Hrev_master Healthcare in Low-resource Settings 2024; volume 12(s1):13066 The effect of family-supportive therapy on the burden of caregivers and Activities of Daily Living among stroke patients Nikmatul Fadilah,1,2 Loetfia Dwi Rahariyani,1 Hilmi Yumni,1 Dinarwiyata1 1Nursing Department, Health Polytechnic of the Health Ministry of Surabaya, Surabaya, East Java; 2Center for Excellence in Science and Technology-Community Empowerment, Health Polytechnic of the Health Ministry of Surabaya, Surabaya, East Java, Indonesia Abstract The role of family members in providing care for stroke patients at home is associated with heightened stress and burden on caregivers. Therefore, this study aimed to analyze the effect of family-supportive therapy on the burden of caregivers and Activities of Daily Living (ADL) among stroke patients. A quasi- experimental method was used with a pre-test and post-test con- trol group. The intervention of family-supportive therapy was given to the treatment group, while the control group received home visits. Samples of 40 caregivers in two primary health care centers in Surabaya were recruited using a multi-stage sampling method. The variables were the burden of caregivers and ADL of stroke patients, while Zarit Burden’s Interview Schedule and Katz Index of Independence in ADL were used as instruments. Data analysis was carried out using a Paired t-test and a Manova test. The results showed that the burden of caregivers in the treatment group decreased, but there was a re-increase after 2 weeks of ther- apy, and the burden in the control group also decreased. ADL of stroke patients in the treatment group increased and tended to per- sist up to 2 weeks after therapy, while the value in the control group decreased. Furthermore, family-supportive therapy did not have a significant effect on the burden of caregivers (p-value 0.12) and ADL (p-value 0.21). To address this challenge, modifying ser- vices through the implementation of community health programs, individual health efforts for stroke patients in the hospital and at home, group services for families providing primary health care, and home visits could be a comprehensive effort. The study found that family-supportive therapy and health education through home visits reduced caregiver burden. Introduction Family is recognized to play a crucial function in health care, particularly during the acute period of disease to the recovery and rehabilitation phase. This is specifically true for non-communica- ble diseases such as stroke, which currently tend to increase in prevalence both in urban and rural areas. However, the responsi- bility of providing care for stroke patients at home can lead to per- sistent stress and burden for caregivers. According to the 2018 Basic Health Research of Indonesia (Riset Kesehatan Dasar), East Java ranked third in stroke preva- lence.1 Weakness, physical disability, psychological problems, and depression cause obstacles to Activities of Daily Living (ADL) and even a decrease in Quality Of Life (QoL).2 A previous study stated that 50% of stroke patients’ caregivers had mild to moderate burden, and 5,8% showed moderate to severe burden.3 Persistent distress eventually strains and burdens both stroke patients and caregivers, in the emotional, social, and financial aspects.4–6 The high burden felt is manifested in the form of symp- toms of anxiety, depression, and low physical health.6 Caregivers often neglect personal health and are generally ignored by health- care professionals while family members pass through the recov- ery phase. To address this challenge, caregivers should also receive attention from health service providers in the form of informational, emotional, and instrumental support, as well as rewards to mitigate burden.7,8 The inability to cope with a crisis capable of causing strain or burden due to a stroke leads to low function and further increases the stressor experienced by family. A valid initial assessment of stroke patients, caregivers, and all family members is crucial for better preparedness to provide care at home. In this context, the assessment of experiences, perceptions, beliefs, and family sup- port is used as the basis for determining appropriate collaborative nursing interventions to make the coping mechanism of caregivers and family adaptive. Consequently, the crisis is resolved, and fam- ily welfare is achieved.9 Interventions currently provided by health services in the acute phase and rehabilitation for stroke cases tend