Importance of social support for Indonesian stroke patients with depression

Nizar Yamanie; Aly Lamuri; Yuli Felistia; Oedojo Soedirham; Windhu Purnomo; Amal Chalik Sjaaf; Muhammad Miftahussurur

doi:10.12688/f1000research.126504.1

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Research Article

Importance of social support for Indonesian stroke patients with depression

[version 1; peer review: 1 not approved]

Nizar Yamanie¹, Aly Lamuri², Yuli Felistia², [...] Oedojo Soedirham³, Windhu Purnomo⁴, Amal Chalik Sjaaf⁵, Muhammad Miftahussurur ^6,7

Nizar Yamanie¹, Aly Lamuri², [...] Yuli Felistia², Oedojo Soedirham³, Windhu Purnomo⁴, Amal Chalik Sjaaf⁵, Muhammad Miftahussurur ^6,7

PUBLISHED 12 Dec 2022

Author details Author details

¹ Doctoral Program of Medical Science, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
² National Brain Center, Jakarta, Indonesia
³ Department of Health Promotion and Behavioral Science, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia
⁴ Department of Biostatistics and Population, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia
⁵ Department of Public Health, Universitas of Indonesia, Jakarta, Indonesia
⁶ Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine-Dr. Soetomo Teaching Hospital, Universitas Airlangga, Surabaya, Indonesia
⁷ Helicobacter pylori and Microbiota Study Group, Institute Tropical Disease, Universitas Airlangga, Surabaya, Indonesia

Nizar Yamanie
Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Aly Lamuri
Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing

Yuli Felistia
Roles: Conceptualization, Methodology, Resources

Oedojo Soedirham
Roles: Conceptualization, Data Curation, Methodology, Validation, Writing – Original Draft Preparation

Windhu Purnomo
Roles: Conceptualization, Data Curation, Methodology, Writing – Original Draft Preparation

Amal Chalik Sjaaf
Roles: Conceptualization, Methodology, Writing – Original Draft Preparation

Muhammad Miftahussurur
Roles: Conceptualization, Supervision, Writing – Original Draft Preparation

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background: Approximately one-third of stroke survivors experience depression at some point, which is linked to poor functional results and high mortality rate. Social support from family, friends, and the community is an intervening variable in stroke outcomes aside from the rehabilitation treatments that patients receive. This study assessed the importance of social support for stroke patients with depression and its relationship with patient rehabilitation.
Methods: This quantitative study used a cross-sectional approach on stroke patients and their families based on data from the Social Security Administrator for Health (BPJS Kesehatan). One hundred and four participants were recruited using purposive sampling by including stroke patients who have used National Health Insurance (JKN) for stroke medications.
Results: We found that instrumental, emotional, interactive, and information support contribute to lowering depressive symptoms. Instrumental support in the form of food availability, money, goods, and services had the highest coefficient value for reducing depression. Emotional support in the form of care and compassion had the second highest value in reducing depression. Further, interaction and informational support remain critical components of social support in reducing depression.
Conclusion: The support system plays a key role in decreasing the depression level in stroke survivors. The family and neighborhood have a significant impact on accelerating the rehabilitation process of stroke patients by providing support.

Keywords

Stroke, social interaction, informational support; non-communicable disease, depression.

Corresponding author: Muhammad Miftahussurur

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2022 Yamanie N et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Yamanie N, Lamuri A, Felistia Y et al. Importance of social support for Indonesian stroke patients with depression [version 1; peer review: 1 not approved]. F1000Research 2022, 11:1484 (https://doi.org/10.12688/f1000research.126504.1) First published: 12 Dec 2022, 11:1484 (https://doi.org/10.12688/f1000research.126504.1) Latest published: 12 Dec 2022, 11:1484 (https://doi.org/10.12688/f1000research.126504.1)

