F1000ResearchF1000Research2046-1402F1000 Research LimitedLondon, UK10.12688/f1000research.126504.1Research ArticleArticlesImportance of social support for Indonesian stroke patients with depression
[version 1; peer review: 1 not approved]
YamanieNizarConceptualizationMethodologyWriting – Original Draft PreparationWriting – Review & Editing1LamuriAlyConceptualizationWriting – Original Draft PreparationWriting – Review & Editing2FelistiaYuliConceptualizationMethodologyResources2SoedirhamOedojoConceptualizationData CurationMethodologyValidationWriting – Original Draft Preparation3PurnomoWindhuConceptualizationData CurationMethodologyWriting – Original Draft Preparation4SjaafAmal ChalikConceptualizationMethodologyWriting – Original Draft Preparation5MiftahussururMuhammadConceptualizationSupervisionWriting – Original Draft Preparationhttps://orcid.org/0000-0003-1415-6033a67
Doctoral Program of Medical Science, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
National Brain Center, Jakarta, Indonesia
Department of Health Promotion and Behavioral Science, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia
Department of Biostatistics and Population, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia
Department of Public Health, Universitas of Indonesia, Jakarta, Indonesia
Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine-Dr. Soetomo Teaching Hospital, Universitas Airlangga, Surabaya, Indonesia
Helicobacter pylori and Microbiota Study Group, Institute Tropical Disease, Universitas Airlangga, Surabaya, Indonesiamuhammad-m@fk.unair.ac.id
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.
Strokesocial interactioninformational support; non-communicable diseasedepression.The author(s) declared that no grants were involved in supporting this work.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).
ResultsSocio-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 (X
2=52.9; p<0.01). Second, high emotional support (91.4%) also significantly influenced the decrease in depression (X
2=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 (X
2=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 (X
2=9.3; p<0.01). Finally, high developmental support (89.4%) indicated a positive correlation (X
2=104.0; p<0.01).
Socio-demographic characteristics of participants.
Variables
n
%
X
2 (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).
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).
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 research
19–21 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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Relationship Of Family Support To Post Stroke Depression Levels In Outpatient Installation Dr. Kariadi Semarang.Proceeding International Conference On Health, Social Sciences And Technology.2021;1:115–117.10.5256/f1000research.138923.r242303Reviewer response for version 1KhatibanMahnaz12Refereehttps://orcid.org/0000-0002-7060-2205
School of Nursing, York University, Toronto, Ontario, Canada
School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
Competing interests: No competing interests were disclosed.
Thank you for sending the manuscript entitled "Importance of social support for Indonesian Stroke Patients with depression" for review. This manuscript reports the correlation between social support for stroke patients with depression and patient rehabilitation among stroke patients and their families. In general, I liked the topic of the study, as social support is a crucial variable in stroke outcomes. However, I believe there are some areas where the author could provide further clarification. Please consider addressing the following details:
Title:
Please modify the title to “Correlation between social support and depression for Indonesian stroke patients: A cross-sectional study” in the title.
Abstract:
Please provide the exact aims of the study. What is your meaning of importance in the “This study assessed the importance of social support for stroke patients with depression and its relationship with patient rehabilitation”? I suggest writing: for example: the correlation between social support for stroke patients with their depression and rehabilitation.
Please provide some information about the questionnaires you applied.
Please address exactly who was your study population. were they the patients, their families, or both?
How did you calculate your sample size?
Although you have mentioned that you used purposive sampling, I cannot find the purpose of sampling. So, add some reasonable purposes, for example: the patient’s depression was confirmed by their physician or something like that.
The result part: You have conducted a correlational or cross-sectional study, which indicates that you should use appropriate connecting words while writing the results. Rather than stating the sentence "Emotional support in the form of care and compassion had the second highest value in reducing depression", it is recommended to frame it as people with stroke who reported less depression also reported receiving more emotional support. This will help in presenting your results more effectively.
Please rewrite the conclusion.
Keywords:
Please provide the most relevant and specialized keywords according to MeSH.
Introduction
It would be beneficial to provide a clear reasoning for examining the correlation between social support and depression in stroke patients. This involves explaining why this correlation is important and relevant, especially in the Indonesian context. A brief discussion on the potential impact of social support on stroke recovery and patient well-being would help strengthen the justification for the study.
At the end of the introduction, the authors’ assumptions are not clearly explained. The readers wouldn’t figure out why they selected these concepts for their study. In my opinion, the introduction could focus more clearly on the rationale for this study.
Method
Please explain your settings in your country.
The authors have mentioned: “The participants included stroke patients and their family members who were selected based on data…”. But, I cannot distinguish the results of patients from family members. Who were the study participants? Patients? Family members? Or both?
Sampling
What was the reason that you chose only >30 years old participants?
Although you mentioned using purposive sampling, the purpose was not clear. Please clarify the purpose, for instance, the physician's confirmation of the patient's stroke, duration of disease, and having no comorbidity diseases such as diabetes, or CHF, ….
Why didn't use a more reliable sampling, for example, cluster or categorical sampling?
Is there only one hospital in Indonesia for stroke patients? If there are several hospitals, explain the reason for choosing one of them, National Brain Center Hospital.
Why did you choose purposive sampling for selecting the participants?
It seems you had the sampling framework that makes it easy to use probability sampling.
Sample size
How did you calculate your sample size?
Did all of the participants respond to the questionnaires? Was there any reduction, incomplete or nonresponding questionnaires?
Measures
The Hamilton Rating Scale for Anxiety (HRSA) is a questionnaire specifically designed to measure anxiety levels and is not recommended for assessing depression. Do you happen to know of any sources that suggest using this scale for measuring depression?
Can you please provide the readers with information about the questionnaire you use to assess social support and its dimensions?
In which language were your questionnaires? How did you ensure their validity and reliability?
How did you apply the questionnaire? By mail?
Data collection
How did you collect the data? By mail, phone, or in presence?
Where did you reach the patients?
Data analysis
According to the authors, the analysis is based on social support, which involves emotional, informational, instrumental, and social interaction support, categorized as low, average, and high. As a standard questionnaire was not employed, the analysis cannot be considered valid.
Results
In the results section of the study, the author stated that there were a total of 104 families, each with a stroke patient. However, the study had a higher number of male participants (67 patients, 64.4%) than female participants (35 patients, 35.6%). This has left me confused about who the participants in the study were.
Again, as the outcomes of depression are based on the anxiety scale and social support was not accomplished by a standard questionnaire, the results are not valid.
Where are the results of rehabilitation? And its scale?
Discussion
The findings related to depression cannot be deemed valid because they were based solely on the anxiety scale, and social support was not evaluated using a standardized questionnaire. Therefore, the discussion and conclusion are questionable.
Is the work clearly and accurately presented and does it cite the current literature?
No
If applicable, is the statistical analysis and its interpretation appropriate?
No
Are all the source data underlying the results available to ensure full reproducibility?
Partly
Is the study design appropriate and is the work technically sound?
No
Are the conclusions drawn adequately supported by the results?
No
Are sufficient details of methods and analysis provided to allow replication by others?
No
Reviewer Expertise:
"Qualitative and Quantitative Research in Health-Related Subjects."InsertRetryMake it persuasive
I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.