Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s2):13308 Psychoeducation through home care strengthens family coping in elderly stroke rehabilitation Aan Nurhasanah, Yuli Mulyanti, Sri Djuwitaningsih, Rosidawati Rositawati, Eros Siti Suryati Health Polytechnic Ministry of Health Jakarta III, Indonesia Abstract Post-stroke patients undergoing rehabilitation require family assistance to perform their daily activities. The family’s responsi- bilities as caregivers can create psychological, social, physical, and financial burdens, highlighting the need for coping strategies that enhance the ability of families and caregivers to alleviate these burdens without jeopardizing their health. Family caregivers are important in providing psychoeducation to post-stroke rehabil- itation patients through home care. The aim of this study was to evaluate the effectiveness of home care in improving family cop- ing strategies for elderly individuals undergoing stroke rehabilita- tion. A quasi-experimental design was implemented with a pre- post-test and control on 64 families, selected by purposive sam- pling. Data were collected using a closed questionnaire and ana- lyzed through t-tests (univariate and bivariate) and multivariate analysis of covariance (MANCOVA). The research results showed significant differences in knowledge before and after being given psychoeducation through home care (p=0.001), with a difference in average value of 0.9183, and family coping scores with a p- value of 0.035, with a difference in average value of 1.100. Providing psychoeducation through home care can significantly enhance family coping mechanisms when caring for elderly patients undergoing stroke rehabilitation. As an independent nurs- ing intervention, psychoeducation, delivered in the context of appropriate home care, plays a crucial role not only in empower- ing families but also in optimizing the environment for recovery. Introduction Stroke is one of the diseases that most often causes a decrease in functional abilities in patients, causing severe dependency.1 It has become a global issue, causing 17 million deaths each year, and is estimated to be the leading cause of death and disability in the world by 2020.2,3 Stroke is a complex condition that affects both the individual and their environment, including the family who cares for them (family caregiver).4 The family’s responsibili- ties as caregivers can create burdens, including psychological issues as well as social, physical, and financial challenges.5 Thus, there is a need for coping strategies to increase the ability of fam- ilies and caregivers to reduce the burden without endangering the family’s health in the form of psychosocial support and family- centered psychoeducational interventions.6,7 Implementing effec- tive coping strategies to reduce the burden on families of stroke survivors can also be achieved by implementing educational pro- grams and muscle relaxation. This is in accordance with research that stated that education and muscle relaxation programs can reduce anxiety, depression, and the burden of care for caregivers of stroke survivors.8 Research regarding the effects of home-based stroke rehabili- tation on increasing the functional abilities and independence of stroke survivors has been conducted in several countries, such as Denmark,9 Thailand,10 and Norway,11 with varying rehabilitation models and outcomes. Comprehensive stroke treatment to increase independence and minimize dependency in stroke patients can be achieved through a rehabilitation program.12 Family and health worker support fac- tors are closely related to patients’ compliance in participating in medical rehabilitation activities after experiencing a stroke.13 In addition, providing health education through exercise and utiliz- ing multimedia resources, along with family support, facilitates this process. This is because, with the development of Information Correspondence: Aan Nurhasanah, Health Polytechnic Ministry of Health Jakarta III, Jakarta, Indonesia. E-mail: Annur140864@gmail.com Key words: elderly; family coping; psychoeducation; home care; stroke rehabilitation. Contributions: AN, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; YM, conceptualization, investigation, methodology, validation, review & editing; SD, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; RR, methodol- ogy, visualization, writing – review & editing; ESS resources, investiga- tion, and writing – review & editing. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and consent to participate: the research was approved by the Health Research Ethics Commission, Poltekkes Kemenkes Jakarta III. During the study, the researchers focused on the ethical principles of autonomy, beneficence, justice, and non-maleficence. Consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Availability of data and materials: all data generated or analyzed in this study are included in this published article. Received: 28 October 2024. Accepted: 17 March 2025. Early view: 16 May 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 12(s2):13308 doi:10.4081/hls.2025.13308 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 prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13(s2):13308] [page 13] and Communication Technology (ICT), health education media are becoming increasingly diverse. Multi-interactive media are partic- ularly engaging, as they make health education more interesting through the combination of animated images and sound.14,15 The influence of interactive multimedia on students’ ability to under- stand mathematical concepts demonstrates that such tools positive- ly affect concept comprehension, which is the focus of this research.16 Home rehabilitation programs help stroke patients recover skills lost due to their condition.17 These programs aim to optimize the patient’s condition and increase their independence and func- tional ability in performing basic daily activities while also assist- ing the patient in adapting socially and mentally. One crucial factor that needs attention is how the family supports the patient. Family support encompasses the acceptance and actions of family mem- bers, including informational support, assessment support, instru- mental support, and emotional support.18 This indicates a relation- ship between the family’s role in caring for and motivating post- stroke patients and the patients’ compliance in participating in rehabilitation.19 Effective and adaptive coping strategies can serve a protective role in alleviating distress for families or caregivers. This study aimed to determine the effect of home care on improv- ing family coping in older people undergoing stroke rehabilitation. Materials and Methods Study design The research employs a quantitative approach using a quasi- experimental design with pre- and post-tests, including a control group. The intervention consists of psychoeducation delivered through multimedia formats such as PowerPoint presentations, images, and videos. The educational session lasted for two sessions of 50 minutes each. It began with a pre-test to assess participants’ baseline knowledge, followed by a psychoeducational intervention focused on stroke recurrence prevention and family coping strate- gies. After the session, a post-test was administered to evaluate knowledge improvement. The results showed a significant increase in knowledge, with an 80% improvement observed. This was fol- lowed by family support activities aimed at assisting in the rehabil- itation care of stroke patients. Study participants The population of this study comprised families who had elderly individuals undergoing stroke rehabilitation through home care and resided in the Cakung District Community Health Center area. The total sample included 30 families in the intervention group and 30 in the control group who met the inclusion criteria: stroke rehabilitation patients receiving home care who were able to collaborate, willing to participate as respondents, and capable of reading and writing. The exclusion criteria included families with- out elderly individuals in stroke rehabilitation, inability to collab- orate, unwillingness to participate as respondents, and inability to read and write. Variables, instruments, and data collection The independent variables comprised five demographic fac- tors: age, sex, education level, occupation, and relationship with the elderly. The implementation period was from March to June 2022. Data collection was carried out pre- and post-intervention by filling out a questionnaire, namely, before and after the interven- tion, as well as from the results of observations carried out on fam- ily health care (assistance) for elderly people undergoing stroke rehabilitation using an observation book. The data collection method employed a structured question- naire consisting of multiple-choice items with four response options: strongly agree, agree, disagree, and strongly disagree. The questionnaire included 15 items assessing problem-solving coping, 20 items measuring self-management learning, and 20 items eval- uating family burden in caring for elderly individuals undergoing stroke rehabilitation through home care. The research method used Pathways of Change, Part II Table 1. Participants’ characteristics (n=60). Variable Intervention group Control group p N % N % Age 0.56 ≤60 yrs 24 80 24 80 >60 yrs 6 20 6 20 Gender 0.40 Man 8 26.7 7 23.3 Woman 22 73.6 23 76.7 Level of education 0.06 Elementary school 5 16.7 7 23.3 Junior high school 8 26.7 9 30.0 Senior high school 17 56.7 9 30.0 College 0 0 5 16.7 Work 0.44 Self-employed 5 16,7 3 10 Civil servants 0 0 1 3.33 Employee 4 13.3 5 16.7 Housewife 19 63.3 19 63.3 Not Working 2 6.7 2 6.7 Relationship with the elderly 0.00 Child 14 46.7 27 90 Grandchild 7 23.3 1 3.33 Son-in-law 9 30 2 6.67 [page 14] [Healthcare in