This section describes the theoretical considerations for the development of a self-managed physical exercise manual supported with the use of available information and communication technologies for physical functional stroke rehabilitation in the community
1.7.1 Overall theoretical considerations
Theory helps to develop new knowledge by providing motivation and guidance to ask clinical questions, and provide a basis for asking a research question (Portney and Watkins, 2009). It can help to guide the development of interventions, and help to explain the findings when developing an intervention (Rycroft-Malone and Bucknall, 2011). Models are important for rehabilitation which can be used to help to form a framework for research and planning of an intervention, the construct of services, and design of research (Wade and de Jong, 2000).
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The following theories underpinned the considerations involved to form the basis for the development of the programme in this research. The details about establishing a new conceptual model for the design of the programme of this research are discussed in the chapter 8a of this thesis. In addition, a conceptual framework is also shown in the chapter 10 suggesting a system to guide the prescription and delivery of the programme.
1.7.1.1 International Classification of Functioning, Disability and Health (ICF) &
stroke
With the vision of developing a programme to support stroke survivors’ physical rehabilitation for their activity and participation in this research, the ICF model1 (WHO, 2013) (see figure 1.7.1.1) was considered to frame the design of this functionally oriented programme. The ICF is used to identify physical consequences, functioning, disabilities and peoples’ lives in society post-stroke (Geyh et al., 2004, Starrost et al., 2008, Algurén et al., 2010, Lemberg et al., 2010). This is based on biopsychosocial model of disability (Stucki and Melvin, 2007, WHO, 2013).
Body function and body domains are related to activity and participation outcomes after stroke (Skidmore, 2003). Activities and participation is a part of WHO’s concept of health and disabilities in the ICF. Self-care is a domain of activity and participation on the ICF core set for stroke (WHO, 2013, WHO, 2011b). Thus the focus of this research is on the management at activity and participation level for physical functioning with the consideration given to the interactions among body structure and functions, and activity and participation; environmental and personal factors.
1 Two parts are involved in the ICF model: functioning and disability, and contextual factors, in which body functions and body structures, and activities and participation are included in the former part, whilst environmental and personals factors are categorised in the later part. Activity is the execution of a task or action by an individual and participation is the involvement in a life situation. (WHO, 2011c)
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Figure 1.7.1.1: The ICF model2 (WHO, 2013)
(Reproduced, with the permission of the publisher, from How to use the ICF: a practical manual for using the International Classification of Functioning, Disability and Health (ICF), Geneva, World Health Organization, 2013 (Box 1, page 7; http://www.who.int/classifications/drafticfpracticalmanual2.pdf, accessed 13 Jan 2014)
1.7.1.2 Chronic Care Model: A conceptual platform
Figure 1.7.1.2 Chronic Care Model (Wagner, 1998) (Effective Clinical Practice is the original source of the above figure. Permission is granted to reproduce the above figure from Effective Clinical Practice)3
2 The permission letter from WHO is attached in the appendix
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The overall concept of this research was inspired with the Chronic Care Model (CCM)4(Care, 2011, Wagner, 1998) (figure 1.7.1.2). In view of the CCM, the concepts of self-management support, delivery system design, decision support, clinical information systems, community resources and policies, and health system are connected with each other to manage chronic health conditions (Wagner, 1998, Epping-Jordan et al., 2004, Bodenheimer et al., 2002b, Singh et al., 2006). It has been shown to be possible to adopt the concepts of the CCM in a healthcare intervention to improve stroke survivors’ health outcomes after discharge (Allen et al., 2004).
The CCM was considered as a platform connecting the concepts of providing self-management and decision support, designing a delivery system, and organising patient’s clinical information for helping stroke survivors with disabilities to self-manage their own exercises in the community in a self-self-managed exercise manual in this research.
1.7.2 Integrating theories for a joint conceptual support
This section presents an overview of the following theories that were used to develop the programme in this research. Self-efficacy has been shown to be useful and important theory for stroke self-management (Jones, 2008, Jones et al., 2009, Jones and Riazi, 2011). However, I needed to consider whether there is any other theory that can also be used to facilitate the delivery of support for stroke self-management, and theory would be most suitable for supporting the concept of using available technologies for stroke self-management.
I considered incorporating other theories into the development of the programme in this research in addition to the key theory: self-efficacy. This was because relying on one theory may not be adequate to support the broader and complex ambition of
3 The permission letter from the American College of Physicians is attached in the appendix.
4 The CCM includes six elements: community, health system, self-management support, delivery system design, decision support and clinical information systems for providing good chronic illness care. Key elements of the CCM are empowering and preparing patients to manage their health via self-management support, delivering high quality care and mobilizing community resources to meet long-term needs in the community
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enabling stroke survivors to self-manage their own exercises using available technologies. The following theories were selected due to their features and constructs, relevant evidence, and potential for the topic area of this research. The details about the way they are used are described in the chapter 8a of this thesis.