to be patient- centered care. For example, during the rehabilitation phase, inter- ventions including therapeutic counseling, psychoeducation, and skills training have proven effective in reducing burden of care as well as increasing satisfaction, welfare, and quality of life among caregivers.4,10 All forms of therapy have the primary objective of providing help to individuals by eliminating or reducing suffering. Although several studies did not state the most effective therapy, several experts mentioned three interventions that reduced burden of mild to moderate care, namely psycho-educational, psychother- apy, and supportive. Family and group supportive interventions can also reduce burden of care and anxiety, while also increasing the ability to care for families with chronic disease, including Significance for public health Caring for stroke patients at home represents a significant source of stress for family members. This study indicates that the implementation of family-support- ive treatment led to a temporary reduction in caregiver burden and a positive improvement in stroke patients' daily activities. To further optimize the program's effectiveness, incorporating community health programs is recommended. This could involve prioritizing individual health initiatives for stroke patients with- in hospital and home settings, providing group services for families focusing on primary health care, and conducting home visits. [page 122] [Healthcare in Low-resource Settings 2024;12(s1):13066] Non -co mmerc ial us e o nly stroke, chronic kidney disease, and mental disease.7,11 Supportive therapy is one of the psychotherapy models that can be applied in the community and hospitals. This therapy is a form of family empowerment aimed at building relationships based on shared understanding and empathy with caregivers by focusing on strengths to help identify resources in the community. It is expect- ed to help family, specifically caregivers effectively resolve prob- lems when caring for family members who are sick, provide moti- vation and change in behavior, as well as carry out adaptive coping strategies.11–13 Therefore, this study aimed to analyze the effect of family-supportive therapy on burden of caregivers and ADL among stroke patients. Materials and Methods A quasi-experimental design was used, with a pre-test and post-test control group. Treatment group was given family-sup- portive therapy, and the control group received home visits. Samples were 40 caregivers in Surabaya recruited from July to September 2018 with multi-stage sampling. Caregivers from Pegirian and Pucang Sewu primary health care served as treatment and control group, respectively. The inclusion criteria included i) primary care provider, ii) family members who provided follow-up care at home, and iii) caregivers living at home with the treated stroke patients. The instruments used were Zarit Burden’s Interview Schedule6,14 and Katz Index of Independence in ADL.15,16 Zarit Burden’s Interview Schedule consists of 22 statements and scoring is carried out using the Likert scale comprising 0=never, 1=rarely, 2=sometimes, 3=often, and 4=always. The assessment of burden caregiver includes scores of 0-20 = no/little, 21-40 = light-moder- ate, 41-60 = moderate-heavy, and 61-88 = very heavy. Katz Index of Independence in ADL has six closed statements covering bathing, dressing, defecating, moving, continental, and feeding. The scoring uses a dichotomy scale (0=dependent and 1=independent). ADL assessment depends on whether patients can perform with or without supervision, direction, assistance, or total care. The previous questionnaire was tested on families who met the criteria but were not selected as respondents and the next step was to test the validity and reliability. All statements in Zarit Burden’s Interview Schedule were valid (p-value >0.30) and reli- able (p-value 0.923). Similarly, all Katz Index of Independence in ADL statements were valid (p-value >0.30) and reliable (p-value 0.870). This study was conducted using two groups, namely the control, and treatment, which received family-supportive therapy in four sessions. On the other hand, the control group received standard intervention of health education through home visits by health care providers. Burden of caregivers and ADL of stroke patients in the control group were measured twice, while in treat- ment group, measurement was carried out three times. Family-supportive therapy was implemented through four ses- sions with a