Development of a continuing care model for older adults with stroke in can tho city, viet nam

DEVELOPMENT OF A CONTINUING CARE MODEL FOR OLDER ADULTS WITH STROKE IN CAN THO CITY, VIET NAM TRAN THI HANH 5437497 PHPH/D Dr.P.H.. This mixed method research was conducted to determine

VIET NAM

TRAN THI HANH

A THESIS SUBMITTED IN PARTIAL FULFILLMENT

OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PUBLIC HEALTH

FACULTY OF GRADUATE STUDIES

MAHIDOL UNIVERSITY

2017

COPYRIGHT OF MAHIDOL UNIVERSITY

I would like to express my gratitude to Assoc Prof Dr Somporn Kantharadussadee Triamchaisri, who had provided me an opportunity to be in the program I would like to express the deepest appreciation to Associate Professor Dr Punyarat Lapvongwatana for her valuable lessons, insightful comments and suggestions with hearted concerns on her students

I am deeply grateful to Associate Professor Dr Nitaya Vajanapoom, Associate Professor Nawarat Suwannapong, Associate Professor Dr Ratchneewan Ross and Lecturer Dr Cua Ngoc Le, my dissertation exam committee, for their encouragement, suggestions and comments on my dissertation were invaluable

Special thanks go to Professor Dr Pimpan Silapasuwan, Associate Professor

Dr Sunee Lagampan and other faculties, for their constructive comments and warm encouragement; to Dr.Surat Boonyakarnkul and Ms Puangpaka Panyo for their kindness and conscientiousness during my developing intervention tools; to our staffs in Dr.PH program and Public Health Nursing Department for their supportings

I would also like to thank Can Tho City People Committee and Can Tho Medical College, who created advantages for my participating in the program; and thanks

my coordinators, my colleagues, my families and my friends, especially my husband during my intensive learning experience

Lastly, it is greatly happy to dedicate my achievement to my late parents' soul, whose morality and lives had oriented my direction of better care for the disabled people Last but not least, special thanks and appreciation for my stroke patients and their families for their great contribution in my research

Tran Thi Hanh,

DEVELOPMENT OF A CONTINUING CARE MODEL FOR OLDER ADULTS WITH STROKE IN CAN THO CITY, VIET NAM

TRAN THI HANH 5437497 PHPH/D

Dr.P.H

THESIS ADVISORY COMMITTEE: KWANJAI AMNATSATSUE, PhD.,

PATCHARAPORN KERDMONGKOL, PhD., RATCHNEEWAN ROSS, PhD., CUA NGOC LE, Dr.PH

ABSTRACT Stroke management has become a public health challenge worldwide because of its severity and impacts, in particular among older adults This mixed method research was conducted to determine the components of the continuing care model (CCM) and to evaluate its effects on older adults with stroke in Can Tho City, Vietnam Based on data from the situation analysis and brainstorming with key stakeholders, the CCM model has seven components, including continuing care management, family caregiver’s training, family caregiver’s support, resource allocation, monitoring for stroke patient care, activities of daily living (ADLs) and rehabilitation care, and family reintegration Among 31 older adults with stroke received a 12-week intervention whereas a comparison group (n=46) received usual care The effects of the model were measured among 55 subjects in terms of older adults with stroke’s self-care agency, functional outcome, quality of life and complications using standard questionnaires According to Mann-Whitney Test, self-care agency, quality of life, functional outcome, and dysphagia among the intervention group have been siginicantly improved comparing with the comparison group (p<0.05) The findings support that the proposed CCM can improve stroke outcomes for older adults with stroke in Can Tho city

KEY WORDS: OLDER ADULTS WITH STROKE / SELF-CARE AGENCY /

QUALITY OF LIFE / FUNCTIONAL OUTCOME

185 pages

2.2.Situation of stroke and its management in Vietnam 202.3.Theories and models related to stroke management 282.4.Researches related to stroke outcomes and interventions 332.5.Theoretical and interventional application in the study 40

4.1.Situation analysis of care for older adults with stroke in

Can Tho City, Vietnam

76

4.2 Development of a Continuing Care Model for Older Adults

with Stroke in Can Tho City, Vietnam

LIST OF TABLES

2.2 The numbers of stroke patients hospitalized in Can Tho City

in the study

48

3.1 Purposive Sampling Distribution in Phase 2: Health professionals

and key stakeholders

59

4.1 Matching findings from Phase 1-2 by continuing care model’s

components

80

4.3 Description for model implementation’s activities 864.4 The activities related to the final CCM’s components by

segments of the continuum of care

88

4.5 The activities related to the final CCM’s components by

segments of the continuum of care

89

4.6 Comparison for characteristics of subjects between groups 954.7 Stroke outcomes among comparison and intervention group 974.8 Severity of functional outcome before and after model

implementation

98

4.9 Model’s effects in comparing stroke outcomes within group 100

LIST OF TABLES (cont.)

4.10 Stroke outcomes between comparison group and intervention

group

103

5.1 The Chronic Care Model (Fiandt, 2006) and the final Continuing

Care Model for older adults with stroke: Components and

adaptation

108

LIST OF FIGURES

2.3 OAWS’s seeking health services after stroke onset 27

3.3 Number of subjects classified by groups and time 58

b Learning how to prevent complications from stroke 65

d Learning how to manage stroke patients after discharge in

Khonkean province

66

g Discussion for process of Discharge Plan in Emergency

Department of Thoi Lai District Hospital

67

h Meeting Thoi Lai District Hospital’s Administration Team for

process of Discharge Plan

67

i Training workshop to standardize contents on teaching 67

k Basic tools for practising physical therapies 67

l Mobilizing participation from Thoi Lai District’s Red Cross

LIST OF FIGURES (cont.)

3.4 a In-depth interviewing a family caregiver 69

o In-depth interviewing nurse leaders in Can Tho City Hospital 69

3.6 The process for Model Implementation and Evaluation 755.1 The Continuing Care Model developed in the study after testing 122

LIST OF ABBREVIATIONS

AHA American Heart Association

SOC Stroke Outcome Classification

ASDS Asian Stroke Disability Scale

BADL Basic Activities of Daily Living

CHS Commune Health Station

DALYs Disability Adjusted Life Years

FES First-Ever-Stroke

HBCM Home-Based Care Model

IFSMT Individual & Family Self-Management Theory

MRS Modified Ranking Scale

NIHSS National Institutes of Health Stroke Scale

SF 36 Medical Outcomes Study Short Form 36

LIST OF ABBREVIATIONS (cont.)

