Introduction

Stroke is a medical emergency, the gap between recovery and impairment or death for people who had a stroke is measured in hours, it is critical for healthcare practitioners to have a basic awareness of stroke and how to respond to it as part of their daily routine (Taylor et al., 2019). Stroke is the major cause of adult disability and the second largest cause of death, it can cause tingling and spasms in the muscles, as well as a lack of ability to detect heat and cold in the body, mind, and emotions. Weakness or paralysis of the extremities, swelling of the arms or legs, and tight or painful joints are all possible side effects (Goudie, 2017).

A stroke can leave a person with a feeling of fatigue that makes daily work difficult. A stroke can have a serious impact on how the brain processes information, depending on where the damage occurred. Memory, learning ability, and general awareness of the environment can be compromised; it can also impair your ability to communicate through speech and writing. The ability to read and concentrate can also be compromised. Sleep disorders can lead to poor memory and cognition (Armstrong, 2018).

Pay interest to the symptoms and signs begin, the duration of time they were gift can have an effect on your remedy options: trouble with speaking and understanding, paralysis or numbness of the face, arm or leg, trouble with seeing in a single or each eyes, sudden, excessive headache, which can be observed through vomiting, dizziness or altered attention and trouble with walking (Murano et al., 2019).

Healthy lifestyle which includes not smoking, maintaining a healthy weight, following a healthy diet, and daily exercise can reduce the risk of having a stroke to the half. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein and can lower the risk of stroke. Stroke risk screenings are an ideal opportunity to lower stroke risk by identifying people or groups of people who are at high risk for stroke. Patients and the community must be educated about recognition and prevention of stroke. Research findings suggest that low-dose aspirin may lower the risk of stroke in women who are at risk (Boehme et al., 2017).

Caregiver is someone who accountable for getting to the wishes of a baby or based adult. A caregiver can offer a huge variety of service, relying at the diploma of disability, economic situation and living environment of the person disability (Reynolds et al., 2019).

The responsibilities of informal caregivers are as follows: Personal care such as (hygiene, nutrition, home care such as cleaning and meal preparation), auxiliary care such as (shopping and transportation), care such as (counseling and emotional support, conversation), and (Care plans such as (establishing and coordinating support for patients) (Brugiavini et al., 2019).

The main goal of teaching community care is to help stroke victims and caregivers achieve independence. The quality of education enhances the ability of clients and families to better care for their needs. Better results can be obtained by considering the client's learning needs in the context of the client's family and community. These results include improved care, ease of recovery, reduced complications of the disease and return to activities of daily living (ADLS) (Orchard et al., 2017)

The Community health nurse in home health care (HHC) is the roles of clinician that provide direct care to the clients and families, which include educator, investigator, administrator and consultant are seen in home health care. The experienced home health nurse manager or the administrator can fulfill this role (Mixon et al., 2020).

Aim of the Study

The aim of this study was to assess the care provided by family caregivers for post stroke patient at home

Research Question:

• What is the health care provided by family caregivers for post stroke patient at home
• Is there relationship between the care provided by family caregivers for post stroke patient at home and their socio-demographic characteristics?

Significance of the study

Globally, 70% of strokes and 87% of both stroke-related deaths and disability-adjusted life years occur in low- and middle-income countries. One in six people worldwide will have a stroke in their lifetime. Fifteen million people worldwide suffer a stroke each year and 5.8 million people die from its (Ramachandran & Rogers-R., 2019).Nearly seventy million people worldwide are affected with stroke annually with a mortality rate among them up to sex million and another sex million had left with permanent disability.

In Egypt, there are 14.8% of people are suffering from stroke, and 1600 cases died every year from stroke. About 47% of patient had at least two or more modifiable risk factors smoking, physical inactivity and hypertension (Aziz et al., 2019).

Post-stroke dementia was detected in 20.8% of patient, it was recorded more in old ages, illiterates, unmarried, unemployed, and those with recurrent stroke and with cerebral infarction. Post-stroke dementia is high in Egypt, especially in those with illiteracy, brain atrophy, severe strokes, and those presented with hemiplegia, sphincter affection, abnormal gait, and psychotic features (Al Fawal et al., 2021).

SUBJECT and METHODS

Aim of the Study

The aim of the current study was to assess the care provided by family caregivers for post stroke patient at home

Research Question:

-     What is the care provided by family caregivers for post stroke patient at home

-     Is there relationship between the care provided by family caregivers for post stroke patient at home and their socio-demographic characteristics?

Research Design:

A descriptive research design was utilized in this study.