duration of 50 minutes and spanning 4 weeks. Measurement for burden of caregivers and ADL of stroke patients was performed in the first session, fourth session, and about 2 weeks after the fourth session. Caregivers in the control group received two-session home visits, with a span of about 2 weeks from the first. A therapy-caring module for stroke patients was used, while burden of caregivers and ADL were measured at the first and second home visits. The variables assessed were burden of caregivers and ADL of stroke patients, while analysis was performed using a paired t-test and a Manova test by SPSS 21st edition. The paired t-test analyzed the relation between burden of caregivers and ADL of stroke patients pre-test and post-test. Manova test analyzed the more sub- stantial impact of family-supportive therapy on changes in burden of caregivers or ADL. Ethical approval letter was received from the Health Research Ethics Commission of Health, Ministry of Health, Surabaya, number 194/S/KEPK/V/2018, on 8th June 2018. Results and Discussion Burden of caregivers in caring for stroke patients in treatment group was reduced but there was a re-increase after 2 weeks fol- lowing family-supportive therapy. Similarly, burden of caregivers in the control group also decreased. ADL of stroke patients in treatment group increased and tended to persist until 2 weeks after therapy, while the value in the control group decreased. In general, family-supportive therapy did not have a significant effect on bur- den of caregivers (p-value 0.12) and ADL of stroke patients (p- value 0.21). Table 1 shows that caregivers of stroke patients in treatment group are mostly aged 46-55 years or early elderly (42.2%), women (82.5%), had elementary school education (40%), unem- ployed (55%), and have family relationships (57.5%). In addition, the majority had length of caring 1-2 years (40%) and 1-2 hours per day (57.5%), as well as had 1-2 health problems (47.5%). In the control group, a significant proportion of caregivers were aged 46-55 years or early elderly (35%), women (65%), had senior high school education (42.5%), unemployed, and entrepreneurs (42.5%). Furthermore, the majority had a length of caring 1-2 years (67.5%) and 1-2 hours a day (70%), had 1-2 health problems (49%), and worked as housewives (50%). Table 2 shows the two heaviest indicators for burden of caregivers , namely physical and financial. Table 3 shows a decreased burden of caregivers in the control group before and after following family-supportive therapy (p- value 0.063; d 2.75). However, 2 weeks after following up the ther- apy, burden increased (p-value 0.103; d -3.7). In the control group, burden of caregivers before and after home visits showed a decrease (p-value 0.000; d 8.525). Table 4 shows that the lowest independent fulfillment of ADL for stroke patients in treatment and control group was bathing. Table 5 shows an increase in ADL of stroke patients in treatment group after following family-supportive therapy (p-value 0.006; d - 3.5). However, 2 weeks after, stroke patients had a decreased ADL (p-value 0.401; d -0.1). In the control group, the decrease in ADL occurred after 2 weeks of home visits (p-value 0.668; d 2.633). Manova test results are shown in Tables 6, 7, and 8. Table 6 shows a variance in burden of caregivers variable between treatment and control groups (p-value 0.061). ADL of stroke patients between treatment and control group had the same variant (p-value 0.693). Table 7 shows that Box’s M tested the null hypothesis stating that the observed covariance matrices of the dependent variable, namely burden of caregivers and ADL of stroke patients were the same across both groups (p-value 0.212). Table 8 shows that family-supportive therapy did not affect burden of caregivers (p-value 0.12) and ADL of stroke patients (p-value 0.21). The partial eta squared value for burden of caregivers was slightly more significant than ADL. Specifically, the partial eta squared value on burden of caregivers was 0.031, implying that the effect of family-supportive interventions reached 3.1%. On the other hand, the impact of family-supportive therapy on ADL was 4th International Nursing and Health Sciences Symposium [Healthcare in Low-resource Settings 2024;12(s1):13066] [page 123] Non -co mmerc ial us e o nly low, estimated at 2% (partial eta square 0.02). Burden felt by most caregivers of stroke patients at home comprises both physical and financial, which are often perceived as more significant compared to