Electronic ISSN 2287-0237




Cerebrovascular disease (CVD) is the second cause of death forthe global population at 5.8 million deaths in 2016.1 Similarlyin Thailand, stroke mortality rate rose from 31.7 per 100,000population in 2012 to 48.7 per 100,000 population in 2016.2 Likewise,Nakhon Sri Thammarat’s Health Service Area XI in Nakhon SriThammarat Province had the highest number of persons with CVD equalto 3,462 in 2017 and Maharaj Nakhon Si Thammarat Hospital alsoshowed that the number of stroke patients rose from 1,923 in 2013 to1,938 in 20153. This resulted in a higher risk of PS due to patientdisabilities4 and the need for care from their respective family caregiversin order to take part in activities of daily life.5 Thus, patients with CVDmight encounter many complications especially PS leading them to beafraid and anxious of wounds with a foul smelling odor.4 Furthermore,patients were concerned with body image, low level of satisfaction andan increase in medical costs. In the United Kingdom, these costs were1.25 times5 more approximately ranging from £1,214 (Pressure scoreStage 1) to £14,108 (Pressure score Stage 4). In Thailand, costs wereapproximately 30,000 Bath/a wound/ 7 (equal to 938 US) or moredepending on length of stay in hospital5 and PS severity.6 Thus, preventionof PS is essential and should be continuously performed at home byfamily caregivers in order to reduce readmission rate from PS. This wasshown to be approximately 12 % in a study in Thailand 8 because ofunchanged patient position.9

A study indicated that family caregivers of pesons withCVD had moderate competency in preventing complicationsbecause caring for CVD persons is complex and needs moreskills and expertise.9 Thus, numerous studies have beenapplied to many activities in intervention programs during theinitial hospital discharge period of approximately 4-12weeks.10-12 The intervention programs help to preventcomplications and include CVD knowledge, caring skills,consultation,10,11 home visits and telephone follow-ups12resulting in a significant increase in knowledge and skills offamily caregivers11-12 and lower PS incidence of patients.10,12Therefore, continuing care by family caregivers at home isessential to prevent PS because of patients’ immobility.A study conducted in the community used a family caregivergroup discussion training program to provide knowledge,skills, and home visits resulting in significant improvedknowledge, attitude and practices.13 Some studies abroad usedsmartphone applications such as Line, and these proved to bemore beneficial as they not only acted as a telephone resourcebut were also used to share knowledge and best practice withmassage techniques, videos, pictures and so on.12 This methodwas useful in order to continually monitor, to care for solvinghealth problems14 and to improve rehabilitation. This in turnresulted in lower complications, a decrease in fatigue amongfamily caregivers15 and reduced expenses and workloads ofhealth care teams.14 Therefore, integrating the Line applicationin PS prevention program is highly recommended and shouldbe more examined especially to study PS prevention outcomeof persons with CVD.

Maharaj Nakhon Si Thammarat Hospital in Nakhon SriThammarat Province, serves rural-urban communities in thesouthern part of Thailand. The hospital has reported an increasingincidence of persons with CVD needing more care from familycaregivers to prevent complications especially PS. Therefore,it is important to draw from Bandura’s self-efficacy Theory16emphasizing family participation with the belief that familycaregivers can provide worthy support and can expect to besuccessful in preventing PS for their patients, and they doprovide appropriate care. Perception of self-efficacy can bedeveloped from four resources namely: 1) Enactive masteryexperience, 2) Vicarious experience, 3) Verbal persuasion, 4)Physiological and affective stages

Thus, this program should be applied to family caregiversin order to enhance knowledge and skills to implement PSprevention measures for their patients. Therefore, researchersare interested in studying the effects of the PS preventionprogram on knowledge and self-efficacy of family caregiversin decreasing PS risk of persons with CVD.

A quasi-experiment research design, two grouppretest-posttest design, was used for this study. Population wasfamily caregivers taking care of persons with CVD. Samplewas family caregivers taking care of persons with CVD residing in the area under the responsibility of the Sub-districtHealth Promoting Hospital, Muang District, Nakhon SiThammarat Province from June-December 2017.Persons who passed inclusion criteria, included:

  1. Family caregivers without any benefit in taking care ofpatients with CVD ≤ 5 years with aged ≥ 20 years old andscore of Barthel Activities of Daily Living ≤ 60 point.
  2. Having a score of Short Portable Mental StatusQuestionnaire > 8 if age > 60 years old.
  3. Being able to use LINE application or telephone tocommunicate in Thai.
  4. Willing to give informed consent to participate in the study.

Participants meeting all four criteria were recruited intothe study. All participants were randomly divided into twogroups by geographic area: Western zone as an experimentalgroup and Eastern zone as a control group. The sample sizewas calculated using power analysis G*Power software17 basedon the findings of two studies18, 19 having an effect with a sizeequal to 2.18. Finally, we enrolled 30 family caregivers takingcare of persons with CVD to obtain sufficient statisticalpower (80%) in predicting the study outcomes with a statisticallysignificant result of p < 0.05.