Setting:

This study was conducted at Minia University Hospital Neurology Outpatient Department. The hospital is located on the west bank of the Nile, opposite the Nile Upper Bridge, south of Minia city. The areas offered were on the western side of the city of Minia and the province of Minia. The hospital consists of two parts, the education part consists of classes for the education and training of medical and nursing students, and the second part consists of 37 outpatient departments and 27 inpatient departments in various specialties. Investigators choose this hospital because it has more cases than any other hospital. The outpatient clinic for nervous system patients in a university hospital works every Saturday and Wednesday and has three doctors (one senior and two juniors) and four nurses every day. Most cases of different age groups, most strokes, occur in the elderly and follow postoperative cases after neurosurgery. Servants of neurological clinic are serving neurological and stroke cases, providing appropriate treatment, wound care for postoperative cases, and referring cases to physiotherapy for rehabilitation

Sample:

Purposive sampling of 180 patients who matched the research criteria was selected at outpatient stroke clinics. The sample was collected through six months from (from first July to the end December 2020). The investigator used to attend of the medical clinic in the Neurology department to follow up the cases, the average number of cases present daily in the clinic is approximately 150 cases that come to follow up. The clinic time was from 9 AM in the morning until 2 PM

Tool of data collection:

Tools were adapted by investigator and it was a structured interviewing assessment questionnaire which is consisted of two tools:

• 1^st tool: consists of two parts :
• part1: Personal & medical Data Questionnaire: Structured Interviewing Questionnaire Form consisted of 15 closed ended questions:  The questionnaire includes: Socio-Demographic characteristics: Of post-stroke patients, this part is covered (i.e., age, sex, marital status & education).

The medical health history of post-stroke patients, it covers the medical diagnosis, date of occurrence, number of recurrence, and types of medications and present complaints (Cornelia et al., 2018).

• Part 2: The Barthel ADL Index: It developed by Barthel (1965)  to assess then degree of independence of the patient it is consist of 10 items (transferring, bathing, dressing, toileting, continence, feeding, stairs, exercises, and grooming) (Ohshima et al., 2017).

2^nd tool: consists of two parts :

• Part 1: post stroke care checklists to assess exercise, medications, preventing another stroke, pressure ulcer, mobility and rehabilitation (Bjornestad, et al., 2018).
• Part 2: Post stroke complications checklists to assess e.g. pneumonia, and urinary tract Infection and Deep venous thrombosis (DVT) (WHO) 2017.

Scoring system

• The Barthel activity of daily living Index (ADL): includes structured face to face interviewing questionnaire consisted. Total possible scores range from (0- 7), with lower scores indicating increased disability Activities of day by day dwelling rating (0-20). Each object scored as follows (0-7) for Dependent, (8-12) for Assisted unbiased with assistant and (13-20) for Independent (Ohshima et al., 2017)
• Post stroke care checklists each item scored as follows: (1) For did not perform (2) for perform incomplete (3) For perform correct and complete the total score is (50-150) categorized as unsatisfied caregiver (50-100) and satisfied caregiver (100-150) (Bjornestad, et al., 2018).
• Post stroke complication checklist questionnaire includes structured face to face consisted of 15 closed ended questions about complications related to stroke. The total score is categorized as follows: (7-14), (10-7) for unsatisfied client, (11-14) for satisfied client (Ohura, et al., 2017).  

Validity of Content:

The content validity of the data collection tools as a post stroke patient personal data questionnaire, the Barthel Index (activity of daily living) tool questionnaire and a post stroke care checklist. tools were submitted to five experts in community health nursing to test their validity. The tools were examined for content coverage, sequence of items, clarity, relevance, applicability, wording, length, format, and overall appearance. Based on experts` comments and recommendations; minor modifications had been made such as rephrasing and rearrangements of some sentences.

Reliability

Internal consistency of interview questionnaire was assessed with the Cronbach's alpha coefficient. Cronbach's alpha coefficient of 0.00 indicates no reliability and a coefficient of 1.00 indicates perfect reliability. However, a reliability coefficient of 0.70 is acceptable. The reliability testing was performed for each tool and the results were as represented in table (A).

Table (A): Conbach’s alpha for each tool:

Pilot Study

A pilot study will be conducted on 10 % of the sample to test study data collection tools in terms of their clarity, applicability, and time required to fulfill it. According to the results, based on the result of pilot study, the necessary modification in the items was done and included in the study.

Ethical Consideration

A written approval obtained from the ethics and research committee of the Faculty of Nursing, Mina University. Oral consent obtained from each participant after explaining the nature & objectives of the study to gain their cooperation. Each assessment sheet was coded and subjects' names were not appearing on the sheets for the purpose of anonymity and confidentiality. Subjects were free to withdraw from the study at any time.

Study Procedure

Permission to conduct the study was obtained from the manager of Minia University Hospital after explaining the importance and purpose of the study and obtained all permissions to collect data. The data were collected through six months from the beginning of July to the ending of December 2020. All needed sheets of the tool were printed, and data were collected from the caregivers. The investigator was meeting the patients and their caregivers in the clinic of nervous system patients in a university hospital that works every Saturday and Wednesday and has three doctors.

After consulting the doctors, I choose the cases based on the criteria shown in the study, if patient is able to check the form by himself or his caregiver Purpose of the study was explained to the caregivers before starting the interview where each caregiver was interviewed individually. Each caregiver took around 45: 60 minute to fill the tool. The investigator read questions and waits until caregivers complete the questionnaire for illiterate caregivers, while caregivers who read and write took questionnaire and filled it by themselves.