Low-resource Settings 2025;13(s2):13308] a pre- and post-test with a control plan for 30 families selected using purposive sampling. Data was collected using a closed ques- tionnaire. Data analysis A research instrument was used to collect primary data, which was then analyzed using both descriptive and inferential statistical methods. Descriptive analysis was conducted to examine respon- dent characteristics, including age, gender, education, occupation, and ethnic background. Inferential analysis involved t-tests (both univariate and bivariate) to assess differences between groups, along with multivariate analysis using multivariate analysis of covariance (MANCOVA) to evaluate the influence of multiple variables simultaneously. Ethical clearance The study received authorization from the DKI Jakarta Health Office and successfully passed an ethical review conducted by the Jakarta III Poltekkes Kemenkes Research Ethics Committee. Written informed consent was obtained from all participants in the study. Results Table 1 presents the distribution of research characteristics for 60 participants, divided into intervention and control groups, with a p-value indicating statistical significance. In terms of age (p=0.56), both groups have an identical distribution, with 80% under 60 years old and 20% over 60, showing no significant differ- ence. Gender distribution (p=0.40) is also similar, with women being the majority in both groups (73.6% in the intervention group and 76.7% in the control group). Regarding education level (p=0.06), more participants in the intervention group completed senior high school (56.7%), while the control group had a higher proportion of participants with junior high school education (30%) and college education (16.7%). Although the p-value is slightly above 0.05, it suggests a possible difference in education levels. Employment status (p=0.44) is comparable between groups, with housewives being the largest category (63.3% in both groups), fol- lowed by self-employed individuals, employees, and those not working, indicating no significant variation. However, the relation- ship with the elderly (p=0.00) shows a statistically significant dif- ference. In the control group, the majority of members are children of the elderly (90%), whereas in the intervention group, only 46.7% are children, with a higher representation of grandchildren (23.3%) and sons-in-law (30%). In conclusion, while most charac- teristics are evenly distributed between groups, the relationship with the elderly differs significantly, suggesting a potential influ- ence on the intervention outcomes. Table 2 presents statistical analyses of various scores related to family ability, coping, and stroke rehabilitation knowledge in both intervention and control groups. The family ability score shows a significant improvement in the intervention group (p=0.001), with an increase from 72.97 to 75.25. In contrast, the control group experienced a minimal increase, from 63.50 to 63.78, which was not statistically significant (p=0.634). The score for increased cop- ing also significantly improved in the intervention group (p=0.000), rising from 69.25 to 76.50, whereas the control group showed only a minor increase, from 60.06 to 61.34, which was not statistically significant (p=0.091). Regarding ability/skills to improve coping, the intervention group exhibited a statistically sig- nificant improvement (p=0.020), while the control group did not. Similarly, knowledge of stroke rehabilitation increased significant- ly in the intervention group (p=0.000), whereas the control group showed little change. Discussion Family assistance for patients undergoing stroke rehabilitation Pathways of Change, Part II Table 2. Multivariate analysis. Variable Group Mean SD 95% CI T p Family Ability Score Intervention group 3.39 -3.50 – -1.05 -3.80 0.00 Before 72.97 After 75.25 Difference -2.281 Control group 3.30 -1.47 – -0.91 -0.48 0.63 Before 63.50 After 63.78 Difference -0.281 Increased coping Intervention group 6.87 -9.72 – -4.72 -5.96 0.00 Before 69.25 After 76.50 Difference -7.250 Control group 4.15 -2.77 – 0.21 -1.74 0.09 Before 60.06 After 61.34 Difference -1.281 Ability/skills to improve coping Intervention -22.812 3.39 -3.67 – -0.32 2.31 0.02 Control -0.2812 3.30 Knowledge of stroke rehabilitation Intervention -7.250 6.872 -8.80 – -3.13 2.28 0.00 Control -1.281 4.152 [Healthcare in Low-resource Settings 2025;13(s2):13308] [page 15] is essential due to the complex nature of stroke and its associated challenges. Families often face significant challenges, sacrificing time and effort to seek information and support as part of the care- giving and healing process. Research on family relationships with elderly individuals shows that the responsibility most often falls on the children. This is largely due to the deep emotional bonds between parents and their children, as well as the sense of duty and obligation