1. Background
Pressure ulcer, which is known as bedsore or decubitus (1), refers to local damage to the skin and the sub-dermal tissue. It develops when the soft tissue between a protruding part of the bone and an external surface is under pressure for a long time (2). Bedsore causes pain, depression, diminished functioning and independence, increased incidence of sepsis and infection (3). All these result in incurrence of staggering costs to patients as well as healthcare and governmental centers (1). In this regard, following cancers and cardiovascular disease, this condition claims the third rank of costly diseases (4).
Stroke is among diseases associated with paralysis, disability, and increased risk of bedsore (5, 6). A total of 85% of stroke patients develop bedsore during their lifetime, 8% of whom die due to this lesion, which is the main cause of bedsore-induced death (7). In Iran, annually, 327 out of 100,000 people experience stroke, which is considered as the most common cause of disability in Iranian adults (3). Patients with stroke are hospitalized until their therapeutic conditions become stabilized, after which they can be discharged (8). Furthermore, 30% to 50% of these discharged patients suffer from severe disabilities, making them completely independent in terms of care provision (9), which is assigned to families after discharge (8). In Iran, due to shortage of governmental centers for rehabilitation and care after discharge of patients with stroke as well as the high healthcare costs in private centers and care provision at home, taking care of stroke patients by the family is very common, and most families accept the responsibility of providing care for the patients (10). The reason is that such patients mostly prefer to be taken care of at home, and typically one of the family members becomes the main caregiver of the patient (11). Nevertheless, most families feel a sense of unpreparedness due to sudden confrontation with stroke and adoption of a new role as the patient caregiver. Accordingly, due to the absence of educational programs, they experience various problems for providing care to the patient (10). In a research conducted by Kao et al. in Taiwan, the main need of family caregivers of these patients was education and awareness about providing care for these patients at home (12). In similar studies performed in Peru, Vietnam, and the United States, family caregivers of patients with stroke needed education and awareness about providing care for these patients (13-15). The reason for ineffectiveness of care provided by family caregivers of these patients may be attributed to their lack of awareness about care related to bedsore (16). For provision of high quality care, family caregivers of stroke patients should know the risk factors of bedsore, risk zones, and preventive strategies, and can employ them in practice (17). If educational programs can convert this information to effective solutions to prevent and treat bedsore and if this information is in line with patient characteristics and knowledge of the learner, they will be very effective (18). Home-based care is a method for planning, implementing, and assessing health care services, which takes place through mutual effective participation between caregivers, patients, and families (19). The home-based care method empowers individuals and families and strengthens independence in them. It also supports decision-making and care provision by the family, respects the choices of the family and patient as well as their values, beliefs, and cultural backgrounds, and overall results in better and greater effectiveness in mitigating subsequent complications of the patient (20, 21).
2. Objectives
Since in Iran the main focus of the healthcare system is on treating stroke at the acute stage of the disease, and home-based healthcare is taken less seriously, and as lack of awareness about preventing bedsore causes increased incidence of bedsore in patients and increased costs and re-hospitalization of the patient, the present study was performed with the aim of examining the effect of home-based training on the incidence of bedsore in patients with stroke discharged from Ali Ebne Abitaleb Hospital, Zahedan, Iran, in 2017.
3. Methods
This study was of a two-group clinical trial, performed in 2017, in Zahedan city, Iran. After the proposal was approved by the Ethics Committee of Zahedan University of Medical Sciences with the ethics code of IR.zaums.rec13960287 and after coordination with the head of this hospital, and explaining the study objectives and receiving informed consent from the eligible patients and main caregivers, subjects were included in the study through available sampling. The sample size with confidence of 95% and test power of 85% was determined as 35 for each group and 70 subjects overall, according to the formula of estimating the prevalence in both groups and based on the results obtained from the study by Benedict et al. (22).
Then, subjects were randomly assigned to 35-subject intervention and control groups. Specifically, colored cards, including red (intervention) and blue (control), including 70 in total (35 of each card) were randomly placed inside a box and given to the family caregivers. Then, everyone picked a colored card randomly from inside the box. Eventually, this procedure was continued without substituting the card until completion of the colored cards.
The inclusion criteria for the patients in this study included absence of any signs suggesting bedsore or skin disorders in the patient at the beginning of this study, being a resident of Zahedan, age of 45 to 75 years old, and bedsore risk score of less than or equal to 14 (being moderately or severely at risk of bedsore, according to Braden scale). Meanwhile, the inclusion criteria for the family caregivers included age of above 18 years, having a caregiver that provided care for a longer time compared to other caregivers, and being literate (ability of writing and reading). On the other hand, exclusion criteria for the patients included re-hospitalization of the patient during the study, death of the patient during the study, having suspicious ulcers or any skin disease. Furthermore, exclusion criteria for the family included absence of more than one session from the educational sessions.
The data collection instrument in this study was a three-part questionnaire. The first part included the personal information of the patient, the second part was the Braden bedsore scale, and the third part was the international form of bedsore. Braden scale was utilized to determine the risk of developing bedsore. The range of the score of this scale, which is determined based on six factors of sensory perception, skin moisture, activity, nutrition, stretching, and friction, is 6 to 23 (Table 1), with lower scores representing higher risk of developing bedsore. Based on this scale, a score of less than 12 represents high risk while 13 to 14 determines moderate risk (23). A score of less than or equal to 14 (moderate and severe risk) was considered as the entrance criterion of the patients. Incidence of bedsore was determined based on a four-point scale of bedsore, proposed by the National Pressure Ulcer Advisory Panel (NPUAP) and approved by the Australian Wound Management Association (AWMA). In this scale, degree one represents initial sign of bedsore, which includes redness in light skins, and purple blue in darker skins. Higher scores, suggesting a specific ulcer with different degrees of intensity (5), were considered as presence of bedsore.