SS-QOL Stroke Specific Quality of Life Scale

OAWS Older Adult With Stroke

SM Self-Management

YLL Years Life Lost

CHAPTER I INTRODUCTION

Stroke management has become a public health problem worldwide In order to improve stroke outcomes for the older adults after stroke, a mixed method study will be conducted in Can Tho City, Vietnam This chapter presents background and significance of stroke and its management, research questions, objectives, expected outcomes and operation definition

1.1 Background and significance

Stroke is a major public health burden worldwide (Warlow, Sudlow, Dennis, Wardlaw, & Sandercock, 2003) It is the second leading cause of death in

2015, occupied 11.1% of death in the world (WHO, 2015) and is the leading cause of acquired disability in adults (Mendis, 2013) When adjusted to the World Health Organization world standard population, incidence rates for stroke ranged from 41 per

100 000 population per year in Nigeria to 316/ 100 000/year in Tanzania (Thrift et al., 2014) It is one of the most demanding public health problems to be faced in the upcoming years particularly for population ageing; stroke incidence increases with age and is likely to increase in the ageing populations The contribution of very old subjects to the global burden of stroke is relevant (Russo, Felzani, & Marini, 2011)

Rates of stroke mortality and burden vary greatly among countries, but low-income countries are the most affected (Johnston, Mendis, & Mathers, 2009; Strong, Mathers, & Bonita, 2007) It was found a statistically significant trend in stroke incidence rates over the past four decades, with a 42% decrease in stroke incidence in high-income countries and a greater than 100% increase in stroke incidence in low to middle-income countries (Feigin, Lawes, Bennett, Barker-Collo, & Parag, 2009) About 85% of all stroke deaths are registered in low- and middle-income countries, which also account for 87% of total losses due to stroke in terms of

disability-adjusted life years (DALYs), calculated, worldwide, in 72 million per year (Di Carlo, 2009) The impact of stroke as measured by disability-adjusted-life-years lost and mortality rate is >3-fold higher in low-income compared with high- and middle-income countries (Brønnum-Hansen, Davidsen, Thorvaldsen, & Group, 2001)

Stroke leads serious consequence to their victims, brings about burden to their families and causes socioeconomic lost to their community It had been found that the estimated cumulative risks for death at 28 days, 1 year, and 5 years after onset were 28%, 41%, and 60%, respectively (Brønnum-Hansen et al., 2001) In general, stroke survivors’ years of life lost is 6 years approximately (Truelsen, Begg, & Mathers, 2000) If secular trends continue, it is estimated that there will be 23 million first-ever strokes and 7·8 million stroke deaths in 2030 (Mendis, 2013) The majority

of stroke survivors could not perform their daily activities and require caregiver assistance for basic needs (Rouillard, De Weerdt, De Wit, & Jelsma, 2012) The direct costs of stroke, both for primary and secondary events, constitute the larger part of healthcare expenditures (Spieler & Amarenco, 2004)

In Asia, the incidence and prevalence of stroke are increasing steadily (Thammaroj, Subramaniam, & Bhattacharya, 2005) Stroke in Asia ranked as the 1stleading cause of death in all countries except Malaysia (Hoy, Rao, Hoa, Suhardi, & Lwin, 2012) Among Asian countries, the highest mortality rates of stroke were reported in Vietnam in 2009 (N.Venketasubramanian, 2009)

Vietnam is in the process of the establishment to improve the strategy against stroke (Michael Brainin, 2011), limited resources for stroke management in Vietnam have been identified (Thính, Lực, Xuyên, Brainin, & Anh, 2008) Before

2008 there was virtually no structures stroke care existing in Vietnam (Michael Brainin, 2011), there was only 50% of provincial hospitals have stroke units; 82.9% stroke victims whose diagnosis confirmed by CT Scan or MRI (Thính et al., 2008) Evidence on rehabilitation programs especially for stroke survivors in Vietnam has rarely been found out

Estimates for some localities in Vietnam indicate that incidence and mortality from stroke are rising It was found that the crude annual incidence rate of total first-ever stroke (FES) in Central Vietnam was 90.2 per 100,000 population (Yamanashi et al., 2016) and the most common risk factors for stroke in the nation

was old age (Triệu, Vẽ, & Hạnh, 2009) In Bavi district of Hatay province, stroke mortality rate is estimated at 73/100,000 population In Hanoi and HCMC, mortality rates are much higher, at around 131/100,000 population (T V T Tran Thi Mai Oanh, Duong Huy Luong, et al , 2009) In Danang, a 28-day crude mortality of 37% was reported among stroke patients registered and the proportion of confirmed hemorrhagic strokes was nearly 50% (Tirschwell et al., 2012) In Can Tho City, stroke has a tendency of increasing rapidly in recent years Stroke incidence increased from 29.96 per 100,000 populations in 1985 to 415.23 per 100,000 populations in 2004 (Tâm, 2005); stroke mortality increased from 5.0 per 100,000 population in 2007 to 19.7 per 100,000 population in 2010 (Truyền, 2011) Vietnamese stroke patients’ mean age was 69 years (Ngọc & Anh, 2013)

Stroke management in Can Tho City is limited There is only one stroke unit among nine district general hospitals (Tham, 2013) Most of the stroke victims are older adults and are treated in an emergency department, at which almost healthcare professionals are non-specialized in stroke field (Giao, 2012; Tham, 2013) Therefore, preparation for stroke family caregivers by stroke unit’s multidisciplinary team has not been performed