emotional, timing, and social. The strain and burden of care- givers are influenced by gender (female), age (elderly), low educa- tion, job (retired), length of care, and mental health. Meanwhile, the influential factors of stroke patients are physical impairment/weakness of motor and cognitive function, depressive symptoms, decreased verbal ability, difficulty walking, and neuro- logical deficits.17,18 The condition of stroke patients who have sequelae contributes to the degree of dependence, which consequently adds to the phys- ical burden of caregivers. The sequelae of stroke patients show mainly in the form of stiffness, weakness, and extremity paralysis (88.75%). Furthermore, the age factor can also increase the depen- dency level, which has an impact on burden of caregivers. Based on the results, 77.5% of stroke patients were in the elderly age group (46-65 years) and 23.75% were more than 65 years. The physiological aging process of the neuromuscular system poten- tially decreases the limbs’ physiological functions, specifically the extremities, including a decrease in ADL ability.17,18 The financial burden is the second major burden of caregivers and is associated with the change in the major role of stroke patients being the head of family, who acts as the main financial source. The data showed that 63.75% of stroke patients were male and the head of family. This condition is in line with a previous study, stating that all families of stroke patients experienced changes in the economy, acting as a high stressor.8,19 Caregivers feel stress due to stroke attacks on family members from the acute therapy period at the hospital to the follow-up phase of care at home. Many stressors during rehabilitation are associat- ed with physical assistance to meet the daily needs of patients.2,20 A significant proportion of caregivers were in early elderly catego- ry (46-55 years) and 73.75% were women, with the majority being wives of patients. In terms of education, 7.5% were uneducated, and 32.5% had only primary school education. Almost half (48.75%) were unemployed (homemakers), while some made efforts to find additional income by becoming entrepreneurs or selling food at home up to 2 years after stroke attack on husbands. Most of caregivers (73.75%) had cared for family members suffer- ing a stroke for ≤2 years, with a therapy duration of 1-4 hours (87.5%). Health problems experienced by caregivers of stroke patients can affect burden. Based on the results, most of caregivers 4th International Nursing and Health Sciences Symposium Table 1. Demographic characteristics regarding caregivers of stroke patients (n=40). Demographic characteristics Category Treatment Control n % n % Age (year) 17-25 years old 4 10 3 7.5 26-35 years old 5 12.5 5 12.5 36-45 years old 12 30 5 12.5 46-55 years old 17 42.5 14 35 56-65 years old 2 5 10 25 >65 years old 0 0 3 7.5 Gender Male 7 17.5 14 35 Female 33 82.5 26 65 Education Not school 4 10 2 5 Elementary school 16 40 10 25 Junior high school 4 10 9 22.5 Senior high school 14 35 17 42.5 Diploma or bachelor’s 2 5 0 0 Postgraduate 0 0 2 5 Employment No employee 22 55 17 42.5 Government employee 2 5 1 2.5 Private employee 5 1.5 5 12.5 Entrepreneurship 10 25 17 42.5 Others 1 2.5 0 0 Family relationship Husband 2 5 8 20 Wife 23 57.5 20 50 Child 8 20 10 25 Others 7 17.5 2 5 Length of caring (year) < 1 year 11 27.5 6 15 1-2 years 16 40 27 67.5 3-4 years 9 22.5 5 12.5 ≥ 5 years 4 10 2 5 Duration of caring 1-2 hours 23 57.5 28 70 (hour/day) 3-4 hours 10 25 9 22.5 5-6 hours 4 10 2 5 ≥ 7 hours 3 7.5 1 2.5 Health problem No problem 10 25 15 37.5 1-2 problems 19 47.5 16 40 3-4 problems 11 27.5 8 20 5 problems 0 0 1 2.5 [page 124] [Healthcare in Low-resource Settings 2024;12(s1):13066] Non -co mmerc ial us e o nly 4th International Nursing and Health Sciences Symposium [Healthcare in Low-resource Settings 2024;12(s1):13066] [page 125] Table 2. Indicators regarding burden of caregivers for stroke patients. Group Indicators for burden of caregivers Mean Pre Post 1 Post 2 Treatment (n=40) Physical burden 1.35 1.17 1.4 Timing burden 0.66 0.55 0.54 Financial burden 1.33 1.05 1.5 Emotional burden 0.70 0.58 0.74 Social burden 0.23 0.2 0.28 Control (n=40) Physical burden 1.85 1.33 - Timing burden 0.59 0.33 - Financial burden 1.80 1.60 - Emotional burden 1.28 0.86 - Social burden 0.19 0.06 - Table 3. Burden of caregivers of stroke patients (treatment and control group). Burden of caregivers Treatment (n=40) Control (n=40) p (paired t-test) Mean SD Mean