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Abstract: Stroke survivors encounter various physical and psychosocial challenges after hospital discharge. Systematic reviews consistently suggest the importance of self-management in promoting post-stroke recovery. However, stroke survivors' performance of self-management behaviors after returning home is poorly understood. This study was conducted to explore how stroke survivors manage their life after returning home from the hospital. This was a qualitative study with individual, semi-structured interviews. We recruited a purposive sample of adults who had a first or recurrent ischemic or hemorrhagic stroke and currently lived at home. Participants were asked about their post-stroke experiences, challenges encountered, and strategies adopted for managing post-stroke conditions. Data were transcribed verbatim and analyzed using thematic analysis. A total of 30 stroke survivors (mean age = 61.97 years, SD = 10.20) were interviewed. Most were men (n = 18), married (n = 25), and retired (n = 21). Two-thirds had experienced an ischemic stroke. Five key themes emerged: pursuing lifelong learning to live well after a stroke; reinterpreting unpleasant experiences as new learning opportunities; engaging in life activities to better adapt to post-stroke challenges; being confident in oneself to persevere in self-management behaviors; and continuing to accept the current self and explore the new self. Participants regarded learning as a prerequisite for improving their affected functions and managing uncertainties in recovery. Learning requires self-participation, building self-efficacy and positive outcome expectations, testing and adapting strategies to one's own health conditions, and engaging in leisure or social activities. These findings will guide future development of interventions for enhancing stroke survivors' recovery outcomes., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Purpose: Evidence shows self-management programs are associated with improved recovery outcomes. This article reports on the effectiveness of a new nurse-led self-efficacy-based stroke self-management program., Methods: A randomized controlled trial of participants recruited from 3 acute stroke units was conducted. The intervention group received the 4-week stroke self-management program. The control group received usual care. All participants were assessed at baseline and 8 weeks after randomization. Data were analyzed using generalized estimating equations. Outcomes included self-efficacy, outcome expectation, and satisfaction with performance of self-management behaviors., Results: One hundred twenty-eight participants were randomized with mean age, 67.46 years (SD, 11.95); 59% men; and mean duration poststroke, 45 days (SD, 26.16). At 8 weeks of follow-up in the intention-to-treat population, the intervention group improved significantly in self-efficacy (95% confidence interval, 2.55-12.45; P <0.01), outcome expectation (95% confidence interval, 5.47-14.01; P <0.01), and satisfaction with performance of self-management behaviors (95% confidence interval, 3.38-13.87; P <0.01) compared with the control. Similar results were obtained at 8 weeks of follow-up in the per-protocol population., Conclusions: The stroke self-management program improved survivors' self-efficacy, outcome expectation, and satisfaction with performance of self-management behaviors., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02112955., (© 2018 American Heart Association, Inc.)

Introduction: The Stroke Specific Quality of Life Scale is a stroke-specific measure of health-related quality of life. However, there has been no Chinese (Hong Kong) version of the scale., Methods: A descriptive study was conducted to examine the reliability, validity and factor structure of the translated version (SSQOL-C) among stroke survivors. Participants completed SSQOL-C, and the Chinese versions of the Medical Outcomes Study Short-Form Health Survey (SF-36), Stroke Self-Efficacy Questionnaire (SSEQ-C) and Frenchay Activities Index (FAI). Thirty of these participants completed the same questionnaires after 4 weeks., Results: A total of 135 stroke survivors (mean age 58.90 ± 9.75) were recruited. SSQOL-C had good internal consistency with Cronbach's alphas for each domain ranging from 0.63 to 0.90. Most domains had moderate to high correlations with similar dimensions of SF-36, SSEQ-C, FAI and Barthel ADL Index total scores (Spearman's rho: 0.40-0.77, p < 0.01), suggesting acceptable convergent validity. Principal component analyses suggested an 11-factor model in contrast to the 12-factor model for the original scale with six new factors emerging and five original factors retained., Discussion: The results suggest SSQOL-C is a reliable and valid tool for measuring Chinese stroke survivors' health-related quality of life. More studies are needed to confirm the 11-factor model of the scale. Implications for rehabilitation The translated Chinese version of the Stroke Specific Quality of Life Scale is a reliable and valid tool for measuring Chinese stroke survivors' health-related quality of life. An 11-factor model in contrast to the 12-factor model for the original scale with six new factors emerging and five original factors retained.