Care for stroke survivors has not been extended beyond hospital after discharge It has not been found out evidence on health care services, following, monitoring from the hospital for stroke survivors after discharged to their home Most

of their family caregivers have to self-manage to cope with this care transition

Particularly for the older patients, stroke incidence increases with age, also

in the very old (Hollander et al., 2003) The prevalence of silent cerebral infarction in

a group of 55 and 64 years is about 11% This prevalence increases in each of older groups and reach 43% in groups of 85 and over (Association, 2006; Rosamond et al., 2007) Thus, older adults with stroke have to face more severe impacts than those in younger age There is a significant impact of age on the therapeutic efficacy of bone marrow-derived mononuclear cells after cerebral ischemia (Wagner et al., 2012) Age may predict poor neurological/functional outcome in stroke (Giantin et al., 2011)

As a result in stroke outcomes in the Can Tho City, the percentage of impairment and disability of stroke survivor in the city is higher than that in the whole country, (40% (Truyền, 2011) versus 12% (Misbach, 2001 ); the percentage of SS

alive and improved in the City is lower than the whole country (15% (Truyền, 2011) versus 62% (Misbach, 2001 ) Among stroke survivors cared at home in the City, those interrupting treatment for stroke occupied 20% (Truyền, 2011)

Limited resources for stroke management in Vietnam have been identified

in spite of the nation’s endeavours Stroke management were mostly provided in provincial hospitals (Michael Brainin, 2011)(Michael Brainin, 2011)(Michael Brainin, 2011)(Michael Brainin, 2011)(Michael Brainin, 2011)[16][16][16], continuous training to empower and establish stroke unit at district or commune level is limited in the country (Thính et al., 2008; Tran Thi Mai Oanh et al., 2010) Lacking heath professional specified in stroke and rehabilitation is another challenge, particularly in the primary care settings, which lead to inadequate rehabilitation after returning home (JICA & Hospital, 2011)

Stroke survivors, suffering from moderate to severe impairment, as well as some, being so disabled, require ongoing placement in long-term care facilities (Tourangeau et al., 2011) Then, continuing care, “the extent to which services are received as part of a coordinated and uninterrupted succession of events consistent with the medical care needs of patients” (Hill, House, & Hewison, 2008), should include those services aimed at preserving and maintaining their functional abilities (Beland & Bergman, 2000)

Thus, care after hospital discharge for OAWS in Can Tho City needs to be improved Preparation for stroke family caregivers to cope with care transition and rehabilitation plan for OAWS after their OAWS discharged from hospital has not been performed Skilled nursing care and monitoring for OAWS have been interrupted after discharge Self-management of OAWS and their family caregivers have not been supported by hospitals All could lead to poor stroke outcomes for OAWS in the City This requires the development of a model of care after hospital discharge for OAWS

in the City to ensure appropriate care

2) After model implementation, the older adults with stroke in the intervention group had better self-care agency than before the implementation and than those who are in the comparison group

3) After model implementation, the older adults with stroke in the intervention group had better functional outcomes than before the implementation and than those who are in the comparison group

4) After model implementation, the older adults with stroke in the intervention group had less complication than before the implementation and than those who are in the comparison group

1.5 Operational definitions

An older adult with stroke in the study referred to those who were aged

60 and over with first-ever-stroke diagnosed as either ischemic stroke or hemorrhagic stroke, who registered at the selected hospitals in Can Tho (Appelros & Viitanen, 2004; Lee et al., 2009; Lindgren, Jönsson, Norrving, & Lindgren, 2007)

The continuing care model referred to a model of care consisting of the

degree to which the care/services needed is coordinated among practitioners and across organization and time (JCAH, 1995) This study defined Continuing Care Model as any care/services provided to the older adults with stroke since the 72h after hospital admission and 3 months after discharge to their homes, aiming to ensure better stroke outcomes Both primary care and speciality care, which was extended from hospital to the OAWS’s home and performed collaboratively by the multidisciplinary team (MT) from hospitals (Gurr, 2009) with family caregiver engagement

Effects of the continuing care model referred to the significant changes

in stroke outcomes between the comparison group and the intervention group before and after the 3-month implementation of the Continuing Care Model In this study, effects of the model were measured in terms of quality of life, self-care agency, functional outcomes, and complications

Quality of life (QoL) referred to the degree of physical and mental health

perceptions of the older adult with stroke QoL is measured in terms of general health perceptions, physical functioning, role limitations due to physical problems, bodily pain, vitality, social functioning, role limitations due to emotional problems and

mental health (Kranciukaite & Rastenyte, 2006; Post et al., 2011)

Self-care agency in the study referred to OAWS’s ability to perform

self-care activities to promote and maintain his/her health (Butler, 2010; Damasio &

Koller, 2013) and to be measured by Appraisal Of Self-Care Agency Scale-Revised (ASAS-R) (Sousa et al., 2010)

Functional outcomes referred to the ability of stroke patients to function

without assistance It was measured by the National Institutes of Health Stroke Scale (NIHSS) (Kwah & Diong, 2014) in the recombinant tissue plasminogen activator stroke trials

Complications from stroke referred to the symptoms occurred during the

3-month implementation, which were dysphagia, pressure ulcers, and pain

Dysphagia was defined as being measured with Diagnostic Criteria for

Functional Dysphagia in Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders (Peppas, Alexiou, Mourtzoukou, & Falagas, 2008) The patients are diagnosed as Functional Dysphagia Disorders when having all of 3 criteria fulfilled for the last 3months with symptom onset

Pressure Ulcers referred to a localized injury to the skin and/or

underlying tissue usually over a bony prominence that was categorized by 4 stages of

© 2007 NPUAP (The National Pressure Ulcer Advisory Panel) (Lyder & Ayello, 2008)

Pain in the study was defined as the perceived level of pain reported by

the older adults with stroke

CHAPTER II LITERATURE REVIEW

In order to improve outcome of stroke management, a continuing care model was developed and examined for its effects on the older adults with stroke in Can Tho City, Vietnam This chapter presented literature review as follows:

2.1 Stroke and stroke management

2.2 Situation of stroke and its management in Vietnam

2.3 Theories and models related to stroke management

- Continuing care model

- Chronic Care model

- Discharge plan

2.4 Researches related to stroke outcomes and management

- Self-care agency and its intervention

- Quality of Life and its intervention

- Functional outcome and its intervention

- Complications from stroke and its intervention 2.5 Theoretical and intervention application in the study