children feel toward their aging parents. To ensure the best possible care, families – particularly adult children – can choose to collaborate with skilled nursing facilities. These partnerships can support families in providing high-quality, professional care tailored to their loved ones’ needs. Middle-aged adults, in particular, often find themselves in the pivotal role of caregivers as their parents begin to experience the challenges of aging.20 A study has also shown that families caring for post-stroke elderly individuals recovering from a stroke must adapt holistical- ly, encompassing biological, psychological, social, and spiritual aspects.21 Family, as a source of social support, can be a key factor in implementing stroke rehabilitation. One study found a relation- ship between family support and the independence of stroke patients;22 if family support is strong, the respondent will be more independent. Family plays an important role in providing care, serving as a nursing caregiver for those with vulnerabilities, including all family members affected by physical disabilities, such as chronic illnesses.18 One alternative solution to the problem is through home care activities, as home care is a health service provided continuously and comprehensively to individuals and families in their own envi- ronment. This support helps families improve, maintain, or restore health while maximizing independence and minimizing disability due to stroke. The research results illustrate that the p-value is 0.000, which means psychoeducation services through home care significantly influence family coping in caring for the elderly with stroke rehabilitation. This is consistent with previous research, which found that implementing home care can strengthen the role of the family and increase family independence in providing opti- mal care at home.23 Similarly, enhancing the role and responsibili- ties of family health can boost family independence in caring for post-stroke patients.24 The results provide an overview of the need for family support and the importance of effective strategies to alleviate the burden on families assisting stroke patients during their rehabilitation. Previous research states that to encourage caregivers to utilize practical coping skills, appropriate programs must be designed and implemented to support them.25,26 Effective use of coping skills to reduce levels of personal burden can improve caregivers’ physical health and psychological well-being.13,7 Psychoeducation significantly reduces the burden experienced by caregivers of stroke survivors.27,28 When providing home care for stroke patients, nurses play a crucial role by offering both psy- choeducational support and caregiver resources.29 The family, as a primary source of social support, can be a key facilitator in pro- moting effective rehabilitation in the home setting. Early initiation of rehabilitation at home has been shown to reduce disability and enhance quality of life. Compared to standard care, home-based stroke rehabilitation is also more cost-effective. However, unre- solved family conflicts can worsen the caregiving environment and negatively impact both patient recovery and caregiver well-being. Conclusions Home care-based psychoeducation demonstrated a measurable impact on the coping strategies employed by families, with notable differences observed between the intervention and control groups. Specifically, the intervention group showed a greater average increase in problem-solving coping scores. Improvements were also recorded in attitudinal aspects, and a significant difference emerged in stroke rehabilitation activities, particularly in the area of skill development. These findings indicate that providing psy- choeducation through home care has a significant effect on enhancing the coping abilities of families caring for elderly indi- viduals undergoing stroke rehabilitation. Family-centered health services delivered via home care can help alleviate the burden faced by caregivers. Promoting healthy coping mechanisms through structured psychoeducation not only supports the health and recovery of elderly stroke patients but also enhances overall family well-being and productivity. References 1. Widarti L, Krisnawati K. Home Care Holistic On The Change Of Anxiety And Depression For The Patient With Stroke Ischemic. J Ners 2012;7:107. 2. Rasyidah QA, Fitryasari R, Wahyudi AS. A Relationship Between Stress Level And Burnout Syndrome With Sleep Quality On Clinical Nursing Students In Faculty Of Nursing Universitas Airlangga. Psychiatry Nurs J (Jurnal Keperawatan Jiwa) 2020;2:16–25. 3. Machin A, Widiawan SP, Lefi A, et al. Stroke Risk Factors Based on The Framingham Stroke Risk Score Among Urban vs Rural Elderly Communities. Mal J Med Heal Sci 2024;20:35–41. 4. Camicia M, Lutz BJ, Markoff N, Catlin A. Determining the Needs of Family Caregivers of Stroke Patients during Inpatient Rehabilitation Using Interview, Art, and Survey. Rehabil Nurs 2019;44:328–37. 