SD 1. Pre-test burden 17.30 11.697 26.23 8.069 2. Post-1 burden 14.55 10.195 17.70 7.532 3. Post-2 burden 18.25 12.689 - - 4. Different pre-post one burden 2.750 7.990 8.525 7.310 Treatment 0.036 Control 0.000 5. Different post-1-post-2 burden -3.700 14.008 - - Treatment 0.103 Table 4. Indicators of ADL among stroke patients. Group Indicator of ADL Mean Pre Post 1 Post 2 Treatment (n=40) Bathing 0.55 0.65 0.68 Dressing 0.68 0.83 0.88 Toileting 0.78 0.83 0.83 Transferring 0.9 0.95 0.95 Continent 0.98 0.95 0.95 Feeding 0.88 0.9 0.93 Control (n=40) Bathing 0.53 0.4 - Dressing 0.78 0.88 - Toileting 0.73 0.83 - Transferring 0.85 0.75 - Continent 0.9 0.98 - Feeding 0.8 0.88 - Table 5. Differences in ADL among stroke patients between treatment and control group. ADL of stroke patient Treatment (n=40) Control (n=40) p (paired t-test) Mean SD Mean SD Pre ADL 4.75 1.548 4.58 4.7 Post -1ADL 5.10 1.317 1.947 1.506 Post -2 ADL 5.20 1.224 - - Different pre-post 1 ADL -0.35 0.77 2.633 1.828 Treatment 0.006 Control 0.668 Different post-1-post 2 ADL -0.1 0.744 - - Treatment 0.401 Non -co mmerc ial us e o nly (68.75%) reported experiencing health problems including fatigue, certain diseases, and irritability. This condition is in line with a pre- vious study, stating that burden of caregivers manifests in the form of anxiety, depression, and low physical health.6,21–23 Common diseases experienced by caregivers include hyperten- sion, diabetes mellitus, gastritis, hypercholesterolemia, and hyper- uricemia. These diseases are included in the non-communicable category, which often require regular and long-term management of therapy to avoid complications. Caregivers tend to ignore per- sonal health problems while caring for stroke patients.24 Caregivers feel burden while caring for stroke patients who need help both physically and emotionally. This statement is a value/belief embraced and influenced by family culture in major Asian countries including Hong Kong. Moreover, it is a religious/religious value system with the principle that caring for sick family members, specifically the elderly, is a service from younger to older family members, specifically parents, as well as wives’ devotion to husbands/partners.25 Based on the results, caregivers of stroke patients who adhered to family-supportive therapy experienced a decrease in burden. However, after 2 weeks, there was an increase in burden of care. Health education provided to caregivers through counseling using modules of care can also reduce burden. Family-supportive thera- py and health education through home visits in families with stroke cases are among the interventions recommended in several previ- ous studies.4,10,26 Based on several reports, family-supportive ther- apy is widely used in family with mental, congenital, and chronic diseases.11,12,20 The objective is not limited to providing support and complementing the experience of isolation but also to plan, orga- nize, and respond positively to pressure, anxiety, burdens, and unpleasant circumstances. Furthermore, this therapy can increase strength, coping skills, and resources, improve autonomy in deci- sion-making, enhance the ability to achieve optimal independence, as well as reduce subjective distress and maladaptive coping responses.27 Evaluation of burden 2 weeks after family-supportive therapy showed an observable increase. Several studies showed that when social support was reduced, some families experienced increased psychosocial burdens and problems. To effectively manage burden and anxiety while caring for stroke patients, supportive therapy needs to be followed up on an ongoing basis with various methods. For example, this can be achieved through the use of information technology that enables health professionals and other therapy members to continually communicate and provide mutual support.11,28 Family-supportive therapy and home visits did not show a dif- ferent effect on burden of caregivers for stroke patients. Family- supportive intervention is a new therapy for caregivers that requires sufficient time to develop mutual trust and empathy between the therapist and members. During session 1, most of ther- apy participants were not able to assertively convey personal expe- riences and opinions about caring for stroke patients. Active partic- ipation of new therapy participants was observed in session 2, underscoring the need for pre-therapy readiness, specifically by health workers who play the role of a therapist. This is crucial to achieve the