Questionnaire took about 60 minute for illiterate caregivers and 45-50 for educated caregivers to complete the tool. The investigator filled (3-5) tools from caregivers daily. Data was collected regarding patients' demographic characteristics, clinical data, knowledge regarding stroke and life style modifications, and factors affecting compliance among patients suffering from recurrent stroke through stroke patients' structured interview questionnaire.Then the investigator determined relation between compliance with life style modifications among patients suffering from cerebrovascular stroke.

Statistical analysis

The data will be tabulated and analyzed by using “statistical package for the social science “(SPSS), descriptive statistics will be utilized as, Frequency, percentage, mean and standard deviation. Qualitative variables were compared using Chi-square test Pearson correlation. P-value less 0.05 was considered as statically significant

Results

Table (1): Distribution of studied caregiver according to demographic characteristics at Minia University Hospital (2020) (N=180).

Table (1) summarizes that, 53.2% of study sample their age ranges from 45:50 and 55:60 years old, with the Mean ± SD = 51.7 ± 6.7 year, 79% of them are married, 5% are widowed, 52.8 of them are illiterate, 6.7% has university education, 94% are extended families while 66.7% have insufficient income to their family and 66.1% of the client numbers of family is 4-5

Table (2): Distribution of post-stroke patients according to medical history at Minia University Hospital (2020) (N=180).

Table (2) presents that, 48.9% of post-stroke patients are diagnosed as stroke and 35% is hypertension complication leaded to stroke happening as regard to onset of diagnosis occurrence stroke, 47.2% of them the date of stroke from 6month to 1 year, 32.8 % of them admitted to ICU unit. Only 32.8% admits by brain bleeding disorders. Regarding the presence of chronic diseases48.9% has hypertension and 20% has heart disease Also, 51.7% of them are cigarette smokers and 23.9 of them are non-smoker. Regarding the Neurological disorder 32.8% of them have brain bleeding and 22.2% of them have brain clots

Table (3): Distribution of study sample caregivers practices for post stroke patients Medication at Minia University Hospital (2020) (N=180).

Table (3) shows that, 57.2 %of caregivers give patient medications on time but only 12.8 %of them don’t. There are 45.6% of study clients use it in right way administration to deal with their patients on the other hand there is

15.6 % doesn’t. There are 40 % of study sample are on incomplete performance to diabetic and hypertensive drugs but 26 % of them are not completely, also 44.4% of them are not storing medications correctly

Table (4): Correlation between Barthel Index and Care Giver Practice, Minia University Hospital (2020) (N=180).

NS = not significance                                       P – value ≤ 0.05                                         *=significant

Table (4) shows that there is no significant correlation between Barthel Index and care giver practices (P= 0.773)

Table (5): Relation between Some Barthel Index and Socio Demographic Variables at Minia University Hospital (2020) (N=180).

NS = not significance                           P – value ≤ 0.05                                               *=significant

Table (5) illustrates that, there are statistical significance differences between total BARTHEL INDEX practices among adult at home with medical diagnosis (p-value = 0.00)

Table (6): Relation between Selected Socio Demographic Variables and Care Givers Practices at Minia University Hospital (2020) (N=180).

NS = not significance      *P – value ≤ 0.05                                                                  *=significant

Table (6): shows that, there are statistical significance differences between total practice patient care givers at home with ICU patient admission. It is observed that 58.3% of care givers having unsatisfactory practice level of care, (p-value = 0.027)

Figure (1): Distribution of study sample according to activity of daily living among patient stroke Barthel Index at Minia University Hospital (2020) (N=180).

Figure (1): explores that, 43.3% of post stroke patient are independent for feeding and 20% of them are unable, also 46.7 % of study clients need help during toilet and 26.7% unable, and 45.7% of them need help during bathing and shower time. As regard as 42.2 % of post stroke patient need help during dressing clothes but only 14.4 % of them is unable. On the other hand there are 14.4. % of study patients is dependent, and 44.4% of them are independent to mobile while 39.4

% needs help during climbing stairs also 28.3% are unable to move up stairs

Figure (2): Frequency Distribution of Study Sample According To Their Complications at Minia University Hospital (2020) (N=180).

Figure (2) summarizes that 75% of the study sample become depressed as quickly as 68 % of them has infected by pneumonia .with inside the equal case 65% of submit stroke sufferers from urinary tract infection. How approximately that 72% of them have mattress sores and seizures post stroke, on the other hand 74% of study sample complain of deep venous thrombosis while 63 % of them have a limb contractions

Figure (3): Frequency Distribution of Study Sample According Barthel Index at Minia University Hospital (2020) (N=180).

Figure (3) clears that 46.7% of my study sample are independent for total Barthel Index while 8.3% are dependent to others during doing their activities

Figure (4): Frequency Distribution of study sample according Total post stroke care practices at Minia University Hospital (2020) (N=180).

Figure (4) shows that 66.1 % of my study sample are satisfied for total post stroke care while 33.9 % of them are unsatisfied to others during doing their activities.