e. Sub-group analysis of age factor versus considerations of using available ICTs

Table 6.5e: Findings of sub-groups analysis between age and considerations of using available ICTs to self-manage exercises

All the interviewed stroke survivors aged 65 or above highlighted availability, perceived usefulness, perceived ease of use of ICTs and user centred design of ICTs for personal needs as essential considerations for them to use available ICTs to manage their physical exercises, although that was not the case for those aged below 65.

Equal numbers of stroke survivors from both groups considered accessibility (N=7) and cost utility (N=2) as important factors for them to use available ICTs.

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6.6 Discussion

This study identified factors to inform the development of a new stroke exercise manual from a patient’s perspective. The importance of involving stroke survivors and their carers for the planning and development of stroke services has been emphasised in clinical guidelines for stroke rehabilitation (ISWP, 2012, NICE, 2013).

It is important to incorporate users’ views at an early stage of the design and development process to meet their needs (Zheng et al., 2007).To facilitate stroke survivors to engage with the management of their own exercise, this study sought to identify core components for the development of a self-managed physical exercise program for stroke survivors with the support of available ICTs from their perspectives. Six key themes were identified from the interviews with 18 community-dwelling stroke survivors and 8 of their carers using the topic guides. The themes are discussed below which served to answer the research questions proposed in the chapter 3 of this dissertation.

Two additional themes emerged from the interviews in addition to answer to the topic guide questions which raised the issues about their attitudes toward managing their own exercise and the rationale underpinning their choices of technology to support to keep managing their own exercise. This helps to further examine their viewpoints about the management of their own exercise using available technology.

Theme A: Daily physical functional difficulties

This theme provides the information to answer the following research question:

“What are the major physical functional difficulties faced by stroke survivors after their discharge from the NHS community stroke rehabilitation services?”

The recovery in impairment and disability have been commonly investigated to study the effect of intervention on stroke rehabilitation for which the ICF framework and core set for stroke have been widely investigated and recommended to classify impairments, disabilities and problems in social functioning (WHO, 2002, Geyh et al., 2004, Lemberg et al., 2010, Langhorne et al., 2011). The ICF has regarded important for stroke rehabilitation (Tempest and McIntyre, 2006, Geyh et al., 2007).

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The use of ICF framework to structure a programme to educate stroke survivors about their functional recovery was shown to be possible and acceptable (Neubert et al., 2011, Best et al., 2010). However, there is no study has adopted the ICF model to develop a self-managed exercise manual for functional stroke rehabilitation. Thus, I have used it to identify and classify functional specific elements in this study.

The information in this theme reflects physical rehabilitation needs of community-dwelling stroke survivors. This helped to determine the way to form a functional oriented exercise manual based on stroke survivors’ desire for physical rehabilitation.

Stroke survivors described a range of difficulties that they have encountered for their physical functioning. This study indicates that the control of voluntary motor movement, the control of reaction and balance, muscle strength, energy and physical tolerance and joint mobility were the functional difficulties of highest concern.

The identified subthemes are in line with the physical disabilities and functional limitations identified by stroke rehabilitation experts in the ICF core set for stroke (Lemberg et al., 2010, Geyh et al., 2004).

Further research will be needed to investigate the reason why certain items were more frequently recognised to understand how different functional difficulties may influence the planning and delivery of physical stroke rehabilitation services.

Theme B: Daily physical functional goals

This theme provides the answers for the following research question:

“What are the common goals of physical functional recovery in the community from the stroke survivors’ perspective?”

Setting functional goals was highlighted in the guideline for stroke rehabilitation as a key priority in the UK (NICE, 2013). Understanding goals of daily activities will help to determine the components required in a stroke self-management rehabilitation programme. It is clear that stroke survivors should be involved in setting goals for community rehabilitation.

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This study suggests a list of functional oriented goals in relation to activity and participation from a stroke survivors’ perspective. This provides a list of user-centred options to design the programme based on their needs and abilities.

There were relatively more items identified in the area of mobility. This implies that the improvement of mobility was deemed as a key goal of functional rehabilitation for daily activities by stroke survivors. This may be because the programme is physical functional oriented, thus, the participants provided more rich information related to the rehabilitation to mobility in this study. This indicates that mobility is regarded as an important aspect in view of setting goals in a self-managed exercise manual from patients’ perspective. Therefore, it is crucial to pay attention to the details of setting goals to facilitate mobility rehabilitation in a self-managed exercise manual for physical functioning after stroke to deliver patient-centred services.

The goals of recreation and leisure, hand and arm use, walking, moving around in different locations indoor, changing basic body position and doing housework were also important concerns of the interviewees. These should be considered in a self-managed exercise manual for functional stroke rehabilitation to enable stroke survivors to set functional goals for their needs in activity and participation in the community.

Theme C: Considerations of self-managing physical exercises

This theme helps to answer the following research question:

“What do stroke survivors consider important in relation to the management of their own exercises in the community?”

Generalised stroke self-management programmes have been shown to be safe, feasible, and acceptable and effective for physical stroke rehabilitation (Huijbregts et al., 2008, Jones et al., 2009, Cadilhac et al., 2011, Jones and Riazi, 2011). Stroke survivors should be actively involved in the planning process for stroke service development, according to current guidance (ISWP, 2012). This study identified specific factors required to facilitate stroke survivors’ engagement with a

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personalised and self-managed exercise manual targeted at their individual physical needs for functional rehabilitation.

This research elicited 14 different considerations of self-managing physical exercises identified from stroke survivors including self-confidence, motivation, external support and reassurance, personalisation of the exercise manual, simple and specific instruction, and application of self-monitoring and self-regulation, relevance to rehabilitation goals and needs and health conditions, teaching and learning how to self-manage exercise, knowledge of safety and risk, technical skills, access to relevant health and social care resources and network, enjoyable exercises, suitable environment, and sustainability. These findings indicate that practical information and skills are required in the programme to address their concerns in self-managing their own exercises in the community.

Theme D: Assistance to self-manage physical exercises

This theme provides the information to answer the following research question:

“What do stroke survivors think can help them to manage their own exercise in the community?”

Although barriers for stroke survivors to participate in exercises have been reported (Rimmer et al., 2008), little was known about what stroke survivors think can help them to manage their own exercises. This study elicited 6 kinds of help including professional contact and support and feedback, peer support and feedback, carer support, financial issues and support, self-management strategies and methods, and education and learning skills for self-management from stroke survivors’ perspective.

These are the helps that they felt useful to assist them to manage their own exercises in addition to understanding their considerations to self-manage exercises in the previous theme. This provides further information to deliver the personalised information to assist stroke survivors to continuously engage in their functional rehabilitation. It appears that it is inadequate to provide information alone as each stroke survivor often needs to manage multiple issues for physical rehabilitation.