objective of therapy in four sessions. Most stroke patients are unable to achieve independence in ful- fillment of bathing, dressing, toileting, mobility, and feeding. The commonly experienced weakness or paralysis of the upper extrem- ities causes stroke patients to feel difficulty in fulfilling ADL, specifically bathing and dressing, leading to the need for care assistance from family members. This inability to fulfill ADL is reportedly associated with sequelae. Based on the results, most stroke patients (88.75%) experienced stiffness, weakness, and extremity paralysis, specifically in the upper limbs. A previous study in Purwokerto (Central Java, Indonesia) reported that in 1-3 months after the attack of stroke, 51.3% achieved mild to minimal independence based on the Barthel Index.29 In contrast, another study found that stroke patients at 6-24 months after occupational therapy achieved an independent activity of 7.7% and 92.3% of non-independent activities.30 A previous investigation at Tugurejo Hospital Semarang stated that 30%, 45%, and 20% of patients were partially, highly, and totally dependent, respectively.15 The decline in ADL ability could also be influenced by age, as 4th International Nursing and Health Sciences Symposium [page 126] [Healthcare in Low-resource Settings 2024;12(s1):13066] Table 6. Manova-test (Levene’s test of equality for error variances). Variable F df1 df 2 sig Burden 3.609 1 78 .061 ADL .157 1 78 .693 Table 7. Manova-test (Levene’s test of equality for error variances). Group N Box test Box’s M F df1 df 2 sig Treatment control 80 4.636 1.502 3 1095120.000 0.212 Table 8. Manova analysis (tests of between-subjects effects). Variable Mean square F Sig Partial Eta Squared Observed Power Burden 198.450 2.470 .120 .031 .342 ADL 3.200 1.600 .210 .020 .239 Non -co mmerc ial us e o nly demonstrated by the results in which 77.5% of stroke patients were 46-65 years old, and 23.75% were older than 65. The decline in the physiological function of the body systems, specifically the neuro- muscular system, impacts the independence of elderly patients to meet daily needs.17,18 ADL of stroke patients whose caregivers followed family-sup- portive therapy slightly increased and tended to persist for up to 2 weeks. Health education provided to caregivers through counsel- ing using care modules did not increase ADL. Family-supportive intervention helped increase individual roles, as motivators for patients. Caregivers convey not only the need to provide physical assistance but also to motivate patients to actively fulfill ADL. Gradual efforts to independently meet daily needs, specifically in the aspect of neuro-muscular function, are required in the rehabil- itation phase to reduce the residual symptoms in the form of weak- ness or paralysis. According to a previous study, stroke patients are advised to continually carry out routine control to monitor the improvement or deterioration in the condition.31 Efforts to increase independence in activities not only affect motor skills but also enhance self-esteem and confidence as well as reduce anxiety due to feelings of helplessness.32 Home visits intervention by health care providers to provide health education for stroke patients and caregivers did not help achieve independence. These home visits, which were carried out two times, had not yet achieved the purpose of establishing a stroke family as the focus of community healthcare activities pro- claimed by Puskesmas. This was because the frequency of visits was still one-third of the normal (about six visits). Currently, home visits remain at the stage of family identifica- tion to recognize health problems. In this context, obstacles are in the form of difficulty meeting the primary care provider for stroke patients who might be working outside home. This condition was supported by the employment data, with almost half of caregivers having no employees (42.5%). Therefore, efforts to follow up on the next home visits are needed to achieve the objectives of family independence, including the fulfillment of ADL. The conditions of stroke patients also contributed to the low ADL ability, specifically in the home visits group. This was supported by the data showing that the majority of caregivers were in the elderly age category, and most patients were in the rehabilitation phase of 1-2 years (82.5%). Family-supportive therapy and home visits did not show a dif- ferent effect on ADL in stroke patients. The similarity can be attributed to the shared