Introduction

Strokes greatly affect the lives of survivors and has been recognized as a main cause of disability.¹ Long-term impairment of motor, sensory, and/or cognitive functions are experienced by stroke patients, and this is highly likely to correlate with social changes.² Strokes have contributed to the death of 6.6 million people worldwide, including 3.3 million due to ischemic stroke, 2.9 million due to intracerebral hemorrhage, and 0.4 million due to subarachnoid hemorrhage.³^,⁴ In Indonesia, approximately 10.9% of the population, over the age of 15, were affected by some form of stroke with the highest occurrence in East Kalimantan (14.7%) and Yogyakarta (14.6%).⁵^,⁶

Patients who have suffered a stroke and their caregivers are burdened with health, economic, and social consequences.⁷ Epidemiological studies have indicated that approximately 30% of stroke patients in the early or late stages develop post-stroke depression, which affects the rehabilitation motivation of patients, reduces the rehabilitation effect, and increases the burden of family care.⁸^–¹⁰ Approximately one-third of stroke survivors experience depression at some point in their lives, which is linked to poor functional results and high mortality.¹¹^–¹³

To be able to live independently, patients must learn adaptation skills, including the ability to search for social resources. A stroke patient also need supports such as emotional, informational, instrumental, and social interaction support.¹⁴^–¹⁶

A patient who maintains meaningful social connections and actively engages in social activities successfully recovers and rejoins society. To interact or participate in social activities, the patients require physical abilities. To provide comprehensive healthcare, functional therapists should address the psychological requirements of stroke patients in addition to rehabilitation activities.¹⁷ This study aimed to assess the importance of social support among stroke patients with depression and the relationship between social support and patient rehabilitation.

Methods

A quantitative, cross-sectional approach was used in this study. The participants included stroke patients and their family members who were selected based on data from the Social Security Administrator for Health (BPJS Kesehatan). Using purposive sampling, we recruited 104 participants aged >30 years. The study period was from November 8^th to December 15^th 2021 and was conducted by Prof. Dr. Mahar Mardjono of the National Brain Center Hospital.

Each of the participant complete the questionnaire. The data were distributed by the Social Security Administrator for Health.

Variables and measurements

The socio-demographic data that were assessed in this study were: age (30–39 years, 40–59 years, and >60 years), sex (male and female), highest education (primary, secondary, and higher education levels), last occupation (public sector, private sector, and retirement/unemployment), salary index (below 4.6 million and above 4.6 million rupiah – based on DKI Jakarta’s minimum standard salary), being a caregiver (yes or no), accompanied by family during check-ups (yes or no), the ownership of National Health Insurance (yes or no), transferred patients (yes or no), first medication (yes or no), stroke duration (>6 months, 7–12 months, and >1 year), returning to work after stroke (yes or no), the status of occupation post-stroke (full-time, part-time, and retirement/unemployment), social support (low, average, or high support),¹⁸ and work productivity (stagnant or decreased).

To measure the support system of caregivers, we used social support terminology, which is divided into emotional, informational, instrumental, and social interaction support (low, average, high). For depression levels, we used the Hamilton Rating Scale for Anxiety (HARS).

Statistical analysis

The data were analyzed using IBM SPSS Statistics version 26.0. (SPSS, Inc., Chicago, IL, USA; RRID:SCR_019096). For categorical variables, values were expressed as proportions and percentages, whereas for quantitative variables, means and standard deviations were reported. Fisher’s exact test was used for other variables. The statistical significance level was set at a p value of 0.05.