2.6 Conceptual Framework

2.1 Stroke and stroke management

2.1.1 Stroke definition, symptoms and diagnosis

World Health Organization has defined a stroke as "rapidly developing clinical signs of focal disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin” (Truelsen, Begg, & Mathers, 2000; Strong, Mathers, & Bonita, 2007; Feigin, Lawes, Bennett, Barker-Collo, & Parag, 2009; Rouillard, De Weerdt, De Wit, &

Jelsma, 2012; Tirschwell, Kukull, & Longstreth Jr, 1999; Johnston, Mendis, & Mathers, 2009; Thành, Liên, Tân, & Tuấn, 2011; Michael Brainin, 2011; Thính, Lực, Xuyên, Brainin, & Anh, 2008) A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue” (WHO, 2013) There are two types of stroke known as primary and secondary stroke based on the first time or more than one time to suffer a stroke (Deaton et al., 2011; Truelsen et al., 2000) Unlike many other cells in the body, when brain cells die, they cannot be replaced

The two broad categories of stroke, haemorrhaged and ischemia are diametrically opposite conditions: haemorrhage is characterized by too much blood within the closed cranial cavity, while ischemia is characterized by too little blood to supply an adequate amount of oxygen and nutrients to a part of the brain (Caplan, 2012)

The most common symptom of a stroke is sudden weakness or numbness

of the face, arm or leg, most often on one side of the body Other symptoms include confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; a severe headache with no known cause; fainting or unconsciousness The effects of a stroke depend on which part of the brain is injured and how severely it is affected A very severe stroke can cause sudden death (WHO, 2012)

The diagnosis of stroke involves a medical history and a physical examination Tests are done to search for treatable causes of a stroke and help prevent further brain damage A CAT scan (a special X-ray study) of the brain is often done to show bleeding into the brain; this is treated differently than a stroke caused by lack of blood supply A CAT scan also can rule out some other conditions that may mimic a stroke A sound wave of the heart (echocardiogram) may be done to look for a source

of blood clots in the heart Narrowing of the carotid artery (the main artery that supplies blood to each side of the brain) in the neck can be seen with a sound wave test called a carotid ultrasound Blood tests are done to look for signs of inflammation which can suggest inflamed arteries Certain blood proteins are tested that can increase the chance of stroke by thickening the blood (MedicineNet, 2011)

In this study, both ischemic stroke and haemorrhagic stroke will be recruited in the Continuing Care Model

2.1.2 Stroke treatment

The most effective stroke treatments can only be given within the first few hours after a stroke has occurred There are two main types of stroke treatment: Treatment of ischemic stroke and Treatment of haemorrhagic stroke (Vega, 2009)

Treatment of Ischemic Stroke

The treatment of ischemic stroke aims to dissolve, remove, or shatter a blood clot that is preventing blood from reaching an area of the brain The most common treatments for ischemic stroke are the following:

Thrombolytic: Thrombolytic (fibrinolytic) drugs help reestablish blood

flow to the brain by dissolving the clots which are blocking the flow In June 1996, the

“clot-buster” Activase® (Alteplase recombinant) became the first acute ischemic stroke treatment to be approved by the Federal Food and Drug Administration (FDA) Activase is also known as tissue plasminogen activator (tPA) To be effective, thrombolytic therapy should be given as quickly as possible (Vega, 2009; Walker, 2012)

TPA (Tissue plasminogen activator, tPA): tPA is an enzyme found

naturally in the body that converts, or activates, plasminogen into another enzyme to dissolve a blood clot It may also be used in an IV by doctors to speed up the dissolving of a clot TPA should be given within three hours of symptom onset It is important for people to understand stroke warning signs and get to a hospital FAST in case they are eligible to receive TPA Time is an important factor associated with determining whether a patient can receive it or not (Vega, 2009; Walker, 2012)

MERCI Retrieval System: The system can be used for patients who are

beyond the 3-hour time window for IV-tPA and it does not have a time limit for its intended use This device offers physicians and patients long-awaited options for stroke intervention and creates a departure from the historic method of caring for stroke patients The Merci Retriever has repeatedly been proven to restore blood flow

in the larger vessels of the brain by removing blood clots (Vega, 2009; Walker, 2012)

Penumbra System: The system allows for safe revascularization of

occluded vessels after an ischemic stroke and also helps restore brain blood flow by using suction to grab blood clots in the brain for treatment of acute ischemic stroke The Penumbra System is a device that is effective if used within eight hours of symptom onset (Vega, 2009; Walker, 2012)

Treatment of haemorrhagic stroke

In a hemorrhagic stroke, the goal is to (1) get the blood pressure under control and (2) correct the cause of the haemorrhage and protect the brain from further damage The haemorrhage causes blood to pool in the brain and thus increases pressure on the brain The doctor will give diuretic drugs to minimize the temporary swelling of the brain tissue Rarely is surgery recommended, but if tests detect an aneurysm, the surgeon may clamp an aneurysm at its base and then remove it The surgeon now has the option to use a catheter, containing a metal coil that passes through the blood vessel in the neck The metal coil causes an aneurysm to clot and seal itself off (Truste, 2009)

2.1.3 Alternative therapies for stroke treatment

In Western medicine, no single form of complementary or alternative medicine (CAM) is commonly used to manage post-stroke rehabilitation or recovery

In East-Asian countries, however, alternative therapies including acupuncture,

massage, yoga, herbal medicine and more are widely used A recent survey reported that 46% of stroke patients use some form of CAM such as herbal medicine, acupuncture-type treatments or chiropractic treatments (Kim, Choi, Lee, Lee, & Han, 2010)

Acupuncture: Acupuncture is an ancient practice in which tiny needles

are inserted painlessly in the skin at designated points to stimulate your body's nerves and muscles Acupuncture can help to relieve pain and get the blood flowing more Acupuncture can be used to help treat difficulties with language and swallowing, as well as paralysis Acupuncture is a common part of stroke treatment in Japan and China (Rodriguez, 2013)

Massage: Massage is known to help with stress reduction and combat

feelings of depression, both of which are common emotional health concerns of stroke patients Keeping stress and depression under control is an important part of stroke treatment, for both mental and physical well-being (Rodriguez, 2013)