focus of both interventions, primarily tar- geting caregivers in the early stages. Consequently, the initial impact of these interventions is largely directed towards achieving objectives related to support for caregivers, rather than ADL abili- ty. The independence of stroke patients in fulfilling ADL is influ- enced by several factors, including age, sequelae, frequency of attacks, duration of disease, rehabilitation, and patient motiva- tion.17,33-34 Caregivers play a significant role as motivators during long-term care at home. Therefore, these individuals should also be targets of public healthcare activities to achieve independent and prosperous family. Conclusions In conclusion, family-supportive therapy decreased burden on caregivers immediately but increased after 2 weeks. In addition, health education activities carried out through home visits also reduced burden. Both of these interventions were recommended to prevent and reduce burden on caregivers, although the most effec- tive method is yet to be proven. Family-supportive therapy and health education through home visits did not directly increase the independence of stroke patients in ADL. Therefore, it was neces- sary to modify several interventions and strengthen patient factors to achieve independence in ADL. References 1. Ministry of Health Republic of Indonesia. Basic Health Research. Jakarta: Ministry of Health Republic of Indonesia; 2018. 2. Ogunlana MO, Dada OO, Oyewo OS, et al. Quality of life and burden of informal caregivers of stroke survivors. Hong Kong Physiother J 2014;32:6–12. 3. Fadilah N, Rahariyani LD. The Impact of Independent of Activity Daily Living among Stroke Patients on Caregivers Burden. J Ners 2020;14. 4. Collins LG, Swartz K. Caregiver care. Am Fam Physician 2011;83:1309-17. 5. Gbiri CA, Olawale OA, Isaac SO. Stroke management: Informal caregivers’ burdens and strians of caring for stroke survivors. Ann Phys Rehabil Med 2015;58:98–103. 6. Kumar R, Kaur S, K R. Burden and Coping Strategies in Caregivers of Stroke Survivors. J Neurol Neurosci 2015;06. 7. Wurtiningsih B. Family Support For Stroke Patients In The Nervous Room Of Dr. Kariadi General Hospital Semarang. Medica Hospitalia J Clin Med [Internet]. 2013 Feb 8 [cited 2023 Aug 13];1(1). Available from: http://medicahospitalia.r skariadi.co.id/medicahospitalia/index.php/mh/article/view/42. 8. Bakas T, Clark PC, Kelly-hayes M, King RB, Lutz BJ, Miller EL. Evidence for Stroke Family Caregiver and Dyad Interventions. Stroke 2014;45:2836–52. 9. Bergstrom AL, Eriksson G, von Koch L, Tham K. Combined life satisfaction of persons with stroke and their caregivers: associations with caregiver burden and the impact of stroke. Health Qual Life Outcomes 2011;9:1. 10. Legg LA, Lewis SR, Schofield-Robinson OJ, et al. Occupational therapy for adults with problems in activities of daily living after stroke. Cochrane Database Syst Rev 2017;7:CD003585. 11. Suprobo KA, Wiyono N, Setyanto AT. The Effect of Supportive Group Therapy on Caregiver Burden in Wives Who Act as Primary Caregivers for Stroke Patients. J Univ Sebel Maret 2015;1–12. 12. Wahyuningsih SAA. Universitas Indonesia Library. Faculty of Nursing, University of Indonesia; 2011 [cited 2023 Aug 13]. The effect of supportive therapy on the ability of families to care for clients with chronic kidney failure (CKF) undergoing hemodialysis at PELNI Hospital, Jakarta. Available from: https://lib.ui.ac.id 13. Hernawaty. Family Supportive Therapy Module: In Families With Mentally Ill Clients. Jakarta, Indonesia; 2015. 14. Scholten EWM, Hillebregt CF, Ketelaar M, et al. Measures used to assess impact of providing care among informal care- givers of persons with stroke, spinal cord injury, or amputa- tion: a systematic review. Disabil Rehabil 2021;43:746–72. 15. Ratnasari P, Kristiyawati SP, Solechan A. Relationship Between Dependence Level On Daily Living Activity And Depression In Stroke Patients At Tugurejo Hospital Semarang. Scientific Paper 2012;0(0). 16. Bekdemir A, İlhan N. Predictors of Caregiver Burden in 4th International Nursing and Health Sciences Symposium [Healthcare in Low-resource Settings 2024;12(s1):13066] [page 127] Non -co mmerc ial us e o nly Caregivers of Bedridden Patients. J Nurs Res 2019;27:e24. 17. Munir B. Basic Neurology. 2th edition. Jakarta: Sagung Seto; 2018. 18. Hinkle JL, Cheever KH. Clinical handbook for Brunner & Suddarth’s textbook of medical-surgical nursing. Lippincott Williams & Wilkins; 2013 Nov 25. 