The instruments used in the present study consisted of thePS prevention program with Bandura’s Self-Efficacy Theory16for 8 weeks, routine nursing care and instruments for datacollection. The intervention program developed by theresearchers was based on a review of literature and Bandura’sSelf-Efficacy Theory (Figure 1). The program given to theexperimental group consisted of two home visits (at week 1&2)to impart knowledge of the PS program and an assessment wasmade using videos, a demonstration20 by tablet and an adaptedhandbook of the PS program in CVD persons,21 a returndemonstration, and Line application or telephone calls twicea week at week 4, 6 and 8 to ask questions and to solve caringproblems as well as giving encouragement. The content of theprogram was validated by three experts of PS care in the fieldsof nursing and surgery. The Content Validity Index (CVI) wasdemonstrated as 0.81.

The routine nursing care given to the control groupinvolved home visits once a month for health assessment,suggestions for health problems and giving reinforcement.The evaluation questionnaires for data collection weredivided into several parts as follows.

The family caregivers’ demographic data questionnaireconsisted of gender, age, marital status, religion, education,occupation, family income, chronic diseases, relationships,care duration, caring experience, training for care and needs.

The CVD knowledge questionnaire was developed byresearchers based on the literature review with true-falseanswers for 30 questions. The CVI was shown as 1 and Kuder-Richardson (KR-20) demonstrated an acceptable reliabilityof 0.77, and 0.67 for the main study. The perceivedself-efficacy in the PS program questionnaire was developedby the researcher with 17 questions. Each item was assessedon a Likert scale from 1-4, where: “1 = not confident”, and“4 = most confident”. The CVI was demonstrated as 1 andCronbach’s Alpha Coefficient showed an acceptable reliabilityof 0.91, and 0.86 for the main study.

Persons with CVD’s demographic data questionnaireconsisted of age, gender, marital status, religion, education,occupation, other chronic diseases, health insurance and lengthof illness.

The Braden Scale for Predicting PS risk was developed byBraden and Bergstrom in 1988, and was translated into Thaiby Raksanan Kwanmuang22 with 6 questions. In this study, theBraden Scale was used with permission. Each item wasassessed on a rating scale from 1-4. A score of less than 12indicated high PS risk. The Cronbach’s Alpha Coefficient wascalculated at 0.69 and 0.70 for the main study.

Data Collection

The study commenced after receiving approval from theInstitutional Review Board, Faculty of Medicine, RamathibodiHospital, Mahidol University (ID No. 12-59-58). All potentialparticipants signed an informed consent form, data werecollected by the researcher in the procedure set out below. Atbaseline, an assessment was conducted in the first week,and all participants were asked to provide demographiccharacteristics, CVD knowledge, perceived self-efficacy in thePS program through answering questionnaires. The BradenScale was used to predict PS risk and to assess the participant’spatient. Then, the participants received the program for 8weeks. Data were obtained after finishing the program at theninth week as at the baseline as shown in Figure 1.


Figure 1: Research Process

Data Analysis

A computer software program was used to analyze datausing descriptive statistics for demographic characteristics anddependent variables including score of CVD knowledge,perceived self-efficacy in the PS program and the Braden Scalefor predicting PS risk. Paired t-test and Wilcoxon signed rankstest were used to compare scores of CVD knowledge, perceivedself-efficacy in the PS program within groups, meanwhileANCOVA and Mann Whitney U test was used to test betweengroups. Wilcoxon signed ranks test and Mann Whitney U testwere used to compare scores of the Braden scale for predictingPS risk within groups and between groups.

Twenty-seven participants in the experimental group andtwenty-six participants in the control group remained in thestudy (due to hospital admission in the hospital, death andmoving to other provinces). Most family caregivers in theexperimental and control groups were females (74.1% and80.8%) with mean ages of 51.04 years (SD = 15.90) and 54.73years (SD = 15.94), respectively. Two-thirds of participantswere either uneducated or educated at the elementary level(63.0% and 61.5%), respectively. Over half of the participantscontinued to work while caring for patients (59.3% and 65.4%,respectively). Two-thirds of the experimental group hadenough money without debts (73.1%) and the control groupequal to 96.2%. Two-thirds of the participants had no chronicdiseases (70.4% and 69.2%). Two-thirds of the participantswere sons/daughters, siblings or parents while the others werehusband or wife (40.7% and 30.8%, respectively). Almost halfof the experimental group and over half of the control grouphad assistance. Both groups had no prior experience of caregiving (88.9% and 84.6%, respectively) and needed help forgiving care at home (77.8% & 55.4%, respectively). Meanmonthly family income was 7,796.30 baht (SD = 7,005.96)and 8,269.23 baht (SD = 6,094.18); and participants providedcare approximately 21 hours a day, almost seven days a weekwith a duration equal to 29.67 months (SD = 16.72) and 34.23months (SD=16.72), respectively. All the participants’demographic data showed no significant difference betweengroups, using the Chi-square test, except family financialstatus (p < 0.05).