Herbal medicines: There are studies being done to determine whether

commonly used Chinese herbal medicines are actually effective as stroke treatments It

is thought that these medicines may boost blood flow in the brain and offer other protective benefits against ischemic stroke But use caution: Further testing needs to

be done because studies to date just don't show enough evidence to either support or oppose using these medications Some herbal medicines that need further study (Rodriguez, 2013)

Aromatherapy: The benefits of aromatherapy as stroke treatment have

not been extensively studied, but one very small recent study did consider the use of aromatherapy along with acupressure another alternative method involving applying pressure to certain points on the body to relieve pain and other symptoms (Rodriguez, 2013)

Tai chi and yoga: Tai chi is a martial art that requires balance and the use

of both sides of the brain This soothing form of exercise makes the mind and body work together to perform coordinated movements, which can benefit stroke patients Yoga is a great stress reducer, and it may also help improve speech, balance, and dexterity An extremely small recent study found that stroke patients saw benefit in each of those areas after taking consistent yoga classes (Rodriguez, 2013)

2.1.4 The continuum of stroke care

It was recommended that patient, family and caregiver education, an integral part of stroke care, should be addressed at all segments across the continuum

of stroke care (Casaubon et al., 2015), as in Figure 2-1

Figure 2.1 Segments of the continuum of stroke care

Evidence shows that after 72 h, post-acute strokes, which is defined as “the period of time immediately after discharge from acute care”, a stroke patient has achieved medical stability and the focus of care becomes rehabilitation (Duncan et al., 2005) In addition, a period of enforced bed rest lasting between 1-3 days post stroke

is recommended to avoid complications from immobilization after stroke (Bernhardt, 2008) Therefore the intervention in the study was conducted at post-acute stroke or after 72h since stroke onset

2.1.5 Measurement of stroke outcomes among older adults with stroke

From the literature review, stroke outcomes among the older adults with stroke can be categorized as Quality of Life, Functional outcomes, Self-care agency and Complications

2.1.5.1 Quality of Life

The term Quality of Life is understood very differently in everyday life and in research Therefore, a prior precise definition of the term is crucial for its scientific use Based on a fundamental WHO definition on health, Quality of Life includes the physical, psychological, and social condition of an individual (Kranciukaite & Rastenyte, 2006) However, it was recommended that researchers should be as specific and clear as possible about the concept and operationalization of QoL in their studies Readers should not take the term “quality of life” for granted but should inspect the topic of the study from the actual measures used (Post, 2014)

Quality of Life of stroke survivors may have some differences among authors Quality of Life of stroke survivors is low at stroke onset, increases

steadily during the first 6 months and little between 6 months (Jaracz & Kozubski, 2003) and 12 months post-stroke (Gbiri & Akinpelu, 2012) Another group of authors found that health-related quality of life appears to be relatively good for the majority

of patients 6 years after stroke (Hackett, Duncan, Anderson, Broad, & Bonita, 2000)

Quality of Life of stroke patients can be improved at the early stage of stroke with intervention After implementation of the Transitional Care Program, quality of life of stroke survivors increased significantly at 12 weeks post discharge (Chalermwannapong, Panuthai, Srisuphan, Panya, & Ostwald, 2010; Baumann, Lurbe, Leandro, & Chau, 2012; Buck, Jacoby, Massey, & Ford, 2000; Hakverdioğlu Yönt & Khorshid, 2012; Kranciukaite & Rastenyte, 2006b; K.-c Lin,

Fu, Wu, & Hsieh, 2011a; Williams, Weinberger, Harris, Clark, & Biller, 1999)

Quality of Life of stroke survivors is commonly measured by the Stroke-Specific Quality of Life Scale (SS-QoL) It was developed in 1999 with the purpose of assessment of health-related quality of life specific to stroke survivors (Williams, Weinberger, Harris, Clark, & Biller, 1999) The 12 domains in this scale include Mobility, Energy, Upper Extremity Function, Work and Productivity, Mood, Self-care, Social Roles, Family Roles, Vision, Language, Thinking and Personality Scoring of the SS-QOL is rated on a 5-point Likert scale The SS-QOL provides domain scores and a summary score, with higher scores indicating better function (K.-

c Lin, Fu, Wu, & Hsieh, 2011)

Stroke-Specific Quality of Life Scale (SS-QoL) was used in several countries, such as Mexico (Cruz-Cruz et al.), China (Hsueh, Jeng, Lee, Sheu,

& Hsieh), and Denmark (Muus, Williams, & Ringsberg, 2007) It was recommended that the 12-domain version of the SS-QOL was useful in capturing the multiple impacts of stroke as well as overall HRQOL status on the basis of patients' perspectives (Hsueh et al.)

2.1.5.2 Functional outcomes

Functional outcomes, the ability of stroke patients to function without assistance, may change by time since stroke onset Most survivors improved functionally at three months (Wasserman, de Villiers, & Bryer, 2009); 16.2% stroke patients achieved functional independence at 6 months (J H Lin et al., 2000) The gender difference was found in functional outcomes of stroke patients Functional

outcomes after stroke are consistently poorer in women (Reeves et al., 2008) Female sex contributes to poorer chronic functional outcomes after acute ischemic stroke (AIS) (Knauft, Chhabra, & McCullough, 2010)

Rehabilitation showed benefit for functional outcomes It was found that good functional gains are achievable after comprehensive rehabilitation (Ng, Stein, Salles, & Black-Schaffer, 2005) Patients with severe strokes who received individualized care on a highly specialized stroke rehabilitation unit achieved impressive functional outcomes (Teasell, Foley, Bhogal, Chakravertty, & Bluvol, 2005) Upper extremity-specific therapy for stroke survivors is one of rehabilitation strategies in acute stroke to get greater functional outcomes (Winstein et al., 2004)

2.1.5.3 Self-care agency

Self-care agency can be defined as an individual's ability to continually evaluate health-related needs and perform self-care activities aimed at promoting and maintaining health and well-being Self-care agency actions (health-promoting behaviours) are developed during life and not only when health problems occur Thus, the objective of self-care agency is to promote health and well-being, as well as prevent and manage illness (Damasio & Koller, 2013) Several self-care agency assessment tools can be found and the Appraisal of Self-care Agency Scale (ASAS) is the most widely used and its reduced version the ASAS-R`