Structural Equation Model

In this study, support systems were indirectly measured as reflective observable variables, including social, emotional, instrumental, informational, and social interaction support. A structural equation model (SEM) model was used to evaluate this relationship using lavaan package in the R project for statistical computing (R Foundation for Statistical Computing, Vienna, Austria; RRID:SCR_001905). Since all the observed variables were ordinal data (a categorized form of the measurement), we performed a polychoric correlation by applying a diagonally weighted least square (DWLS) estimator to the SEM model. Goodness of fit in the SEM model was measured using relative fit metrics, that is, the comparative fit index (CFI) and Tucker-Lewis index (TLI), and absolute fit metrics, namely the root mean square error of approximation (RMSEA) and standardized root mean residual (SRMR). For CFI and TLI, the thresholds for goodness of fit were >0.9 CFI, <0.08 for RMSEA, and <0.1 for SRMR. After confirming the latent construct of the support system, we further evaluated the relationship between the support system and depression scores by fitting a structural equation model (SEM).

Results

Socio-demographic data of participants

The total number of participants in this study was 104 families each containing a stroke patient. The majority of participants were older than 60 years (50%), followed by those who were 40–59 years (46.2%). The study involved a higher number of male participants (67 patients, 64.4%) than female participants (35 patients, 35.6%). Most participants had secondary education (44.2%), followed by higher levels (41.3%). All working participants were employed in the private sector, and as many as 58 (55.8%) earned a monthly income over 4.6 million rupiah (67.3%).

The participants tended to have no caregivers during the stroke (93.3%). Approximately 89.4% of the participants had been visiting the medication center facility with their families. Nearly all participants were covered under National Health Insurance (98.1%), and 58.7% were classified as transferred from primary healthcare facilities. Approximately 89.4% of the participants were not on medication for the first time. In addition, 65.0% of participants decided not to work after experiencing a stroke. Further, 66.3% of the participants were retired or unemployed. Moreover, approximately 84.5% of the participants declared that their work productivity decreased after their stroke.

The socio-demographic characteristics of the participants are depicted in Table 1. First, with regard to family support, patients who received this support at a high level (89.4%) demonstrated a significant correlation with the decrease in depression (X²=52.9; p<0.01). Second, high emotional support (91.4%) also significantly influenced the decrease in depression (X²=27.2; p<0.01). Third, patients who received a high level of instrumental support from their families (83.4%) were more likely to have decreased depression levels (X²=56.7; p<0.01) that those who received low or an average level of support. Fourth, high-level informational support from the family (87.5%) tended to decrease depression levels among stroke patients (X²=9.3; p<0.01). Finally, high developmental support (89.4%) indicated a positive correlation (X²=104.0; p<0.01).

Table 1. Socio-demographic characteristics of participants.

Variables	n	%	X² (p value)
Age
- 30–39 years	4	3.8	60.3
- 40–59 years	48	46.2	(0.19)
- >60 years	52	50.0
Gender
- Male	67	64.4	2.14
- Female	37	35.6	(0.34)
Education
- Primary level	15	14.4	1.39
- Secondary level	46	44.3	(0.84)
- Higher level	43	41.3
Last occupation
- Public sector	10	9.6	3.58
- Private sector	58	55.8	(0.46)
- Retirement/unemployment	36	34.6
Salary
- <4.6 million	34	32.7	1.61
- >4.6 million	70	67.3	(0.44)
Having caregiver
- Yes	7	6.7	3.50
- No	97	93.3	(0.17)
Accompanied by family
- Yes	93	89.4	0.64
- No	11	10.6	(0.72)
Ownership of National Health Insurance
- Yes	102	98.1	0.56
- No	2	1.9	(0.75)
Transferred patient
- Yes	61	58.7	1.28
- No	43	41.3	(0.52)
Status of medication
- First time	11	10.6	0.11
- More than once	93	89.4	(0.94)
Stroke duration
- <6 months	63	60.6	4.54
- 7–12 months	21	20.2	(0.33)
- >1 year	20	19.2
Returning to work post-stroke
- Yes	36	35.0	0.66
- No	67	65.0	(0.71)
Status of occupation
- Full-time	16	15.4	0.57
- Part-time	19	18.3	(0.96)
- Retirement/unemployment	69	66.3
Working productivity
- Decrease	87	85.6	1.88
- Stagnant	15	14.4	(0.39)
Social interaction support
- Low	2	1.9	52.9
- Average	9	8.7	(0.00)
- High	93	89.4
Emotional support
- Low	4	3.8	27.2
- Average	5	4.8	(0.00)
- High	95	91.4
Instrumental support
- Very low	1	1.0
- Low	2	1.9	56.7
- Average	14	13.7	(0.00)
- High	87	83.4
Informational support
- Low	2	1.9	9.31
- Average	11	10.6	(0.00)
- High	91	87.5
Developmental support
- Low	1	1.0	104
- Average	10	9.6	(0.00)
- High	93	89.4

