Judith Redfern

Qualitative Studies of Stroke A Systematic Review

Background and Purpose— Qualitative studies are increasingly used to investigate social processes and phenomena influencing health behaviors and service provision. We aimed to identify the scope of published qualitative studies of stroke, consider their relevance to development and delivery of services for people with stroke, and make recommendations for future work. Methods— Literature review of published articles was identified by systematically searching online literature databases using keywords from the start of each database until 2002. Articles were reviewed by 2 authors, using a standardized matrix for data extraction. The 2003 European Stroke Initiative recommendations for stroke management were used to categorize the literature for consideration of its contribution to stroke research. Results— We included 95 articles. Their empirical contribution includes an emphasis on recording the “human” experience of stroke; identification of needs as perceived by patients and their families, differences in priorities between patients and professionals, and barriers to best-quality care. We identified 12 papers that were specifically undertaken to develop or evaluate interventions. Conclusions— Qualitative studies have addressed a wide range of issues related to the impact of stroke on individuals and caregivers, and to the organization and delivery of services. Significant problems remain in ensuring the delivery of best-quality stroke care, which such studies have the potential to address. Maximizing this potential requires greater collaboration between nonclinical and clinical scientists, service providers, and users to formulate research questions of interest as well as new research strategies, such as meta-analysis, to pool qualitative research findings and multisited investigations.

Self-Reported Long-Term Needs After Stroke

Background and Purpose— Development of interventions to manage patients with stroke after discharge from the hospital requires estimates of need. This study estimates the prevalence of self-reported need in community-dwelling stroke survivors across the United Kingdom. Methods— We conducted a survey of stroke survivors 1 to 5 years poststroke recruited through Medical Research Council General Practice Research Framework general practices and 2 population-based stroke registers. Levels and type of need were calculated with comparisons among sociodemographic groups, disability level, and cognitive status using the &khgr;2 test or Fisher exact test, as appropriate. Results— From 1251 participants, response rates were 60% (national sample) and 78% (population registers sample) with few differences in levels of reported need between the 2 samples. Over half (51%) reported no unmet needs; among the remainder, the median number of unmet needs was 3 (range, 1 to 13). Proportions reporting unmet clinical needs ranged from 15% to 59%; 54% reported an unmet need for stroke information; 52% reported reduction in or loss of work activities, significantly more from black ethnic groups (P=0.006); 18% reported a loss in income and 31% an increase in expenses with differences by age, ethnic group, and deprivation score. In multivariable analysis, ethnicity (P=0.032) and disability (P=0.014) were associated with total number of unmet needs. Conclusions— Multiple long-term clinical and social needs remain unmet long after incident stroke. Higher levels of unmet need were reported by people with disabilities, from ethnic minority groups, and from those living in the most deprived areas. Development and testing of novel methods to meet unmet needs are required.

Behavioral Risk Factor Prevalence and Lifestyle Change After Stroke: A Prospective Study

BACKGROUND AND PURPOSE Stroke patients have a 15-fold increased risk of recurrent stroke, and those with > or =1 risk factor have a further increased risk of recurrence. Previous work found management of physiological risk factors after stroke to be unsatisfactory, but there is little information on behavioral risks within the stroke population. This study estimates behavioral risk factor prevalence after stroke and explores lifestyle change. METHODS The study used data from the population-based South London Stroke Register, collected prospectively between 1995 and 1998. Main measures included smoking status, alcohol use, and obesity. Logistic regression was used to determine sociodemographic differences in these measures. RESULTS At 1 year after stroke, 22% of patients still smoked, 36% of patients were obese, and 4% drank excessively. Younger patients, whites, and men were more likely to smoke, and younger whites were more likely to drink excessively. Women and nonwhites were more likely to be obese. Those living in hospital, nursing home, or residential care and nonwhites were more likely to give up smoking, but there were no other associations between lifestyle change and the sociodemographic characteristics of patients. CONCLUSIONS Different behavioral risk factors were associated with specific sociodemographic groups within the stroke population. After stroke, high-risk groups should continue to be targeted to prevent stroke recurrence. However, the relationship between sociodemographic characteristics and lifestyle change remains unclear; more research is needed into the process of change to find out how best to intervene to improve secondary prevention.

