Purpose: In the United States, stroke is the leading cause of disability. The majority of survivors sustain permanent physical and/or cognitive impairments. Stroke survivors with impairments experience depression, loss of functional independence, and poor quality of life (QOL). Stroke disparities exist among different racial and ethnic groups of the US population. Latinos experience a first time stroke at a younger age compared to non-Latino Whites. As a result, Latinos live with impairments for a greater number of years. The vast majority of stroke survivors return to live in their communities. Reintegrating into home and social activities is key to survivors’ perceived QOL. This dissertation project sought to understand from an ecological framework the post-stroke community reintegration experiences of Latino older adults in an urban New York City neighborhood. The study also sought to examine the viewpoints of health and social service providers, whose opinions, actions, and programs can support stroke survivors’ reintegration into community. Methods: Qualitative in-depth interviews were conducted with 30 Latino stroke survivors 50 years of age and older who had experienced a disabling stroke within 36 months. In addition, 20 health and social service providers based in a large medical center, and multiple senior centers in the northern Manhattan section of New York City were interviewed. The stroke survivor data was analyzed using a phenomenological approach. A thematic analysis approach was used to analyze the data from the health and social service informants. Data analysis identified physical, psychological, social, and environmental factors pertinent to stroke survivors’ community integration experiences. These identified factors were categorized into macro-, exo-, meso-, and micro-levels to capture the psycho, social, and environmental ecology in which community reintegration takes place for Latino stroke survivors. Results: Qualitative accounts of survivors revealed several microsystem factors, including a struggle to maintain a positive self-concept and to engage in activities associated with valued identities and roles, while simultaneously suffering chronic pain, fatigue, and functional limitations. Changes in their affect lead survivors to socially isolate themselves. In addition, they relied more on women than men for social support, a salient mesosystem factor. Survivors encountered significant exosystem level barriers in the environment that limited their ability to travel and access activities. For some, these barriers inadvertently left survivors homebound. Survivors also encountered a societal culture, a macrosystem factor, which stigmatized them due to their impairments. Interviews with health and social service professionals revealed various factors that influenced community reintegration of people with stroke. At the macrosystem level, funding for programs and healthcare financing dictated services and eligibility criteria. In the exosystem, a segmented medical model of care postponed the conversation on community integration. Professional practices, organizational level constraints and culture were mesosystem level factors that influenced community reintegration. The confluence of these factors created an ecological system that influenced stroke survivors’ opportunities to socially engage in their home and community life. Conclusion: An ecological approach provides a useful framework to understand the complexity and potential interplay of factors that contribute to community integration post-stroke for Latino older adults in an urban area.

This thesis investigated planned nursing intervention based on a detailed assessment to determine whether this would result in stroke patients and their families having a better understanding of pathology, a shorter hospitalization, and the ability to cope with minor problems and activities of daily living when discharged. An experimental group supervised by the author was compared with a control group. In addition, the patient's initial and discharge level of independent function was compared with the control group.The investigation revealed that there was a positive relationship between planned nursing intervention and the increase in knowledge of pathology, ability to cope with minor problems and the activities of daily living. The hypothesis that a shorter hospitalization would result for the experimental group was not proven. All patients increased their level of independent function. The experimental group had a higher level of independent function at discharge than the control group.Ball State UniversityMuncie, IN 47306

