTs, summarised in Table 1, were reviewed and were conducted in Australia (1), the Netherlands (2) and the USA (4).

How were the study findings combined?
The findings are presented narratively around the theories underpinning the interventions. Effect sizes were computed for the three studies reporting sufficient data, and forest plots constructed.

Findings of the review

Of the seven RCTs reviewed, only two indicated the method of randomisation and only two established their sample sizes through power analysis. In general, sample sizes were relatively small and losses of participants by the time of follow-up were relatively high. Various methods of data analysis and outcome measurement were used.

Family systems theory
One study of education plus family counselling showed that improved family functioning was maintained in the six months after the end of the intervention relative to the control group. This was significantly associated with improvements in the functional status of the stroke survivor. However, there was no evidence for better general health among informal carers.

Cognitive behavioural therapy (CBT)
One study compared education plus counselling, based on CBT, with education only and with a control group of carers living with a stroke survivor. All three conditions showed worsening family functioning after stroke, but both intervention groups deteriorated significantly less in terms of problem solving, communication and global family functioning. The counselling group also showed significantly improved patient adjustment relative to the control group. Follow-up at a year showed that the positive effects of the interventions were maintained, with counselling plus education performing better than education alone on problem solving, communication, behaviour control, global family functioning and patient adjustment.

Stress coping model
One study was based on the provision of a stress coping manual and audiotape in which the intervention group also took part in group sessions conducted by telephone conference. There were no significant differences for depression, loneliness or stress, but the intervention group did report a significant gain in sense of competence at six month follow-up. Conversely, the control group reported significantly greater burden. A second study compared individual and group-based support programmes to enhance the confidence of carers in knowledge of patient care, active coping strategies, mental well-being, vitality, social support, assertiveness and reducing strain. At follow-up after a month both interventions contributed significantly to increased confidence in knowledge about patient care and the use of active coping strategies, with no differences between the individual and group modes of delivery. A third study reporting follow-up at six months still showed a small to medium increase in knowledge and the use of active coping strategies in the intervention groups.

Social problem solving theory
One study compared the effectiveness of seven telephone calls or seven home visits over a 12 week period designed to teach carers to use social problem solving skills. During the intervention the telephone group reported significantly reduced depression, more positive problem-solving skills and greater preparedness. However, there were no significant differences between the groups on these outcomes after the end of the intervention, and no significant differences in respect of general health or carer burden. A second study by the same research team compared a telephone-based problem solving intervention with a sham group receiving telephone contact and with a routine care control group. At 13 weeks after discharge the intervention group showed significantly better social functioning, with improvements in vitality, mental health and role limitations related to emotional problems.

Authors' conclusions

Direct comparisons are difficult because of the different theoretical models and approaches used, and there are ‘some marked differences in results’ between studies. Overall, the findings ‘tentatively indicate that interventions designed to target psychosocial outcomes in informal carers of survivors of stroke can lead to better family functioning and promote problem solving and may protect against the negative psychological impact of caring for someone with stroke.’ More research is clearly needed, preferably using the same outcome measures to allow comparability.

Implications for policy or practice

The results of the review ‘suggest that those working with survivors of stroke and their families should consider providing interventions for primary carers.’ They indicate that positive benefits can be delivered in the short term by ‘relatively short interventions’ that can be provided by telephone on a group basis, and which combine counselling and education with a focus on problem solving and coping with stress.

Subject terms:
problem solving, psychosocial intervention, stress, stroke, behaviour therapy, carers, counselling;
Content type:
systematic review
Link:
Journal home page
ISSN print:
1359-107X

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