The ASAS was developed based on Orem's Self-care Deficit Nursing Theory, which emphasizes patient responsibility for self-care behaviours, and aims

to evaluate patient awareness of health needs and promotes self-care In its original version, the ASAS comprised 24 items responded on a five-point Likert scale ranging from 1 (totally disagree) to 5 (totally agree) The ASAS was a one-dimensional measure which provides a general and non-specific appraisal of self-care agency Therefore the revised version (ASASR) developed and tested in the Brazilian population with an acceptable reliability was used to measure self-care agency among stroke patients The ASAS-R consists of 24 statements affirming one’s ability in self-care agency also using a five-point Likert scale ranging from 1 (totally disagree) to 5 (totally agree)

2.1.5.4 Complications

Stroke patients are susceptible to many complications (Kumar, Selim, & Caplan, 2010) These events have a substantial effect on the final outcome of

patients with stroke and often impede neurological recovery Pneumonia, venous thromboembolism, fever, pain, dysphagia, incontinence, and depression are particularly common after a stroke and usually require specific interventions for their prevention and treatment (Kumar et al., 2010) It has been found that the most common complications at early stage of stroke are pressure ulcer, confusion, dysphagia, pain and constipation (Gbiri & Akinpelu, 2012; Langhorne et al., 2000; Phan Thai Nguyen & Nhi, 2009; Trang, 2010)

Specific complications are different from authors’ findings and time duration after stroke event (Bray et al., 2013; Phan Thai Nguyen & Nhi, 2009) This is found and illustrated in Table 2 – 2 Among these complications, pressure ulcer, constipation and dysphagia have been found out in the highest percentages in

Vietnam at early stage of stroke (Phan Thai Nguyen & Nhi, 2009; Trang, 2010)

The impact of pressure ulcers is significant in terms of both financial and non-monetary costs Each Stage III or Stage IV pressure ulcer can add

$14,000 to $23,000 to the cost of the patient's care Non-monetary costs, often described as the hidden costs of pressure ulcer care, include the emotional and physical impact on patients and their family caregivers (Niezgoda & Mendez-Eastman, 2006)

To help prevent pressure ulcers in older stroke patients, the findings suggest that healthcare providers assess activity, moisture, nutrition, friction and shearing, as well as psychological assessment for depression (Suttipong & Sindhu, 2012) It has been found that the incidence of Stages I and II pressure ulcers could be reduced by educating the staff and using a body wash and skin protection products (Lyder & Ayello, 2008)

Dysphagia

Dysphagia is a potentially serious complication of stroke (Foley, Teasell, Salter, Kruger, & Martino, 2008) and extremely common following stroke It was found out at a high proportion during hospital admission, more than 60%

of stroke survivors (Martino et al., 2005; Shaker & Geenen, 2011) and could reach 94% at six months post-stroke (Langdon & Blacker, 2010; Rouillard, De Weerdt, De Wit, & Jelsma, 2012)

Malnutrition, dehydration, and infection are common consequences of dysphagia Another consequence is a significant decrease in quality of life (Shaker & Geenen, 2011) Dysphagia has a significant impact on hospital length of stay and

is a bad prognostic indicator (Altman, Yu, & Schaefer, 2010) Despite this propensity for recovery, dysphagia carries a sevenfold increased risk of aspiration pneumonia and is an independent predictor of mortality (Singh & Hamdy, 2006)

Early recognition of dysphagia and intervention in the hospitalized patient is advised to reduce morbidity and length of hospital stay (Altman

et al., 2010) Using the gagging swallowing screen (GUSS) for dysphagia screening in acute stroke patients is recommended (John & Berger, 2015)

Complications after stroke onset are described in Table

2-1 It was found that complications occupied a high percentage of stroke patients (54%-83%) There are many syndromes of complications The three syndromes of complications were selected for the study consisted of Pressure ulcers, Dysphagia and Pain because of their higher percentage in compared to other complications

in Can Tho

Pain

Stroke patients can experience a variety of pain, such as central post-stroke pain, headaches, and musculoskeletal issues (Nesbitt, Moxham, Ramadurai, & Williams, 2015) It was found that development of chronic pain is more common in stroke patients, particularly pain from other long term conditions (Klit, Finnerup, Overvad, Andersen, & Jensen, 2011) Evidence was found that almost one-third of the stroke patients developed shoulder pain after stroke onset, a majority with moderate– severe pain

Shoulder pain restricts patients’ daily life after stroke (Lindgren, Jönsson, Norrving, & Lindgren, 2007) Shoulder pain affects from 16% to 72% of patients after a cerebrovascular accident Hemiplegic shoulder pain causes considerable distress and reduced activity and can markedly hinder rehabilitation (Walsh, 2001) Evaluation of post-stroke pain should be part of stroke follow-up (Klit

et al., 2011) It was recommended that shoulder pain, upper limb motor function, and function independence were significantly improved after comprehensive rehabilitation (Zhu, Su, Li, & Jin, 2013)

Table 2.1 Complications after stroke onset

Complications (% ) The 1 st day Within 7 days Two weeks After 4 months During hospitalization

Urinary tract infection 10 a + 24 d ; 4.3 e ; 8 f

a: (Adrian Khan, Akhtar Sherin, Hussein Ahmad, & Khalil, 2011) b: (Navarro et al., 2008) d: (Langhorne et al., 2000)

c: (Lindgren, Jönsson, Norrving, & Lindgren, 2007) e: (V S Doshi, J H Say, S H-Y Young, & Doraisamy, 2003)

f: (Phan Thai Nguyen & Nhi, 2009) h: (Rouillard et al., 2012) k: (Shaker & Geenen, 2011) j: (Martino et al., 2005)

l: (Langdon & Blacker, 2010) m: (Gbiri & Akinpelu, 2012) n: (Trang, 2010) p: (McLean, 2004)