1.7.2.1 Social cognitive theory
Social cognitive theory (SCT) is a psychological concept of health behaviours theory (HBT) (Painter et al., 2008) which focuses on people’s motivation to change behaviour (Weinstein, 1993). I have selected SCT to develop the intervention, since the theoretical basis of most self-management programmes for chronic diseases are often constructed with SCT and self-efficacy (Bodenheimer et al., 2002a, Lorig and Holman, 2003, Jones, 2006). The SCT aims to predict behaviour and its change.
The key constructs of SCT include personal characteristics, self-efficacy, expectation, self-regulation, behavioural capacity, emotional coping, observational learning and reinforcement. Self-efficacy and outcome expectancies are central determinants of the motivation of behaviours (Bandura, 1986, Bandura, 1989, Bandura, 1991, certain circumstance (Bandura, 1977, Bandura and Adams, 1977, Bandura, 2000).
Perceived self-efficacy can affect people’s selection of activities and behaviours (Bandura and Adams, 1977, Bandura, 1977, Bandura, 1993). Self-efficacy beliefs may determine a persons’ feelings, thoughts, motivation and behaviour towards their health, which has been commonly been used in self-management interventions for chronic conditions including stroke (Jones and Riazi, 2011).
5 Self-efficacy is the primary construct of the SCT (Bandura, 1997). It is shown to be a key element for stroke self-management according to current evidence (Jones and Riazi, 2011, Korpershoek et al., 2011)
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The proposed key effectiveness of self-management for chronic conditions is the change in the individual’s confidence and belief that they can take control over their life despite their disease (DH, 2001). This is central to the core value and function of self-efficacy.
Evidence indicates improved self-efficacy is associated with improved health behaviours and clinical outcomes (Silva, 2011). Self-efficacy may be associated with patient empowerment, with patients accepting responsibility to manage their own condition and being encouraged to solve their own problems based on information (Bodenheimer et al., 2002a).
Self-efficacy has been proven to be beneficial and the key element for stroke self-management (Jones and Riazi, 2011, Korpershoek et al., 2011). Therefore, it was used as a core theory which underpins the design of the programme in this research to facilitate stroke survivors’ competence to self-manage. The concepts of four common sources of self-efficacy: mastery experiences, vicarious experiences (modelling), verbal persuasion (social persuasion) and physiological feedback (Jones, 2011, Lorig and Holman, 2003, Bandura, 1997a, Bandura, 1997b). They were involved in the programme development, which are detailed in chapter 8a.
1.7.2.2 Learning theories
Stroke rehabilitation programmes extend what patients can do for themselves for health and functional status and encourage them to be independent and self-reliant.
Longer term stroke rehabilitation should aim at educating stroke survivors to maximise their functional abilities for daily activities (Aziz, 2010). Functional stroke recovery is deemed as a learning process (Gelber et al., 1995, Kwakkel et al., 1999), and self-management support often involves education. Educational theory has been suggested as a basis for later stage in stroke rehabilitation (Young and Forster, 2007). Neuroplasticity is important for brain recovery and the rehabilitation of motor function after stroke, in which learning is crucial (Dimyan and Cohen, 2011, Langhorne et al., 2011, Cramer and Riley, 2008, Ivanco and Greenough, 2000).
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Current self-management interventions have a more educational focus (Jones, 2011).
However, stroke survivors may not have been able to learn to self-manage by trial and error (Jones et al., 2013b). This raises a question about how can we help them to learn to self-manage to enable them to take control over their own rehabilitation.
Therefore, a group of educational theories were adopted to generate a new conceptual support to educate stroke survivors to learn how to self-manage their own exercises for physical functional rehabilitation during the development of the programme in this research.
Knowles’ adult learning theory (Andragogy)
The intervention in this research is planned to be developed for adult stroke survivors. Thus, educational concepts for adult learners are needed to address their learning needs. Andragogy refers to adult learning principles (Knowles, 1973, Hough, 1984). It suggests adults are independent and self-directing, have accumulated experience as a rich resource for learning, value learning via integrating the demands of their everyday life, become ready to learn when they need to know or do somethings, more interested in immediate and problem centred approach and more internally motivated to learn (Knowles, 1973, David and Patel, 1995, Kaufman, 2003, Smith, 2004, Green and Ellis, 1997). Andragogy have been used to form the intervention and enable stroke survivors to learn for their fucntional recovery needs.
Self-regulated learning
Self-regulation can be defined as the process for a person attempts to control personal, behavioural and environmental factors to attain and maintain personal goals (Schunk and Zimmerman, 2012, Maes and Karoly, 2005, Zimmerman, 1990).
It is closely related to self-efficacy. Self-efficacy belief is regarded as an important determinant of human self-regulation as people’s beliefs about their capabilities may influence the choices they make, their aspirations, the amount of effort they mobilise, and how long they persevere in the face of difficulties (Ayotte et al., 2010, Zimmerman, 2000, Bandura, 1991, Bandura and Jourden, 1991, Schunk, 1989).
Therefore, self-regulation concept is relevant to self-management in this study. Self-regulated learning (SRL) is the way for learners to master their own learning, via
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actions and processes directed at acquisition of information or skills. Zimmerman suggested that self-regulated learners plan, set goals, organize, self-monitor and self-evaluate during acquisition in their learning (Schunk and Zimmerman, 2012, Zimmerman, 2002, Clark and Zimmerman, 1990, Zimmerman, 1990). Self-regulatory behaviour has been suggested to be directly related to physical activity (Ayotte et al., 2010). This is in line with the vision of enabling stroke survivors to take control over the management of their own rehabilitation exercises in this research. Hence, SRL was used to support the programme to facilitate stroke survivors to regulate the process to learn to self-manage their own exercises.
Self-regulated learning often involves metacognitive, motivational, and behavioural processes to acquire knowledge and skills including goal-setting, planning, learning strategies, self-reinforcement, self-recording, and self-instruction (Schunk and Zimmerman, 2012, Pintrich, 2000, Zimmerman, 2000, Clark and Zimmerman, 1990, Schunk, 1990, Zimmerman, 1990). In particular, the SRL process and components proposed by Zimmerman were adopted in this research out of other existing SRL models since that is goal-oriented and self-generated by nature.
According to Zimmerman’ model for SRL, learning environmental influences, personal (self) influences and behavioural influences are suggested determining factors to SRL of which task analysis, self-motivation, self-control, self-observation6, self-judgement7, and self-reaction8 are involved throughout SRL process. In view of personal influence of Zimmerman’s model, person’s self-efficacy beliefs determine the individual’s learning. Self-observation, self-judgement and self-reaction are proposed to be factors influencing the individual’s behaviours in SRL process (Schunk and Zimmerman, 2012, Puustinen and Pulkkinen, 2001, Clark and Zimmerman, 1990). Therefore, this model is in line with the vision of helping stroke survivors to learn to take control over the management of their own programmes for
6 Self-observation refers to explicit attempts to perceive one’s own behaviour (Clark and Zimmerman, 1990)
7 Self-judgement involves using criteria to assess the situation or problem (Clark and Zimmerman, 1990).
8 Self-reaction refers to the responses to self-observations and self-judgement about the individual’s own behaviour and the impact of that behaviour the one’s immediate environment (Clark and Zimmerman, 1990).
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the goal of physical functional rehabilitation. The details about using the concepts of SRL to develop the programme are described in the chapter 8a of this thesis.
Motor learning therapy
Motor learning theory (MLT) was considered to facilitate and understand the process of self-managing physical exercises using the developed programme for the purpose of functional stroke recovery. Motor learning is a theory about the skill acquisition and modification of motor movement for stroke rehabilitation. It involves the analysis and training of specific tasks (Graham et al., 2009, Carr and Shepherd, 1989).
Schmidt proposed motor learning as a set of processes correlated with practice or experience causing relatively permanent changes in the capabilities of responding (Schmidt, 2008, Schmidt, 1991).
Based on the mechanisms of neuroplasticity, the recovery of motor functions can be improved via motor learning poststroke. The motor learning process may happen through functional reorganization in cortical areas of the brain (Subramanian et al., 2010). Skill acquisition, motor adaption and decision making to determine correct movement are included in motor learning processes (Krakauer, 2006). The improvement of functional motor performance is suggested as the focus of exercise training for functional skills after stroke (Shepherd, 2001), whilst motor relearning programme was found to be effective to improve functional skills for stroke recovery (Chan et al., 2006).
The focus of motor relearning is on the active participation of the stroke survivor with guidance and feedback for movement correction (Van Vliet and Wulf, 2006, Sparkes, 2000). Evidence indicates that repetitive task-specific training is beneficial for the improvement of motor function recovery after stroke, of which the provision of feedback on performance is recommended for task-specific practice (Langhorne et al., 2011, Langhorne et al., 2009a). Feedback can provide information on the improvement of movement and is suggested as an important factor for motor learning after stroke. It can be classified into either extrinsic or intrinsic. Intrinsic feedback is to provide sensory information whilst performing movement tasks.