The characteristics of persons with CVD, the experimentaland control groups had a similar proportion of male (55.6%and 50%) with a mean age of 77.44 years (SD = 13.07) and73.50 years (SD = 14.54). Both groups were uneducated andeducated at the elementary level (85.2%, and 76.9%) andworked before illness (88.9% and 69.2%, respectively). Meanscore of activities in daily living indicated low level (M =33.89, SD = 16.95; M = 38.08, SD = 21.96, respectively).There was no statistical difference between groups excepthealth insurance (p < 0.05).

Before testing hypotheses, all study variables were testedfor normality and it was found that a mean score of CVDknowledge and a mean score of PS risk did not show normaldistribution. After receiving the PS prevention program,family caregivers in the experimental group had a higher meanscore of CVD knowledge and perceived self-efficacy in thePS prevention program than before the program with astatistical significance (p < 0.001) as shown in Table 1.

Before comparing the groups of family caregivers, theresults showed that only the mean score of perceived selfefficacyin PS program was significantly different. Afterreceiving the program, the mean score of CVD knowledge inthe experimental group was significantly higher than thecontrol group (Z = -3.61, p < 0.001) as shown in Table 2.Using Analysis of Covariance (ANCOVA), the experimentalgroup had a significantly higher mean score of perceived selfefficacyin the PS program score than the control group(F = 6.51, p < 0.05) as shown in Table 3.

Table 1: Comparison of mean score of CVD knowledge and perceived self-efficacy in PS program among family caregiverspre-test and post-test the experiment in the experimental group using the Wilcoxon signed ranks test and paired t-test (n = 27)

Table 2: Comparison of mean score of CVD knowledge between the experimental and control groups after receiving thePS prevention program using the Mann-Whitney U test (n = 53)

Table 3: Comparison of mean score of perceived self-efficacy in PS programbetween the Experimental Group (n = 27) and the Control Group (n = 26) afterreceiving the PS prevention program using ANCOVA statistics

Table 4: Comparison of mean score of PS risk in the Experimental Group (n = 27) and the Control Group(n = 26) pre-test and post-test the program using the Wilcoxon signed ranks test

Table 5: Comparison of mean pressure sore risk scores between the Experimental Group who received the PS prevention program andthe Control Group who received routine care using the Mann-Whitney test (n = 53)

The Wilcoxon signed ranks test was applied because ofthe non-normal distribution of the mean score of PS risk ofpersons with CVD in the experimental group who had receivedthe program as this had a significantly higher mean score ofPS risk than before receiving the program (p < 0.001). Thisindicated the experimental group with high scores had lowerPS risks as shown in Table 4. However, the mean score of PSrisk was not different when compared with the control groupusing Mann-Whitney Test (Z = -1.61; p > 0.05) as shown inTable 5.

After receiving the PS prevention program, the experimentalgroup had a significantly higher mean CVD knowledge scoreand a PS program perceived self-efficacy score whencompared with before receiving the program and the controlgroup (p < 0.001, p < 0.05) because family caregivers in theexperimental group received the PS prevention program basedon Bandura’s Self-Efficacy Theory.16 This is defined as :vicarious experiences through the cognitive process by providingCVD knowledge and PS program during home visits; Enactivemastery experiences through the motivational process bydemonstration and return demonstration of PS program;Verbal persuasion and preparation of physiological andaffective states through the affective process with two-waycommunication to listen problems, obstacles, participatoryproblem-solving and giving encouragement via LINE applicationor telephone follow-up. These processes lead to increasedknowledge and capabilities in the prevention of PS risk forpersons with cerebrovascular conditions. The findingsconcurred with previous studies revealing that family caregiversof persons with CVD showed improved knowledge and careskills after receiving a discharge plan program more thanbefore receiving the program21,23-24 as well as improvedknowledge in preventing complications.23

Moreover, persons with CVD in the experimental groupwho received the program had a significantly higher meanscore of PS risk than before the program (p <0.001) becauseof an increase in CVD knowledge and the PS program ofperceived self-efficacy score of family caregivers who weretrained in the program. However, mean PS risk scores of theexperimental group (16 ± 2.04) was higher than the controlgroup (15.08 ± 2.19) but this was not a significant difference.This might be because the control group (mean 34.23 months)had more experience to provide care for persons with CVDthan the experiment group (mean 29.67 months).

In addition, the control group had more assistance (61.5%)than the experimental group (44.4%). Furthermore, theexperimental group had more financial problems (25.9%) thanthe control group (3.8%). This finding differed from a studyrevealing that the experimental group had significantly lowerbedsore complications than the control group.19

The PS prevention program should be applied to familycaregivers in order to enhance CVD knowledge and selfefficacyto take care of persons with CVD. This enablescaregivers to take better care of their patients resulting inpreventing PS risk. Therefore, the PS prevention programshould be useful for other family caregivers of persons withCVD to prevent PS and further research should be conductedat the one year follow-up point for further PS risk prevention.