Background: With the increasing incidence in stroke and the resultant high prevalence of residual disability resources are not adequately meeting the needs of the patients. Furthermore patients continue to express dissatisfaction with their care. New interventions are being developed and evaluated. However, when offered these new interventions, patients may refuse or not participate fully. A stroke workbook intervention was developed through a line of research examining the role of perceived control in recovery. During the randomised controlled trial (RCT) evaluating its efficacy patients failed to fully participate in the activities proposed in the workbook. Why, when there is such a dearth of treatment available, do stroke patients not fully participate in or adhere to the interventions offered? Methods: Three studies were conducted, a predictive study using the intervention group of the RCT exploring the demographic, clinical and psychological factors predicting adherence; a predictive study using one of the intervention groups from a larger 2x2 RCT to examine the predictors of adherence to an easier intervention (video); and a third longitudinal study examining the efficacy of an even simpler intervention (letter) on increasing adherence to the video. The theoretical framework of Leventhal's Self Regulation Model was used to develop the letter intervention and to explain the findings. Results: Five types of adherence behaviours emerged from the three studies, all with their own difficulties of definition, measurement and their individual predictor variables. Gender, impairment and illness representations were all predictive of adherence. An easier intervention promoted adherence especially for men and the more impaired. Women appeared to adhere more readily to the complex intervention. These gender differences may be associated with illness representations. A theoretical-based letter does not increase adherence per se but may increase the amount of adherence to an easier intervention. Conclusion: Adherence behaviour is not one type of behaviour and is associated with measurement difficulties. The Self-Regulation model appeared to offer some logical explanations to the findings. The findings have clinical implications and could possibly be associated with patients' satisfaction with care.

published_or_final_version / Nursing Studies / Master / Master of Nursing

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Public Health / Master / Master of Public Health

Background and Purpose Stroke is the loss of brain’s function caused by hypoxia of brain cells depending on the severity and the location of the stroke. In Hong Kong, strokes are the 4th leading cause of death and morbidity in the year of 2010. Dysphagia is a common morbidity related to stroke. Approximately, 50% of stroke patients with dysphagia are suffered with aspiration and aspiration pneumonia which may lead to increased length of stay in hospitals, mortality rate and medical costs. An early nursing dysphagic screening and assessment protocol can help in early detect of dysphagia and therefore help to reduce incidence of aspiration and pneumonia. In order to understand the effectiveness of the nursing dysphagic screening and assessment protocol for the acute stroke patients, a number of studies have been reviewed to gather evidences for the translational research. A bedside nursing swallowing screening and assessment for patients with stroke is developed by incorporating findings from the literature review. Review Question In comparison to the routine care, is the nursing dysphagia assessment intended for the acute stroke patients more effective in reducing (1) the waiting time for having swallow assessment and the (2) the incidence of aspiration and pneumonia? Methods A systematic review of literatures from Ovid Medline (from 1946 to 2012), Pubmed (all dates), CINAHL Plus (from 1971 to 2012) and China Journal Net (from 1912 to 2012) was conducted. Five studies of bedside swallow screening and assessment that can be performed by nurses were selected and critically appraised using the recognized assessment criteria. Results The key components identified from the reviewed studies including swallowing assessment should be performed by trained nurses and acute stroke patients should be alert and able and can keep the sit up position during the swallowing assessment. Moreover, water swallowing test must be included as a part of the swallow assessment and assessment should best be performed in daily basic. Patients should be keeping nil of mouth when they failed the screening and referred for further assessment and management. Implementation potential in terms of transferability, feasibility and the cost benefit ratio of the proposed innovation were assessed. A communication plan was developed for the integration of the proposed innovation into the clinical setting. Outcome measures such as positive predictive value of detecting dysphagia, mean waiting time of waiting the initial swallow screening, occurrence of pneumonia, staff knowledge and compliance were identified to evaluate the effectiveness of the proposed innovation and guideline. Conclusion The findings of this systematic review showed that the nursing dysphagic swallow screening and assessment is effective in detecting the dysphagia of the acute stroke patients. Further development of the proposed innovation will be conducted in the clinical setting in order to satisfy the needs of the acute stroke patients. / published_or_final_version / Nursing Studies / Master / Master of Nursing