2.2 Situation of stroke and its management in Vietnam

2.2.1 Situation of stroke in Vietnam

Stroke prevalence has been increasing dramatically within 30 years since

1970 to 2011 and will keep on increasing at which stroke in low-income and income countries needs more concerns According to the WHO Statistical Information System (WHOSIS), by 2005, the total number of cardiovascular disease deaths had increased globally to 17.5 million from 14.4 million in 1990 (WHOSIS, 2008) Of these, stroke attributed 5.7 million (Gaziano, Bitton, Anand, Abrahams-Gessel, & Murphy, 2010; Mathers, Boerma, & Ma Fat, 2009; WHO, 2012)

middle-The number of stroke death worldwide is projected to rise from 6.5 million

in 2015 and to 7·8 million in 2030 (Strong, Mathers, & Bonita, 2007) In addition, the trend of stroke in low-middle income countries had been statistically significant increased over the past four decades, with a greater increase in stroke incidence in low

to middle-income countries (Feigin, Lawes, Bennett, Barker-Collo, & Parag, 2009)

In addition, evidence showed that there was a higher proportion of ageing people in stroke victims It has been found that the prevalence of silent cerebral infarction in the age group of 55 and 64 years is about 11% This prevalence increases

to 22% in age group of 65 and 69 years; 28% in age group of 70 years and 74; 32% in age group of 75 and 79 years; 40% in age group of 80 and 85 years, and 43% in age group of 85 years and over (CTRND, 2013) Therefore the increasing ageing population worldwide will make more burdens of stroke globally

Stroke leads severe consequences to its population Stroke remains one of the top causes of mortality and disability-adjusted-life-years (DALYs) lost globally (Mukherjee & Patil, 2011) Beside mortality and DALY loss, stroke remains serious sequel to their victims both in physical and mental health The majority of stroke survivors could not perform their daily activities Many stroke survivors were not independent in housework (60.9%), food preparation (52.2%), shopping (80.4%) and public transport use (65.2%) Of the stroke survivor, 29% of them were severely disabled; requiring caregiver assistance for basic needs, and 20% could not be left alone (Rouillard et al., 2012)

Stroke causes burdens to their victim’s families Stroke survivors have to depend on their family members More than 50% of them required assistance in dressing, bathing, and use of stairs The majority of stroke survivors required full assistance in meal preparation (77%), housekeeping (70%) and laundry (82%) Rarely did subjects returned to paid employment (Hartman-Maeir, Soroker, Ring, Avni, & Katz, 2007) Family caregivers report that they suffer both physically and psychologically and find themselves overwhelmed with strain, experiencing burden and exhaustion (Oupra, Griffiths, Pryor, & Mott, 2010)

The direct costs of stroke constitute the larger part of healthcare expenditures (Spieler & Amarenco, 2004) In 2007, costs of stroke care in the US was about $40 billion for direct and indirect costs in which inpatient hospital costs for an acute stroke event account for 70% of first-year post-stroke costs Loss earnings are expected to be the highest cost contributor (Tirschwell, Kukull, & Longstreth Jr, 1999) The mean cost of stroke in France is estimated at 18,000 Euros for the first 12 months Disability accounts for 42 percent of the variable cost of stroke (Spieler & Amarenco, 2004) The average monthly monetary value of informal care was 4642.6 baht, based on 2006 prices (Arthorn Riewpaiboon, 2009)

Stroke mortality and its burden vary greatly among countries, but income countries are the most affected More seriously, of total stroke deaths, 87% was in low-income and middle-income countries (Gaziano et al., 2010; Lim et al., 2007; Strong et al., 2007) There was a ten-fold difference in rates of stroke mortality and Disability Adjusted Life Years (DALY) lost between the most-affected and the least-affected countries (Johnston, Mendis, & Mathers, 2009)

low-Asians may face more serious health problems from a stroke in comparing those in the world Of the worldwide increasing population, 61.04% is Asians (Cohen, 2012; Jullamate, 2007) in which the proportion of group 60 and over is approximately

as high as that in the world in 2025 expectedly However, this ageing group in Asia will dramatically increase to be higher than that in the world in 2050, 23.6% and 21.6% (UN, 2005)

In Vietnam, stroke incidence is about 200,000/year, there are approximately 486,000 still alive, and mortality is at 104,800/year (Thành, Liên, Tân,

& Tuấn, 2011) From 1985 to 2004, stroke incidence in Can Tho City has increased

about 13.86 times higher, (29.96 in 1985 verses to 415.23 per 100,000 populations in 2004) (Tâm, 2005) Currently, the mortality rate of stroke in Can Tho City had been increased 3.94 times higher within 3 years from 2007 to 2010 (5.0 versus 19.7 per 100,000 population) (Truyền, 2011) The stroke prevalence has increased from 75.57 per 1,000,000 population in 2002 to be 129.56 per 1,000,000 population in 2004 (Tâm, 2005)

According to the official statistics from the Health Department of Can Tho City, the stroke patients admitted in 9 district hospitals in the city had increased 1.65 times from 2007 to 2011 (2,392 in 2007 and 3,936 in 2011), from which both haemorrhage and ischemia were increased (Table 2 – 1) (Giao, 2012)

Table 2.2 The numbers of stroke patients hospitalized in Can Tho City (2004-2011)

Source: Can Tho Health Department (Giao, 2012)

2.2.2 Policy related to stroke management in Vietnam

Stroke management national wide has been faced with both opportunity and threat in the context of the nation

Law on Elderly (Law-39/2009/QH12, 2009), which has been amended and supplemented, and promulgated by The National Assembly in 2009, brings about health care policy and social welfare for the elderly that benefits to OAWS More special, (Decree-6/2011/ND-CP, 2011) provides that besides the priority in health care and in participation in social activities, the elderly get health insurance and a monthly allowance This may help OAWS more advantages in their current situation

The Government of Viet Nam has adopted and implemented a number of laws, policies, standards, and initiatives pertaining to people with disabilities, including their right to productive and decent work (V T B Minh, 2013) This may create more benefits for OAWSs’ community integration