Background: Recovery after stroke is long-term and demanding. Optimising community-residing stroke survivors' capability to self-manage their health is integral. Recent systematic reviews have shown that stroke self-management programmes were associated with significant improvement in stroke survivors' health-related quality of life and self-efficacy. However some programmes were not designed with an underpinning theoretical framework. The aim of this study is to compare the effectiveness of a nurse-led stroke self-management programme with usual care on recovery of community-residing stroke survivors., Methods/design: A single-blinded, two-arm, randomised controlled trial will be conducted. Patients with a history of first or recurrent ischaemic or haemorrhagic stroke who will be discharged to home settings will be recruited from acute stroke units of three acute public hospitals in Hong Kong. The estimated sample size is 160 (80 participants per group). Eligible participants will be randomised to receive either usual care or a 4-week nurse-led community-based self-management programme plus usual care after discharge. The programme, underpinned by Bandura's constructs of self-efficacy and outcome expectation, includes one individual home visit, two community-based group sessions, and three follow-up phone calls. Primary outcomes include stroke survivors' self-efficacy and outcome expectation of performing self-management behaviours. Secondary outcomes include health-related quality of life, satisfaction with performance of self-management behaviours, depressive symptoms, and community reintegration. Participants will be assessed at baseline and at 8 weeks after randomisation. Generalised estimating equations will be performed to evaluate the significance of changes in outcomes over time by treatment condition. Research ethics approvals were obtained., Discussion: It is expected that stroke survivors receiving the stroke self-management programme will have improved self-efficacy, outcome expectation, and performance of stroke self-management behaviours. Enhanced quality of life and level of community reintegration, and decreased depressive symptoms are also expected. The study results will provide valuable evidence to inform future identification and evaluation of best approach to deliver stroke self-management programmes to enhance community-residing stroke survivors' recovery., Trial Registration: ClinicalTrials.gov identifier: NCT02112955 ; date of registration: 09/04/2014.

Background: Self-efficacy is a significant factor influencing stroke survivors' participation in self-care and outcomes. The Stroke Self-Efficacy Questionnaire (SSEQ) is a stroke-specific measure of stroke survivors' self-efficacy in performing daily functional activities and self-management. However, there has been no Chinese version of the questionnaire., Objective: The current study aims to examine the reliability and validity of a translated Chinese version of SSEQ (SSEQ-C)., Methods: The English version of SSEQ has been translated into Chinese. A descriptive study was conducted. A convenience sample of 135 Chinese stroke survivors (mean age 58.9, SD 9.75) was recruited from three community centers and a stroke support group. Eligible participants completed the SSEQ-C, and the Chinese versions of General Self-Efficacy Scale (GSES), Frenchay Activities Index (FAI), and Stroke-Specific Quality of Life Scale (SSQOL). Thirty of the participants completed the questionnaires at baseline and 4 weeks afterwards., Results: SSEQ-C had a high internal consistency (Cronbach's α 0.92). Test-retest reliability was satisfactory with the intraclass correlation coefficient of the total scale 0.52. Positive correlations were found between the total scores of SSEQ-C, GSES, FAI, and SSQOL (Spearman's ρ: 0.48-0.68, p < 0.01), suggesting acceptable convergent validity. Principal component analysis suggested a two-factor model, namely "Live with new challenges" and "Activity and exercise engagement" in contrast to the single-factor model for the original questionnaire., Conclusion: The results suggest SSEQ-C is a reliable and valid tool for measuring Chinese community-dwelling stroke survivors' self-efficacy in managing post-stroke condition. More studies are warranted to confirm the two-factor model of the questionnaire.