The efficacy of stroke units has been extensively investigated in clinical trials. However, little information is available to the health care providers and policy makers on the benefits of stroke unit care in Hong Kong. The quality of life of our local stroke patients is largely unknown. The objective of this study was to compare the 2-month outcomes after stroke admitted to either a stroke unit or a non-stroke unit. Outcomes included mortality, dependency, institutional care and quality of life. This was a prospective observational study conducted in a regional, tertiary hospital in Hong Kong. Baseline demographic and clinical data were collected from the subjects. The 36-Item Short-Form health survey (SF-36) questionnaire was administered to them. Follow up assessment at two months were made for mortality, dependency, institutionalisation, length of hospital stay and SF-36. Eligible subjects were Cantonese-speaking Chinese aged 18 years or over. They should provide written informed consent, and verbally and cognitively competent in completing the SF-36 questionnaire 162 patients with acute stroke were included in the analysis. 106 patients were solely managed in the stroke unit. 41 patients were managed in other wards (as the control group). There were no statistically significant differences found between the two groups for death alone, death or dependency, and death or institutionalisation. Multivariate logistic regression analyses showed similar findings. Mean lengths of acute and total hospital stay were similar between the two groups. Quality of life was impaired during the acute phase of stroke as reflected by low Physical Functioning (PF) and Social Functioning (SF) dimensions of the SF-36. At two months, significant improvement was observed in five out of eight dimensions of the SF-36 as well as its two summary scores, Physical Component Summary (PCS) and Mental Component Summary (MCS). There were several limitations in our study, namely small number of patients, minor stroke severity and tertiary hospital setting. In conclusion, no significant differences in the clinical outcomes were found between the stroke unit group and the control group. These findings were inconclusive in view of limitations in this study. Stroke affected quality of life. Future researches with larger sample size are warranted. / published_or_final_version / Public Health / Master / Master of Public Health

OBJECTIVES: The primary objective of this study was to evaluate the effectiveness of of oral health promotion interventions on both clinical oral health, and oral opportunistic pathogens in hospitalized patients following acute stroke. Secondary objectives were to investigate the development of infectious complications, as well as health-related quality of life during the hospitalization period, and to monitor clinical oral health, oral opportunistic pathogens, and health-related quality of life following hospital discharge. METHODS: A total of 102 patients were recruited into a clinical trial conducted among stroke patients in a rehabilitation ward. Patients were randomly assigned either: 1) oral hygiene instruction 2) oral hygiene instruction and chlorhexidine mouthrinse or 3) oral hygiene instruction, chlorhexidine mouthrinse, and assisted brushing. Dental plaque, gingival bleeding, oral opportunistic pathogens, health-related quality of life, oral health-related quality of life, and functional status were assessed at baseline and review. The development of infectious complications was also monitored during the clinical trial. Patients completing the clinical trial were assessed at six months following hospital discharge. RESULTS: Eighty-one patients were available for review at the end of the clinical trial. Reductions in dental plaque (PI) scores were significantly greater in the two groups receiving chlorhexidine compared to the group receiving oral hygiene instruction alone (p<0.001). Reductions in gingival bleeding (GBI) scores were three to four-fold greater in groups receiving chlorhexidine. Almost three quarters (72.8%) of patients harbored oral aerobic and facultatively anaerobic Gram-negative bacilli (AGNB) at baseline. Over half of the patients had detectable Staphylococcus aureus (56.8%) and yeasts (59.3%). Percentage frequencies and viable counts of pathogens remained relatively stable during the course of the clinical trial, and no significant differences were observed between groups (p>0.05). No cases of pneumonia were observed during the course of the clinical trial. Health-related quality of life (p<0.001), oral-health related quality of life (p=0.014), general functional disability (p<0.001), and toothbrushing ability (p=0.001) improved significantly during hospitalization. A total of 52 patients were reviewed six months following hospital discharge. PI scores were significantly higher than those observed at the end of the clinical trial (p<0.001), but were still significantly lower than those documented at baseline (p<0.001). Changes in GBI scores did not reach statistical significance (p>0.05). Percentage frequencies of AGNB (p=0.001), and viable counts of both AGNB (p<0.001) and yeasts (p=0.028) were significantly reduced at six months. No significant gains in life quality or oral functional disability were observed following hospital discharge (p>0.05). CONCLUSIONS: The clinical oral health condition of stroke patients may be safeguarded following acute stroke with the use of chlorhexidine mouthrinse in conjunction with a standard mechanical plaque removal regimen. These interventions are acceptable to the majority of patients, and their administration poses a minimal burden to rehabilitation ward staff. There was, however, no significant difference in the effectiveness of the three different oral health promotion interventions in combating oral opportunistic pathogens. Gains in quality of life and oral functional disability were largely limited to the in-hospital rehabilitation period. / published_or_final_version / Dentistry / Doctoral / Doctor of Philosophy

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences