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NRI 98-183 – HSR&D Study

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NRI 98-183
Culturally Sensitive Models of Stroke Recovery and Caregiving After Discharge Home
Maude R. Rittman PhD MSN BSN
North Florida/South Georgia Veterans Health System, Gainesville, FL
Gainesville, FL
Funding Period: October 2000 - March 2006

BACKGROUND/RATIONALE:
Stroke is the leading cause of disability in the (US) and the third leading cause of death. A 1999 study suggests a much higher incidence of stroke than previously reported, estimating 259 new strokes per 100,000 population. Findings from this study also indicate that incidence of stroke increased exponentially with age and is consistently higher for males than females. Stroke also occurs more frequently among African-Americans and Hispanics. More stroke survivors are receiving the majority of their care in the home, placing a substantial burden on informal caregivers.

OBJECTIVE(S):
The goals of this study included: (1) Describe stroke recovery trajectories for African-American, Puerto Rican Hispanic, and non-Hispanic white veterans across two years following discharge home, (2) Explore variations in stroke recovery and describe strategies used by survivors to manage the illness course at home among three ethnic groups, (3) Explore the use of formal and informal health services and identify barriers to recovery at home, (4) Explore changes in burden, coping, depression, hours of caregiving and general health status of stroke caregivers over time for each ethnic group, (5) Describe the types of assistance informal caregivers provide during the first year to facilitate stroke recovery.

METHODS:
This is a prospective cohort multi-site study. A total of 250 participants (125 veterans and 125 caregivers) were enrolled in the study. Participants included 33 African Americans, 49 Puerto Rican Hispanic and 43 non-Hispanic white veterans. Subjects and their caregivers were enrolled prior to discharge for acute stroke. Data were collected at 1, 6, 12, 18, and 24 months following discharge home. Trained research assistants of the same ethnicity as the veteran collected data during home visits. Qualitative data included in-depth interviews with stroke survivors about their life following stroke. Quantitative data from the veteran included type of stroke, co-morbidities (Charlson Co-morbidity Scale), functional assessments (Functional Independence Measure, FIM), instrumental activities of daily living (Frenchay Activity Index, FAI), depression (Geriatric Depression Scale, GDS), and mental status (Mini-Mental Status Exam, MMSE). Caregiver data were collected at the same time points and included caregiver burden (Sense of Competence Scale, SOC), coping (Sense of Coherence), depression (GDS), hours and type of caregiving provided, and general health of caregivers across two years.

FINDINGS/RESULTS:
Controlling for covariates, growth models indicate that racial/ethnic groups differed in their initial status (i.e., FIM at discharge) and in patterns of recovery across 24 months. Puerto Rican veterans had greater functional impairment (lower motor FIM and FAI scores) compared to whites and African Americans. African Americans had less depressive symptomology and a better recovery trajectory compared to whites and Puerto Ricans. However, the average Puerto Rican had depressive symptoms within the depressed range. Changes in one’s sense of self following a stroke are related to depression. Puerto Ricans experience more disruption in sense of self than other groups across all time points. Experiences related to connectedness and isolation affected veterans across 12 months of the recovery trajectory. Results suggest the majority of white veterans maintain and recover a greater sense of connectedness throughout the twelve months and Puerto Ricans experience the greatest sense of isolation initially post stroke. Puerto Rican veterans experienced no or low community integration throughout this recovery period more often than other groups. Puerto Rican veterans and caregivers reported greater need for formal care services and greater use of selected services. There are no racial and ethnic differences in the level of caregiver burden and caregiver coping, although African American caregivers have a lower average GDS score which indicates lower levels of depressive symtomology. Puerto Rican caregivers spend the most hours per day, and have the most help with their care recipient compared to whites and African Americans. Caregiving tasks did not vary by race/ethnicity and included cooking, clothes/dressing, housework, personal care (bathing etc.), transportation, medical help, finances, shopping, and companionship.

IMPACT:
Results indicate that the recovery of stroke survivors varies by race/ethnicity in (a) functional status, (b) activities of daily living, (c) depression, (d) sense of self, (e) connectedness, (f) social participation. Across the board Puerto Ricans on average were more impaired (functional status and activities of daily living) at discharge and experienced slower recovery across the 24 month time period.

PUBLICATIONS:

Journal Articles

  1. Hinojosa RA. Dominating the other: Discursive Constructions of Hegemonic Masculinities through Comparative Practice. The Journal of men's studies. 2010 May 1; 18(2):179-194.
  2. Schmid AA, Rittman M. Consequences of poststroke falls: activity limitation, increased dependence, and the development of fear of falling. The American Journal of Occupational Therapy: Official Publication of The American Occupational Therapy Association. 2009 May 1; 63(3):310-6.
  3. Hinojosa MS, Rittman M, Hinojosa R. Informal caregivers and racial/ethnic variation in health service use of stroke survivors. Journal of rehabilitation research and development. 2009 Jan 1; 46(2):233-41.
  4. Hinojosa MS, Rittman M, Hinojosa R, Rodriguez W. Racial/ethnic variation in recovery of motor function in stroke survivors: role of informal caregivers. Journal of rehabilitation research and development. 2009 Jan 1; 46(2):223-32.
  5. Van Puymbroeck M, Hinojosa MS, Rittman MR. Influence of sense of coherence on caregiver burden and depressive symptoms at 12 months poststroke. Topics in Stroke Rehabilitation. 2008 May 1; 15(3):272-82.
  6. Hinojosa R, Boylstein C, Rittman MR, Hinojosa Sberna M, Faircloth CA. Constructions of Continuity after Stroke. Symbolic Interaction. 2008 Apr 17; 31(2):205-222.
  7. Chumbler NR, Rittman MR, Wu SS. Associations in sense of coherence and depression in caregivers of stroke survivors across 2 years. The journal of behavioral health services & research. 2008 Apr 1; 35(2):226-34.
  8. Haun J, Rittman MR. The Continuum of Connectedness and Social Isolation During Post Stroke Recovery. Journal of Aging Studies. 2008 Jan 10; 22(1):54-64.
  9. Schmid AA, Rittman M. Fear of falling: an emerging issue after stroke. Topics in Stroke Rehabilitation. 2007 Sep 1; 14(5):46-55.
  10. Uphold CR, Van Puymbroeck M, Rittman MR, Sberna Hinojosa M. Predictors of Positive Aspects of Caregiving and Depression Among Informal Caregivers of Stroke Survivors. Journal of the American Geriatrics Society. 2007 Apr 1; 55(4, Supplement S1-146):S215.
  11. Rittman M, Boylstein C, Hinojosa R, Hinojosa MS, Haun J. Transition experiences of stroke survivors following discharge home. Topics in Stroke Rehabilitation. 2007 Mar 1; 14(2):21-31.
  12. Boylstein C, Rittman M, Hinojosa R. Metaphor shifts in stroke recovery. Health communication. 2007 Jan 1; 21(3):279-87.
  13. Hinojosa MS, Rittman MR. Stroke caregiver information needs: comparison of Mainland and Puerto Rican caregivers. Journal of rehabilitation research and development. 2007 Jan 1; 44(5):649-58.
  14. Tiegs TJ, Heesacker M, Ketterson TU, Pekich DG, Rittman MR, Rosenbek JC, Stidham BS, Gonzalez-Rothi LJ. Coping by stroke caregivers: sex similarities and differences. Topics in Stroke Rehabilitation. 2006 Apr 1; 13(1):52-62.
  15. Ellis C, Rosenbek JC, Rittman MR, Boylstein CA. Recovery of cohesion in narrative discourse after left-hemisphere stroke. Journal of rehabilitation research and development. 2005 Nov 1; 42(6):737-46.
  16. Van Puymbroeck M, Rittman MR. Quality-of-life predictors for caregivers at 1 and 6 months poststroke: Results of path analyses. Journal of rehabilitation research and development. 2005 Nov 1; 42(6):747-60.
  17. Faircloth CA, Boylstein C, Rittman M, Gubrium JF. Constructing the stroke: sudden-onset narratives of stroke survivors. Qualitative Health Research. 2005 Sep 1; 15(7):928-41.
  18. Williams CL, Rittman MR, Boylstein C, Faircloth C, Haijing Q. Qualitative and quantitative measurement of depression in veterans recovering from stroke. Journal of rehabilitation research and development. 2005 May 1; 42(3):277-90.
  19. Boylstein C, Rittman M, Gubrium J, Behrman A, Davis S. The social organization in constraint-induced movement therapy. Journal of rehabilitation research and development. 2005 Apr 1; 42(3):263-75.
  20. Chumbler NR, Rittman MR, Van Puymbroeck, Vogel WB, Qin H. The sense of coherence, burden, and depressive symptoms in informal caregivers during the first month after stroke. International journal of geriatric psychiatry. 2004 Oct 1; 19(10):944-53.
  21. Faircloth CA, Rittman MR, Boylstein CA, Van Puymbroeck. Energizing the Ordinary: Biographical Work and the Future in Stroke Recovery Narratives. Journal of Aging Studies. 2004 Sep 29; 18(4):399-413.
  22. Rittman M, Faircloth C, Boylstein C, Gubrium JF, Williams C, Van Puymbroeck M, Ellis C. The experience of time in the transition from hospital to home following stroke. Journal of rehabilitation research and development. 2004 May 1; 41(3A):259-68.
  23. Faircloth CA, Boylstein C, Rittman M, Young ME, Gubrium J. Sudden illness and biographical flow in narratives of stroke recovery. Sociology of Health & Illness. 2004 Mar 1; 26(2):242-61.
  24. Faircloth CA, Rittman MR, Boylstein CA, Young ME. Disrupted Bodies: Experiencing the Newly Limited Body in Stroke. Symbolic Interaction. 2004 Mar 1; 27(1):71-87.
  25. Boylstein CA, Rittman MR. The Importance of Narratives in Stroke Rehabilitation. Implications for practice and policy. Generations (San Francisco, Calif.). 2003 Oct 1; 27(3):49-54.
  26. Gubrium JF, Rittman MR, Williams C, Young ME, Boylstein CA. Benchmarking as everyday functional assessment in stroke recovery. The journals of gerontology. Series B, Psychological sciences and social sciences. 2003 Jul 1; 58(4):S203-11.
Conference Presentations

  1. Van Puymbroeck AM, Uphold CR, Sberna Hinojosa M, Rittman MR. Positive Aspects Of Caregiving and Depression Among Informal Caregivers of Stroke Survivors: Preliminary Findings. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2007 Nov 17; San Francisco, CA.
  2. Sberna Hinojosa M, Rittman MR. Racial and Ethnic Variation in Stroke Caregiving. Poster session presented at: Festival of International Caregiving, Disability, Aging and Technology Annual Conference; 2007 Jun 17; Toronto, Canada.
  3. Rittman MR, Sberna MA. Racial/Ethnic Variation in Recovery From Stroke: The Role of Caregivers. Paper presented at: American Sociological Association Annual Meeting; 2006 Aug 12; Montréal, Canada.
  4. Chumbler NR, Rittman MR, Qin H, Wu SS. Changes in Sense of Coherence and Depressive Symptoms among Informal Caregivers of Stroke Survivors Across Two-Years. Paper presented at: American Heart Association / American Stroke Association International Stroke Conference; 2006 Feb 17; Orlando, FL.
  5. Byers KL, Rittman MR. Evaluating the Sense of Competence Questionnaire when Used with Diverse Populations. Poster session presented at: VA Department / National Institutes of Health Caregiver Forum; 2006 Jan 26; Bethesda, MD.
  6. Faircloth CA, Boylstein CA, Van Puymbroeck. Using Qualitative and Quantitative Methods: An Interdisciplinary Approach. Paper presented at: Evidence-Based Rehabilitation Joint Annual Conference; 2004 Sep 12; Ponte Vedra, FL.
  7. Rittman MR. The Experience of Time in the Transition from Hospital to Home Following Stroke. Paper presented at: Minnesota Health Resources Annual Conference; 2004 Apr 30; Banff, Canada.
  8. Rittman MR. Managing a Longitudinal Multi-Site Study Combining Qualitative and Quantitative Methods. Paper presented at: Minnesota Health Resources Annual Conference; 2004 Apr 30; Banff, Canada.
  9. Williams CL, Buscemi C, Rittman MR, Gubrium JF, Young ME, Boylstein CA, Chumbler NR. Cultural differences in stroke recovery among Hispanic American Veterans. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2003 Nov 22; San Diego, CA.
  10. Rittman MR. Culturally Sensitive Models of Stroke Recovery and Caregiving after Discharge Home. Paper presented at: University of Florida College of Nursing Faculty Annual Forum; 2003 Nov 14; Gainesville, FL.
  11. Boylstein CA. The Presentation of Self After Stroke. Paper presented at: American Sociological Association Annual Meeting; 2003 Aug 17; Atlanta, GA.
  12. Chumbler NR, Van Puymbroeck, Rittman MR, Vogel WB, Qin H. Depression Among Caregivers of Veterans with Stroke: The Mediator Effect of Sense of Coherence. Paper presented at: AcademyHealth Annual Research Meeting; 2003 Jun 29; Nashville, TN.
  13. Rittman MR. Caregiver Depression Related to Stroke. Paper presented at: Alpha Theta Chapter of Sigma Theta Tau International Annual Conference; 2003 Feb 21; Gainesville, FL.
  14. Williams CL, Velozo CA, Rittman MR. Cross Cultural Measurement of Depression in Community-Dwelling Veterans Recovering from Stroke. Paper presented at: Alpha Theta Chapter of Sigma Theta Tau International Annual Conference; 2003 Feb 21; Gainesville, FL.
  15. Williams CL, Sanchez TR, Rittman MR, Gubrium JF, Young ME, Boylstein CA. Health Promotion Among African American Veteran Stroke Survivors. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2002 Nov 25; Boston, MA.
  16. Rittman MR, Chumbler NR, Vogel WB, Qin H. Caregiver Coping Related to Burden and Depression at One Month After Discharge Home. Paper presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2002 Oct 13; Washington, DC.
  17. Rittman MR. Culturally sensitive models of stroke recovery and caregiving after discharge home. Paper presented at: VA HSR&D National Meeting; 2002 Feb 13; Washington, DC.
  18. Rittman MR, Williams CL, Chumbler NR, Gubrium JF, Young ME, Vogel WB, Gonzalez Rothi, Boylstein CA. Qualitative analysis of the experience of stroke recovery and caregiving after discharge home. Paper presented at: VA RR&D Annual Conference; 2002 Feb 10; Washington, DC.


DRA: Health Systems
DRE: Diagnosis, Treatment - Observational
Keywords: Caregiving, Ethnic/cultural, Nursing, Stroke
MeSH Terms: Cultural Diversity