Background/purpose: We aim to evaluate the accuracy of the new prehospital notification criteria for patients with potential acute stroke in the prehospital setting., Methods: We conducted a retrospective observational study from March 2011 to February 2013 of potential acute stroke patients prenotified using the new criteria which were: (1) positive Cincinnati Prehospital Stroke Scale (CPSS); (2) symptom onset within 3 hours; and (3) blood glucose level > 60 mg/dL. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the new criteria were calculated and outcomes of acute stroke patients were reported. Data of all patients with stroke or transient ischemic attack (TIA) transported to the destination hospital were also obtained to evaluate the compliance of emergency medical technicians., Results: There were 2888 patients suspected of stroke by emergency medical technicians and 221 patients prenotified due to meeting the criteria. The PPV, NPV, sensitivity, and specificity of the new criteria were 76.9%, 96.6%, 64.9%, and 98.1%, respectively. Onset time > 3 hours (24/51, 47.1%) and seizure (27.5%) were the two most common conditions leading to false prenotification. Of all prenotified patients, 23.1% (51/221) received thrombolytic therapy. Hemorrhagic stroke or ischemic stroke with hemorrhagic transformation (53.8%) and minor symptoms or rapid recovery (26.9%) were the most common reasons excluding correctly prenotified patients from thrombolytic therapy., Conclusion: The accuracy of the new prehospital stroke criteria has higher PPV and specificity compared to previous CPSS validation studies., (Copyright © 2015. Published by Elsevier B.V.)

Background/purpose: To determine whether utilization of emergency medical service (EMS) can increase use and expedite delivery of the thrombolytic therapy in acute ischemic stroke patients., Methods: We analyzed consecutive patients presenting to the emergency department (ED) with an ischemic stroke within 72 hours of symptom onset from a prospective stroke registry. Variables associated with early ED arrival (within 3 hours of stroke onset) and administration of intravenous thrombolytic therapy were analyzed., Results: From January 1, 2010 to July 31, 2011, there were 1081 patients (62.3% men, age 69.6 ± 13 years) included in this study. Among them, 289 (26.7%) arrived in the ED within 3 hours, and 88 (8.1%) received thrombolytic therapy. Patients who arrived at the ED by EMS (n = 279, 25.8%) were independently associated with earlier ED arrival (adjusted odds ratio = 3.68, 95% confidence interval = 2.54-5.33), and higher chance of receiving thrombolytic therapy (adjusted odds ratio = 3.89, 95% confidence interval = 1.86-8.17). Furthermore, utilization of EMS significantly decreased onset-to-needle time by 26 minutes in patients receiving thrombolytic therapy., Conclusion: Utilization of EMS can not only help acute ischemic stroke patients in early presentation to ED, but also effectively facilitate thrombolytic therapy and shorten the onset-to-needle time., (Copyright © 2013. Published by Elsevier B.V.)