Viet Nam’s Ministry of Heal reflects strategic plan on development of traditional medicine to 2030 (Decision-122/QĐ-TTg, 2013) This plan aims to strengthen the system of traditional medicine from central to local levels, improve the quality and effectiveness of the medicine department in the provincial hospitals, district, and enhance activities of traditional medicine in commune health stations Traditional medicine is widely used and occupied 25% at the commune level, and 9%

at the provincial and district level The Traditional Medicine Departments are available in the majority of provincial and district general hospital Most commune

health stations (79.3%) offer traditional medicine services (WHO & MOH, 2012)

OAWS’ using traditional medicine services is commonly observed and considered as rehabilitation treatment post stroke

However, health services in Vietnam have mostly focused on curative care: 81.8% health workforce was on curative care versus 12.9% on preventive care and no data for primary care (Tran Thi Mai Oanh et al., 2010) Then preventive care and primary care for post-stroke have been neglected

The cost for treatment and care is a heavy burden for OAWS and their family Approximately 42% of the population of Viet Nam is covered by health insurance (WHO & MOH, 2012) However, health insurance does not cover the cost for high medical techniques This cost may not be affordable by some of OAWSs

2.2.3 Stroke management at national level

Limited resources for stroke management in Vietnam have been identified

in spite of the nation’s endeavours Many regions with provincial hospitals are not well equipped and cope with difficulties to receive updated medical information (Michael Brainin, 2011; Thính, Lực, Xuyên, Brainin, & Anh, 2008)

Stroke unit mostly focuses in provincial hospitals (Michael Brainin, 2011) Continuous training to empower and establish stroke unit at district or commune level

is limited in the country (Thính et al., 2008; Tran Thi Mai Oanh et al., 2010)

A low number of rehabilitation staffs (one physical therapist per 108 beds (JICA & Hospital, 2011) so that only 10 percent of the cardiovascular accident and head trauma patients received rehabilitation treatment after returning home (JICA & Hospital, 2011)

Traditional medicine and alternative therapies are commonly used in stroke care However, besides traditional medicine practitioners, there is 12% had no professional training but learned the profession through traditional apprenticeship (WHO & MOH, 2012) Both privacy clinics and this kind of traditional practitioners are used as stroke services in the community, in particular for OAWS after hospital

discharge

As mentioned previously, health services in Vietnam are mostly focused

on curative care (Tran Thi Mai Oanh et al., 2010) Then hospital care for OAWS shows its strengths in curative care Intravenous thrombolytic therapy has been implemented at several hospitals (Hayashi, Hai, & Tai, 2013; Lien, Tuan, & Linh, 2013; Nguyen et al., 2010) Evidence on preventive care and primary care in stroke have limited in the country

The combination between Western and Eastern approach for stroke treatment is normally observed in hospitals Although it has not been systematically found out how traditional medicine contribute to post-stroke treatment, however, acupuncture method in patients after cerebral stroke phase for motor recovery results quite well (Thanh, Hiện, & Hồng, 2010)

As mentioned previously, medical records do not follow the patient, resulting in poor continuity of care and weak linkages between facilities Coordination between treatment and prevention is also weak (WHO & MOH, 2012) This is commonly observed in post-stroke

Evidence on rehabilitation programs for stroke survivors in Vietnam has rarely been found out However many other rehabilitation programs in Vietnam have been implemented to support disabled people caused by any reasons (Muller, 2007);, (VNAH, 2013); (JICA & Hospital, 2011) There are new programs supporting disabled people such as “US program supporting people with disabilities” (BTA, 2013)

2.2.4 Stroke management in Can Tho City

Can Tho City is one of the five biggest cities in Vietnam It is located in Mekong Delta, the South of Vietnam (Figure 2 – 2)

Stroke management in Can Tho City reflects some similarities of that in nationwide However, it has also owned some special aspects as follow:

Figure 2.2 Location of Can Tho City, Vietnam

Resources for stroke management

Table 2 – 3 shows stroke unit and the numbers of patient bed among nine general hospitals in the City Only one stroke unit is available among nine general hospital districts (Giao, 2012; Tham, 2013)

Department of Traditional Medicine is considered as health facility for OAWS’s rehabilitation during hospitalization Six among nine general hospitals have Department for Traditional Medicine where stroke patients are commonly referred from stroke unit or emergency department to be kept in treatment and care for post-stroke before hospital discharge For those hospitals without Department for Traditional Medicine (DTM), stroke patients are referred to Medicine Department (MD)

Lacking health professional specialized in stroke, therefore hospital care

for OAWS in district hospitals is mostly managed by general clinicians, except Central

City Hospital, which has a stroke unit Hospital care for OAWS is mainly focused on

curative care; then primary care and preventive care for complications have not been

noticed

Not only lacking clinicians to treatment for stroke, the percentage of

nurses in the city is lowest in the country The proportion of nurses among total health

manpower in Can Tho City is at the lowest in the country (19.69% in comparing

22.23%, the average of that in the whole country) (MOH, 2011) This could lead

disadvantages to patients, including OAWS

Table 2.3 Stroke Unit and Department of Traditional Medicine in district hospital

(Tham, 2013)

Unit

Traditional Medicine Dep (TMD)

Patient beds Total (TMD)

OAWS’s seeking health services

OAWS’s seeking health services is mostly spontaneous at stroke event and

support from health system is limited (Figure 2 – 3)

When a stroke happens, stroke victims are transferred to the closest health

services either hospitals or commune health station (CHS) In cases of the stroke

victims transferred to CHS, they will be transferred again to hospitals by which they

may get help After acute hospital care, which is common for the first week of hospital admission, stroke patients will be referred to either department for traditional medicine

or medicine departments

After discharge from general district hospitals, Traditional Medicine Hospital and their homes are their options for post-stroke When back home, OAWSs commonly use private clinics and traditional practitioners for alternative care

Evidence on medical records to follow the stroke patients after hospital discharge has been limited Care after discharge for OAWS is mostly replied on private clinics, alternative care, and traditional practitioners

Health services for OAWS

Like stroke care national wide, care for stroke in the city at hospitalization phase is mostly focused on curative care, evidence on preventive care and primary care have been limited in stroke management in the City

Evidence on medical records to follow the stroke patients after hospital discharge is not available Therefore how continuity of care performed for OAWS has not been determined

Figure 2.3 OAWS’s seeking health services after stroke onset