Patterns of smoking cessation in the first 3 years after stroke: the South London Stroke Register

Background Stroke survivors are at high risk of recurrent strokes and other vascular events. Smoking is an established risk factor for stroke, with cessation recommended for secondary prevention. Little is known about patterns of smoking cessation after stroke. Design A prospective cohort of patients was identified. Methods Data were derived from the population-based South London Stroke Register. Self-reported smoking status was measured at the time of stroke, at 3 months, and at 1 and 3 years after stroke. Stroke survivors, who were smoking at the time of stroke and were alive 3 years later, were included. Logistic regression was used to examine associations between age, sex, ethnicity, socioeconomic status, risk factors, stroke subtype, disability, and probability of attempting and maintaining smoking cessation. Results Complete smoking data were available for 363 survivors with strokes between 1995 and 2003. In all, 71% of the smokers had attempted to quit within 3 years; 30% had quit and maintained cessation at 1 and 3 years; 10% had quit immediately after stroke, but had subsequently relapsed (smoking again at 1 and 3 years); and 25% of the smokers had quit after 3 months. Black ethnicity [odds ratio (OR): 6.20; confidence interval (CI): 2.39–16.10] and more severe disability (P = 0.035) were predictors of attempts to quit. Older age (OR: 0.30; CI: 0.13–0.71) and black ethnicity (OR: 0.30; CI: 0.15–0.60) reduced the likelihood of smoking at 3 years. Among those attempting cessation, being older predicted maintenance (OR: 4.50; CI: 1.50–13.51). Conclusion The majority of smokers had attempted to quit after stroke; however, a minority achieved sustained cessation in the longer term. Cessation patterns are complex, and interventions should be targeted at multiple time points.

Stop Stroke: Development of an innovative intervention to improve risk factor management after stroke

OBJECTIVE Stroke survivors are at high risk of stroke recurrence yet current strategies to reduce recurrence risk are sub-optimal. The UK Medical Research Council (MRC) have proposed a framework for developing and evaluating complex interventions, such as community management of stroke secondary prevention. The Framework outlines a five-phased approach from theory through to implementation of effective interventions. This paper reports Phases I-III of the development of a novel intervention to improve risk factor management after stroke. METHODS The pre-clinical/theoretical phase entailed reviewing the literature and undertaking quantitative and qualitative studies to identify current practices and barriers to secondary prevention. In Phase I (modelling), findings were used to design an intervention with the potential to overcome barriers to effective stroke secondary prevention management. The feasibility of delivering the intervention and its acceptability were tested in the Phase II exploratory trial involving 25 stroke survivors and their general practitioners. RESULTS This led to the development of the definitive risk factor management intervention. This comprises multiple components and involves using an on-going population stroke register to target patients, carers and health care professionals with tailored secondary prevention advice. Clinical, socio-demographic and service use data collected by the stroke register are transformed to provide an individualised secondary prevention package for patients, carers and health care professionals at three time points: within 10 weeks, 3 and 6 months post-stroke. CONCLUSION The intervention is currently being evaluated in a randomised controlled trial. Further research is needed to test generalisability to other aspects of stroke management and for other chronic diseases. PRACTICE IMPLICATIONS The MRC Framework for complex interventions provides a structured approach to guide the development of novel interventions in public health. Implications for practice in stroke secondary prevention will emerge when the results of our randomised controlled trial are published.

Streamlined research governance: are we there yet?

Despite the promise of a new streamlined process for gaining research ethics and governance approval, Nina Fudge, Judith Redfern, Charles Wolfe, and Christopher McKevitt argue that the process is still dogged by delay and arbitrary decisions