Background: To compare the management cost and cost-effectiveness of dabigatran with warfarin in patients with nonvalvular atrial fibrillation (AF) from the hospital's and patients' perspectives., Hypothesis: Dabigatran is more cost-effective than warfarin for stroke prevention of AF in Hong Kong., Methods: The analysis was performed in conjunction with a drug utilization evaluation of dabigatran study in a teaching hospital in Hong Kong. The study recruited 244 patients who received either dabigatran or warfarin for stroke prevention of AF. A cost-effectiveness analysis was performed and was expressed as an incremental cost-effectiveness ratio (ICER) in averting a cardiac event or a bleeding event. A sensitivity analysis was used on all relevant variables to test the robustness., Results: From the hospital's perspective, the dabigatran group had a lower total cost of management than that of the warfarin group (median: US$421 vs US$1306, P < 0.001) (US$1 = HK$7.75) and was dominant over warfarin. From the patients' perspective, the total cost of management in the dabigatran group was higher than that in warfarin group (median: US$1751 vs US$70, P < 0.001), and the ICER in preventing a cardiac or bleeding event of dabigatran vs warfarin was estimated at US$68,333 and US$20,500, respectively. If dabigatran was subsidized by the hospital, a higher cost would be incurred by the hospital (median: US$1679 vs US$1306, ICER (cardiac and bleeding events): US$15,163 and US$4549, respectively)., Conclusions: The study favored dabigatran for stroke prophylaxis in patients with nonvalvular AF in Hong Kong under the current hospital's perspective and provided a reference for further comparisons under patient and subsidization perspectives., (© 2013 Wiley Periodicals, Inc.)

Background: Dabigatran is an oral direct thrombin inhibitor recently approved for stroke prevention in atrial fibrillation (AF) as an alternative to warfarin. The primary advantages of dabigatran are freedom from monitoring and less interaction with other drugs and food. It is ideal for patients who are unwilling to adhere to regular coagulation monitoring or whose therapeutic effect using warfarin is not optimal despite adequate monitoring and management. However, the impact of dabigatran on health-related quality of life (HRQoL) and drug compliance has been less evaluated. This study aimed to evaluate the clinical and humanistic outcomes of dabigatran use in Hong Kong., Hypothesis: Dabigatran 110 mg twice daily was non-inferior in stroke prophylaxis in AF patients compared to adjusted-dose warfarin; while dabigatran 150 mg twice daily was superior to adjusted-dose warfarin in the real world data in Hong Kong., Methods: We retrospectively analyzed 244 patients with newly diagnosed AF and prescribed dabigatran (n = 122) or warfarin (n = 122) for stroke prophylaxis from the Prince of Wales Hospital between January 2010 to November 2011. Clinical outcomes including death, stroke, bleeding, and HRQoL using the EuroQol EQ-5D-5L were compared between patients on dabigatran and warfarin., Results: The median duration of follow-up was 310 days. Stroke occurred in 2 patients (1.64%) in the dabigatran group and 4 in the warfarin group (3.28%) (adjusted hazard ratio [HR]: 0.53, P = 0.47). Bleeding of any degree occurred in 28 patients on dabigatran and 38 patients on warfarin (adjusted HR: 0.76, P = 0.28), with age over 70 years and renal impairment being significant positive predictors of bleeding (P = 0.01 and 0.02, respectively). Dyspepsia was the most common adverse event of dabigatran over warfarin (19.7% vs 8.2%, P = 0.01). Rate of discontinuation of dabigatran was 25.4%, with dyspepsia being the most common cause for discontinuation (6 patients, 4.92%). There was no significant difference in drug compliance or HRQoL at 1 year between the 2 groups (utility score 0.77 [dabigatran] vs 0.74 [warfarin], P = 0.28)., Conclusions: In Hong Kong, the clinical efficacy and safety of dabigatran were comparable to that of warfarin, and drug compliance and HRQoL of using dabigatran and warfarin were similar after 1 year of use., (© 2012 Wiley Periodicals, Inc.)