Association between various types of social support and depression status among stroke patients

Initially, we assessed a latent construct of the support system, reflected as the categorized variables of social support, emotional support, instrumental support, informational support, and recognition. The latent variable was assessed using a SEM model using a DWLS estimator, resulting in a fit model (CFI=1, TLI=1, RMSEA=0, and SRMR=0.05). The seemingly high CFI and TLI, along with a very low RMSEA, could indicate a small sample size and low correlation among the observed variables. Although the model is constrained to the sampled population, it provides the insight that all measures correspond to the latent construct of the support system. In the SEM model, social support was used as a reference for the other variables. All the variables positively contributed to the latent construct of the support system, indicating that all the instruments measured the same dimension. From the following table, we can conclude that instrumental support provides the highest contribution to the support system, whereas informational and social interaction support make the lowest contribution to the support system (Table 2).

Table 2. Relationship between variables in the support system.

Types of Support	B	SE	Z	p
Support system (latent)
Social	1.00	-	-	-
Emotional	0.94	0.32	2.98	0.003
Instrumental	1.18	0.40	3.02	0.003
Informational	0.73	0.24	3.04	0.002
Social interaction	0.73	0.23	3.21	0.001

* Significant (p<0.05)

Since the model returned a good fit, we determined how the latent construct of a support system corresponded to the measure of depression using a structural equation model (SEM) as depicted in Figure 1. Upon model fitting, the model indicated CFI=1, TLI=1, RMSEA=0, and SRMR=0.05, similar to the model fitness of the SEM model. The reflective behavior of each observed variable follows a trend similar to that of the SEM model, where instrumental support has the highest contribution and informational support has the lowest contribution. The estimated latent variable of social support is inversely proportional to depression, where each additional point in social support reduces the depression score by 0.2 points (p=0.042).

Figure 1. The relationship between social support system and depression.

Discussion

This study found that socio-demographic factors, particularly age and sex, play a significant role in depression levels among stroke survivors. Most stroke patients are over 60 years of age. The findings of the present study are in line with the results of other research¹⁹^–²¹ which demonstrated that the onset of a stroke mostly occurred among elderly individuals aged 60–80 years. In fact, age is a non-modified factor for ischemic stroke because of the changing anatomy of arteries, which tend to become narrower and harder with aging. Aside from age, we found that sex has also been classified as a predominant factor of strokes, in which males are more likely to be diagnosed with a stroke compared with females, similar to a previous study.¹⁹^,²⁰^,²²

This research found that a variety of support systems for stroke patients, including instrumental, emotional, information, and social interaction support, are inversely proportional to the level of depression. Instrumental support was the first significant support. Family instrumental support is a type of support directly provided by the family, such as loans for food, money, goods, and services.²¹ According to instrumental support is direct and tangible, such as lending money or alleviating the stress which accompanies performing tasks.²³ This study found that instrumental support had a significant positive relationship with low levels of depression. This finding is in line with the findings of previous studies.²⁴

Emotional support has a significant relationship with low depression levels in stroke patients. Theoretically, people have a propensity to absorb the emotions and moods of others, which occurs through unconscious interactions.²⁵ The close partners of patients, including caregivers and family members realize the anxiety and depression of the patients.²⁶