5. Kusumawardani W, Yusuf A, Ni’mah L. Family burden and coping in family caregivers of patientwith schizophrenia. Indian J Public Heal Res Dev 2019;10:1506–10. 6. Herawati C, Suwandono A, Putra ST, et al. Effect of psychoe- ducation-modification on the improvement of spiritual response, perception stigma, anxiety level and cortisol levels among lepers. Indian J Public Heal Res Dev 2019;10:1873–8. 7. Yunita FC, Yusuf A, Nihayati HE, Hilfida NH. Coping strate- gies used by families in Indonesia when caring for patients with mental disorders post -pasung, based on a case study approach. Gen Psychiatry 2020;33. Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0- 8 5 0 7 9 6 6 6 5 7 6 & d o i = 1 0 . 1 1 3 6 % 2 F g p s y c h - 2 0 1 8 - 100035&partnerID=40&md5=4e1248e2e33a75dc09f773fe35 3c2d6e 8. Wang J, Dang W, Hui W, et al. Investigating the Effects of Intrinsic Motivation and Emotional Appeals Into the Link Between Organic Appeals Advertisement and Purchase Intention Toward Organic Milk. Front Psychol 2021;12. 9. Rasmussen RS, Østergaard A, Kjær P, et al. Stroke rehabilita- tion at home before and after discharge reduced disability and improved quality of life: A randomised controlled trial. Clin Rehabil 2016;30:225–36. 10. Chaiyawat P, Kulkantrakorn K. Effectiveness of home rehabil- Pathways of Change, Part II [page 16] [Healthcare in Low-resource Settings 2025;13(s2):13308] itation program for ischemic stroke upon disability and quality of life: A randomized controlled trial. Clin Neurol Neurosurg 2012;114:866–70. 11. Askim T, Mørkved S, Engen A, et al. Effects of a community- based intensive motor training program combined with early supported discharge after treatment in a comprehensive stroke unit: A randomized, controlled trial. Stroke 2010;41:1697–703. 12. Winstein CJ, Stein J, Arena R, et al. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke 2016;47:e98–169. 13. Sumakul VDO, Notobroto HB, Devy SR. Coping Strategies, Self-Efficacy, and Perception Among Family Caregivers for Post-Stroke Survivors in Indonesia. Malaysian J Public Heal Med 2022;22:124–30. 14. Kustyarini K, Utami S, Koesmijati E. The Importance of Interactive Learning Media In A New Civilization Era. Eur J Open Educ E-learning Stud 2020;5. 15. Abdulrahaman MD, Faruk N, Oloyede AA, et al. Multimedia tools in the teaching and learning processes: A systematic review. Heliyon 2020;6. 16. Novitasari D. Pengaruh penggunaan multimedia interaktif ter- hadap kemampuan pemahaman konsep matematis siswa. FIBONACCI. J Pendidik Mat dan Mat 2016;2:8–18. 17. Mayo NE. Stroke Rehabilitation at Home: Lessons Learned and Ways Forward. Stroke 2016;47:1685–91. 18. Friedman MM, Bowden VR JE. Buku Ajar Keperawatan Keluarga Teori dan Praktik. In: EGC. 5th ed. Jakarta: EGC; 2012. 19. Putri Utami K, Rizky Rinanda Nur Fauziyah A, Faradilla Rahim A. The Relationship Between Family Involvement in Physiotherapy Home Programs and Activity Daily Living in Post-stroke Patients. KnE Med 2023. 20. Morais D, Faria C, Fernandes L. Filial Maturity and Caregiving to Aging Parents. Geriatr 2024;9. 21. Creasy KR, Lutz BJ, Young ME, Stacciarini JMR. Clinical Implications of Family-Centered Care in Stroke Rehabilitation. Rehabil Nurs 2015;40:349–59. 22. Setyoadi S, Nasution TH, Kardinasari A. Hubungan Dukungan Keluarga Dengan Kemandirian Pasien Stroke Di Instalasi Rehabilitasi Medik Rumah Sakit Dr. Iskak Tulungagung. majalahkesehatan 2017;4:139–48. 23. Hapsari MA, Mubarokah K. Analisis Kesiapan Pelaksanaan Rekam Medis Elektronik (RME) Dengan Metode Doctor’s Office Quality-Information Technology (DOQ-IT) di Klinik Pratama Polkesmar. J-REMI J Rekam Med dan Inf Kesehat 2023;4:75–82. 24. Bahadoram S, Arsalani N, Fallahi-Khoshknab M, et al. The Principles of Home Care for Patients with Stroke: An Integrative Review. Iran J Nurs Midwifery Res 2024;29:503– 14. 25. Kazemi A, Azimian J, Mafi M, et al. Caregiver burden and coping strategies in caregivers of older patients with stroke. BMC Psychol 2021;9. 26. Sawab S, Bahrudin M, Catharina Daulima NH. Hopelessness Experience among Stroke Survivor in Semarang. J Ners 2015;10. 27. Putri TARK, Ramadita W, Supriatin E, Hayati SN. Psychoeducational Intervention for Family Caregiver Burden in Stroke Patients Care. Risenologi 2022;7:21–5. 28. Sudja N, Meirina M. Psychoeducation Intervention Increase on The Ability of The Pre-Senile Hypertension Management. J Ners 2017;9:66–73. 29. Hanik EN, Lestari D, Laily H, et al. The effect of family psy- choeducation therapy on the anxiety level of family of patients with CRF undergoing hemodialysis. Int J Pharm Res [Internet] 2020;12:1691–6. Available from: https://www.scopus. com/inward/record.uri?eid=2-s2.0-85089700697&doi= 10.31838%2Fijpr%2F2020.12.04.246&partnerID=40&md5=d f2db9d1e4640cf3a51ed7e4f1533662 Pathways of Change, Part II [Healthcare in Low-resource Settings 2025;13(s2):13308] [page 17]