Aim: To establish the psychometric properties of the Chinese version of the State Self-Esteem Scale in stroke patients., Background: Self-esteem is seen to enhance peoples' ability to cope with disease: low self-esteem may inhibit participation in rehabilitation and thus result in poor health and social outcomes. Although the Chinese version of the State Self-Esteem Scale has been used as an outcome measure for stroke rehabilitation, no study has examined its factor structure in this patient group., Design: A cross-sectional design., Methods: A convenience sample of 265 Chinese stroke patients (mean age 71·4, SD 10·3 years), with a minimum score of 18 out of a possible 30 for the Mini Mental State Exam recruited from two regional rehabilitation hospitals in Hong Kong. An exploratory factor analysis and an internal consistency analysis of the State Self-Esteem Scale were conducted. Pearson's correlation coefficients were calculated between the State Self-Esteem Scale and the Geriatric Depression Scale to determine convergent validity., Results: The final factor solution comprised a three-factor model with correlated constructs and accounted for 49·5% of the total variance. Significant negative correlations were found between the Geriatric Depression Scale and the State Self-Esteem Scale subscale scores (r-0·31 to -0·55, p < 0·01), indicating that the State Self-Esteem Scale had acceptable convergent validity. The new three-factor structure had higher Cronbach's alphas when compared with the original three-factor structure., Relevance to Clinical Practice: The State Self-Esteem Scale appears to be a useful measure for assessing state self-esteem in stroke patients. To establish the concurrent, discriminative and construct validities, the factor structure of the SSES could be further developed and tested., (© 2011 Blackwell Publishing Ltd.)

Aim and Objective: The primary aim was to examine the prevalence of poststroke depression in Chinese stroke survivors six months after discharge from a rehabilitation hospital. A second aim was to determine whether six-month poststroke depression was associated with psychological, social and physical outcomes and demographic variables., Background: There has been increasing recognition of the influence of depression on poststroke recovery. While some previous studies report associations between depression and social, psychological, physical and clinical outcomes, few studies had sufficient sample sizes for regression analysis thereby limiting the clinical applicability of their findings., Design: A cross-sectional design was used., Method: Data were collected from 124 male and 86 female stroke survivors (mean age 71.7, SD 10.2 years). The Geriatric Depression Scale was used to measure depression, the State Self-esteem Scale to measure state self-esteem, the London Handicap Scale to measure participation restriction, the Social Support Questionnaire to measure satisfaction with social support and the Modified Barthel Index to measure functional ability., Results: Forty-two survivors (20.5%) reported mild and 33 (16.1%) reported severe depression. The presence of depression was associated with low levels of state self-esteem, social support satisfaction and functional ability. Logistic regression analysis revealed that these variables were statistically significant in predicting the probability of having depression (p < 0.05)., Conclusions: Analyses in the present study revealed distinct patterns of correlates of depression, and the results were in agreement with prior studies that depression has a consistent positive association with physical disability, living arrangements and social support and no significant association with the different types of brain lesion., Relevance to Clinical Practice: There is a need, routinely, to assess stroke survivors for depression and, where necessary, to intervene with the aim of enhancing psychological and social well-being., (© 2010 Blackwell Publishing Ltd.)

Background: Apart from promoting physical recovery and assisting in activities of daily living, a major challenge in stroke rehabilitation is to minimize psychosocial morbidity and to promote the reintegration of stroke survivors into their family and community. The identification of key factors influencing long-term outcome are essential in developing more effective rehabilitation measures for reducing stroke-related morbidity. The aim of this study was to test a theoretical model of predictors of participation restriction which included the direct and indirect effects between psychosocial outcomes, physical outcome, and socio-demographic variables at 12 months after stroke., Methods: Data were collected from 188 stroke survivors at 12 months following their discharge from one of the two rehabilitation hospitals in Hong Kong. The settings included patients' homes and residential care facilities. Path analysis was used to test a hypothesized model of participation restriction at 12 months., Results: The path coefficients show functional ability having the largest direct effect on participation restriction (beta = 0.51). The results also show that more depressive symptoms (beta = -0.27), low state self-esteem (beta = 0.20), female gender (beta = 0.13), older age (beta = -0.11) and living in a residential care facility (beta = -0.12) have a direct effect on participation restriction. The explanatory variables accounted for 71% of the variance in explaining participation restriction at 12 months., Conclusion: Identification of stroke survivors at risk of high levels of participation restriction, depressive symptoms and low self-esteem will assist health professionals to devise appropriate rehabilitation interventions that target improving both physical and psychosocial functioning.