Extrinsic feedback is provided from external environment via the provision of information about the knowledge of performance (KP) and the knowledge of results
41 practical ways to provide optimal feedback and information to facilitate the process of motor learning for continued functional recovery of stroke survivors. However, how motor relearning effects the longer term after stroke remains unclear (Langhammer and Stanghelle, 2003). Thus, it is necessary to discover how to transfer and maintain the effect of motor learning for continued stroke recovery. The details about using the MLT to formulate the programme of this research are described in chapter 8a.
1.7.2.3 Technology acceptance model
The use of available information and communication technologies (ICTs) include:
DVDs, mobile phones, emails, and videoconference etc.; are considered to be involved to provide support to stroke survivors to self-manage their own exercises in this research. However, it is important to consider how the users of those technologies think when incorporating the idea of using ICTs in order to motivate them to use them. Thus, it is necessary to consider the users’ view in using available ICTs for the purpose of self-managing exercises.
Based on the principle of User-Centred Design (UCD), which is an approach generally referred to underpinning philosophy and methods focusing on designing incorporating users throughout the development process to design technologies systems (Gould and Lewis, 1985, Abras et al., 2004); it is necessary to explore how
9 Knowledge of performance (KP) refers to extrinsic feedback on the nature of the movement pattern used to achieve the goal of the movement with the concern of how the person moved. The KP focuses on the timing and frequency of information delivered to the learner. Knowledge of results (KR) is the goal-related extrinsic feedback with the focus on the outcomes of the movement BROWN, V. A., GROOTJANS, J., RITCHIE, J., TOWNSEND, M. & VERRINDER, G. (2007) Jackie Green and Jane South, LENNON, S., MCKENNA, S. & JONES, F.
(2013) Self-management programmes for people post stroke: a systematic review. Clinical Rehabilitation, 27, 867-878
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users think in order to develop the intervention using technologies. UCD has recently been suggested to develop interactive health technologies for patients and used to design assistive technology for stroke survivors (Ma et al., 2007, Dabbs et al., 2009).
Hence, concepts about users’ behaviours, acceptance and willingness in using ICTs are considered to support an acceptable and usable intervention in this study.
Fred Davis proposed the Technology Acceptance Model (TAM)to analyse why users accept or reject information technology (Davis, 1985, Venkatesh, 2000, Venkatesh and Davis, 2000). It is selected as the underpinning model to provide a basis to understand how to incorporate ICTs into a self-managed programme to support stroke survivors to manage their own exercises in this research. Key beliefs in TAM10 are “perceived usefulness” (PU) and “perceived ease of use” (PEOU). These are relevant to the understanding and explanation of users’ underlying psychology, internal beliefs, behaviours, intentions, and attitudes and acceptance towards using technology (Silvestre et al., 2009, Davis, 1985, Davis, 1989, Davis et al., 1989, Davis, 1993) (see figure 1.7.2.3).
With regards to the value of the UCD, it was essential to understand users’
acceptance and perception toward selecting and using available ICTs to develop a usable intervention as the focus of this study was to develop an acceptable and usable intervention for actual practice. Thus, TAM is a fundamental principle underpinning the idea of using available ICTs to support stroke survivors, who are the users; into this research.
10 The PU and PEOU are key determinants of user’s intention to adopt technology. The PU concerns the degree to which a person believes that using the new system will facilitate the user to complete his/her tasks.
The PEOU is the extent to which the user believes that using the system will be free of effort. Both factors can influence user's attitude and intention towards using a system
43 (Davis et al., 1989) (Reprinted by permission, Fred D. Davis, Richard P. Bagozzi and Paul R. Warshaw, User acceptance of computer technology: a comparison of two theoretical models, Management Science, volume 35, number 8, Aug 1989. Copyright 1989, the Institute for Operations Research and the Management Sciences, 5521 Research Park Drive, Suite 200, Catonsville, Maryland 21228 USA.)11
The TAM is proven to be useful to help to understand and explain users’ behaviours in implementation of information technology (Legris et al., 2003). The TAM focuses on system design features and is suggested to be used as a guide to design efforts (Taylor and Todd, 1995). Technologies have been used to provide stroke rehabilitation in recent studies (Johansson and Wild, 2011, Parker et al., 2013, Mawson et al., 2013). However, little is known about using the concepts of TAM to facilitate the delivery of community stroke rehabilitation services using appropriate and available ICTs. The details about using the concepts of TAM for the development of the programme are described in the chapter 8a of this thesis.
1.7.3 National and clinical guidelines for stroke rehabilitation
Clinical guidelines provide a source of information about the management of clinical conditions that can assist practitioner and patient to discuss different options for
Clinical guidelines provide a source of information about the management of clinical conditions that can assist practitioner and patient to discuss different options for