Social interaction support is also positively correlated with depression levels in stroke patients, wherein the higher the social interaction support they received from the family, the lower their depression level. Supporting this finding, a study revealed that using social interaction support as a rehabilitation strategy to improve the quality of life of stroke patients is effective.²⁷ Furthermore, stroke patients feel isolated, and their physical and psychological conditions will improve only if they obtain a high degree of social interaction support. Moreover, social interaction support is associated with a decline in depression symptoms,²⁸ and prevents stroke recurrence.²⁹^,³⁰

Informational support was highly likely to be associated with low depression levels in stroke patients. Information support is defined as the provision of knowledge to seek help in solving practical problems. If this form of support is combined with emotional and instrumental support, it is referred to as the quality of social support. concluded that informational support aimed to fulfil the psychological and physiological needs of stroke patients and can be gained through social interaction support.⁸ In contrast, one study indicated that the majority of stroke patients did not receive appropriate informational support, especially from their families.³¹

Furthermore, several important limitations of this study must be considered. Firstly, this was a cross-sectional study, which did not imply causality. Secondly, a recall memory bias could have occurred when the health history of patients was enquired. However, the data were representative of the data obtained from the National Brain Center Hospital.

Conclusions

Instrumental, emotional, interactive, and information support play key roles in decreasing depression in stroke patients. Families of patients have a significant impact on providing these types of support. Hence, rehabilitation of stroke patients involving the family is important to increase the possibility of preventing depression due to a stroke. Social interaction should be the predominant support for stroke patients since this support can not only improve physical rehabilitation but also the psychological conditions of patients. The findings of this study suggest that practitioners should educate the families of stroke patients on how to strengthen the mental health of the patients using a combination of informational and social interaction support. We suggest a public policy to initiate the establishment of a social support center for stroke patients for social therapy and rehabilitation to improve the condition and quality of life.

Consent

The authors certify that the participants provided informed consent after the objectives of the study were explained. Before recruiting participants, we provided detailed information and confirmed their agreement to participate by obtaining their signatures in the informed consent form. The families have been informed that names and initials will not be published, and due efforts will be made to conceal the identities of patients, but anonymity cannot be guaranteed.

Ethical approval

This study obtained ethical approval from Prof. Dr. Mahar Mardjono of the National Brain Centre Hospital Research Ethics Committee (reference number LB.02.01/KEP/089/2021).

Author Contributions

Nizar Yamanie: Conceptualization, Methodology, Writing—original draft preparation, Writing—review and editing; Aly Lamuri: Conceptualization, Writing—original draft preparation, Writing—review and editing; Yuli Felistia: Conceptualization, Methodology, Resource, Writing—review and editing; Oedojo Soedirham: Conceptualization, Methodology, Data curation, Validation, Writing—original draft preparation; Windhu Purnomo: Conceptualization, Methodology, Data accuracy, Writing—original draft preparation; Amal Chalik Sjaaf: Conceptualization, Methodology, Writing—original draft preparation; Muhammad Miftahussurur: Conceptualization, Supervision, Writing—original draft preparation.

Data availability

All data underlying the results are accessible through Mendeley data storage.

Data for: Importance of social support for Indonesian stroke patients with depression. https://doi.org/10.17632/xpzcnf3998

The project contains the following underlying data:

- data (The directory containing all input data):
- ○ clean.csv (De-identified primary data)
- ○ sub-data.csv (Subset of data used for fitting a SEM)
- RData (The directory containing R session objects):
- ○ 01-linear-model. RData (Objects from script 01-linear-model. R)
- ○ 02-pca. RData (Objects from script 02-pca. R)
- ○ mod-cfa-support-system. Rds (The CFA model)
- ○ mod-linreg. Rds (The linear regression model)
- ○ mod-pca-support-depression. Rds (The PCA model)
- ○ mod-sem-support-depression. Rds (The SEM model)

Reporting guidelines

Data repository name: https://doi.org/10.17632/xpzcnf3998

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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