19. Pambudi HA. Phenomenological Study: Family Anxiety in Stroke Patients Treated in the HND Room of Saint Lukas, Santa Elisabeth Hospital, Semarang. 2009 [cited 2024 Aug 13]. Available from: https://www.semanticscholar. org/paper/Studi-Penomenologis-%3A-Kecemasan-Keluarga- Pada-Yang-Pambudi/321d42b1cafdaab97e55557c072c 69eccd4c6367. 20. Handayani DY, Dewi DE. Analysis of quality of life of patients and families after stroke (with residual symptoms). Psycho Idea 2009;7:35-44. 21. Malhotra R, Chei CL, Menon EB, et al. Trajectories of positive aspects of caregiving among family caregivers of stroke-sur- vivors: the differential impact of stroke-survivor disability. Top Stroke Rehabil 2018;25:261–8. 22. Mckendry S, Wright M, Stevenson K. Why here and why stay? Students’ voices on the retention strategies of a widening par- ticipation university. Nurse Educ Today 2014;34:872–7. 23. Chow SKY, Wong FKY, Poon CYF. Coping and caring: Support for family caregivers of stroke survivors. J Clin Nurs 2007;16:133–43. 24. Bakas T, Austin JK, Habermann B, et al. Telephone Assessment and Skill-Building Kit for Stroke Caregivers. Stroke 2015;46:3478–87. 25. Chow EOW, Nelson-becker H. Spiritual distress to spiritual transformation : Stroke survivor narratives from Hong Kong. J Aging Stud 2010;24:313–24. 26. Björkdahl A, Nilsson ÅL, Sunnerhagen KS. Can rehabilitation in the home setting reduce the burden of care for the next-of- kin of stroke victims? J Rehabil Med 2007;39:27–32. 27. Stuart GW. Pocket Book of Mental Health Nursing. 5th ed. Jakarta: EGC; 2007. 28. Azza A, Susilo C, Efendi F. Supportive group therapy as a pre- diction of psychological adaptation of breast cancer patients undergoing chemotherapy. Indian J Public Heal Res Dev 2018;9:441. 29. Fadlulloh SF, Upoyo AS, Hartanto YD. The Relationship between the Level of Dependence in Fulfilling Daily Living Activities (ADLs) and Self-Esteem of Stroke Patients at the Neurology Polyclinic of Prof. Dr. Margono Soekarjo Hospital, Purwokerto. JKS 2014;9:134–45.. 30. Santoso TA. Independence In Eating, Bathing And Dressing Activities In Stroke Patients 6-24 Months After Occupational Therapy - Diponegoro University Institutional Repository (UNDIP-IR) [Internet]. 2003 [cited 2023 Aug 13]. Available from: http://eprints.undip.ac.id/12631/. 31. Mandic M, Rancic N. The recovery of motor function in post stroke patients. Med Arh 2011;65:106–8. 32. Farmer O, Belton S, O’brien W. The Relationship between Actual Fundamental Motor Skill Proficiency, Perceived Motor Skill Confidence and Competence, and Physical Activity in 8- 12-Year-Old Irish Female Youth. Sport 2017;5. 33. Fadilah N, Rahariyani LD. The Impact of Independent of Activity Daily Living among Stroke Patients on Caregivers Burden. J Ners 2019;14:188–94. 4th International Nursing and Health Sciences Symposium Correspondence: Nikmatul Fadilah, Nursing Department, Health Polytechnic of the Health Ministry of Surabaya, Jl. Pucang Jajar Tengah Street No. 56, Kertajaya, Gubeng, Surabaya, East Java, Indonesia. Tel.: +62315027058- Fax: +625028141. E-mail: nikmatulf@poltekkesdepkes-sby.ac.id Key words: Activities of Daily Living; burden of caregivers; family-sup- portive therapy; home visits. Contributions: NF participated in the study design, data collection and analysis, manuscript writing, and reference search. LDR participated in the study design, data collection, and analysis. HY participated in manu- script writing and reference searches. D participated in data collection and reference searches. Conflict of interest: the authors declare no potential conflict of interest. Funding: this study was financially supported by Health Polytechnic of the Health Ministry of Surabaya. Ethics approval: an ethical approval letter was received from the Health Research Ethics Commission of Health, Ministry of Health, Surabaya, number 194/S/KEPK/V/2018, on 8th June 2018. Clinical trials: not applicable. Conference presentation: part of this article was presented at the 4th International Nursing and Health Sciences Symposium, from 27th-28th of October 2023, Universitas Brawijaya, Malang, East Java Indonesia. Acknowledgment: the authors are grateful to the Director of Surabaya Health Polytechnic, who provided funding for this study. Received: 3 November 2023. Accepted: 11 June 2024. Early view: 10 September 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12(s1):13066 doi:10.4081/hls.2024.13066 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 128] [Healthcare in Low-resource Settings 2024;12(s1):13066] Non -co mmerc ial us e o nly