Table 1.Braden Pressure Ulcer Risk Assessment
| Factors | Barden Scale | |||
|---|---|---|---|---|
| Sensory perception | 1. Completely limited | 2. Very limited | 3. Slightly limited | 4. No impairment |
| Moisture degree to which skin is exposed to moisture | 1. Constantly moist | 2. Very moist | 3. Occasionally moist | 4. Rarely moist |
| Activity degree of physical activity | 1. Bedfast | 2. Chairfast | 3. Walks occasionally | 4. Walks frequently |
| Mobility ability to change and control body position | 1. Completely immobile | 2. Very limited | 3. Slightly limited | 4. No limitations |
| Nutrition usual food intake pattern | 1. Very poor: Never eats a complete meal. | 2. Probably inadequate | 3. Adequate | 4. Excellent |
| Friction and shear | 1. Problem | 2. Potential problem | 3. No apparent problem | |
For data collection in the intervention group, before discharging the patient from the hospital, an educational session as group lecture was held for two hours at the hospital for the patient and their family members and specifically for the main caregiver of the patient about stroke, risky factors, and problems caused by stroke. Next, the address and telephone number of the patient’s caregiver were obtained, and again a two-hour educational session was held in the second week after discharge about the ways that bedsore develops, as well as in the third week after discharge about recognizing different types of bedsore and methods for preventing bedsore for the main caregiver of the patient, as face-to-face education. Furthermore, an educational pamphlet was prepared about the explained points and provided to the main caregiver of the patient. After three months, the patients in the intervention and control groups were re-evaluated in terms of bedsore. The patients of the control group only received routine care.
At the end, the obtained data were analyzed by the chi-square and t-test, using SPSS 21.
4. Results
During the study, no attrition occurred in the samples either from patients or caregivers, and all 17 subjects remained in the study up to the final stage. The results of this study indicated that most patients (52.9%) were female. Also the mean age of the studied patients was 61.97 years and most of them were married (98.57%). Statistical analysis indicated no significant difference in terms of personal characteristics (Table 2).
Table 2.Baseline Personal Characteristics of Patients and Family Caregivers in the Intervention and Control Groupsa
| Variable | Group (Patients) | P Value | |
|---|---|---|---|
| Control | Intervention | ||
| Patient | |||
| Age | 62.46 ± 10.34 | 61.49 ± 10.71 | 0.70 |
| Gender | 0.23 | ||
| Male | 19 (54.3) | 14 (40) | |
| Female | 16 (45.7) | 21 (60) | |
| Marital status | 0.99 | ||
| Single | 1 (2.9) | 0 (0) | |
| Married | 34 (97.1) | 35 (100) | |
| Family Patient Caregiver | |||
| Age | 40.23 ± 11.20 | 36.06 ± 10.87 | 0.11 |
| Gender | 1.00 | ||
| Male | 12 (34.3) | 12 (34.3) | |
| Female | 13 (65.7) | 13 (65.7) | |
| Marital status | 0.59 | ||
| Single | 9 (25.7) | 11 (31.4) | |
| Married | 26 (74.3) | 24 (68.6) | |
| Educational status | 0.58 | ||
| Under dipploma | 18 (51.4) | 21 (60) | |
| Upper diploma | 17 (48.6) | 14 (40) | |
| Occupation status | 0.47 | ||
| Unemployed | 17 (48.6) | 15 (42.9) | |
| Employed | 18 (51.4) | 20 (57.1) | |
aValues are expressed as mean ± SD or No. (%).
The mean age of the main caregiver of the family was 38.14 years, most of whom were female (65.7%), with educational level of diploma and above (44.28%), and 52.85% of them were unemployed. Comparing the two groups in terms of demographics of the family caregivers, no significant difference was obtained (Table 2).
Comparison of the two study groups showed that the incidence of bedsore was significantly lower in the intervention group compared to the control group (P = 0.046), which was 25.7% and 48.6% in the intervention and control groups, respectively (Table 3).
Table 3.Comparison of Frequency of Bed Sore in Two Intervention and Control Groupsa
| Bed Sore | Groups | P Value | |
|---|---|---|---|
| Control | Intervention | ||
| Yes | 17 (48.6) | 9 (25.7) | 0.046 |
| No | 18 (51.4) | 26 (74.3) | |
aValues are expressed as frequency (%).
5. Discussion
The results of the present study showed that home-based care and relying on training of the main caregiver of the patient can be effective in reducing incidence of bedsore in patients with stroke, which is one of the most common secondary complications associated with their diseases.
Concerning incidence of bedsore, the results of the present study showed that the frequency of bedsore incidence decreased significantly in the patients of the intervention group, whose caregivers had received home-based care training at the time of discharge as well as two and three weeks after discharge, when compared to the patients in the control group, who had received only routine trainings of the ward at the time of discharge. Some studies have also reported similar findings. Soozani and Hasani concluded that training of standard care guide and pressure ulcer treatment to caregivers of spinal cord injury patients with pressure ulcer under at-home care, which was received from the welfare organization of Shahrood city, can be effective in reducing the prevalence and improving bedsore (16). In the study of Thompson et al. performed with the aim of investigating the effect of a skincare protocol, such as washing the site and protecting the skin of under-pressure sites (including the sacrum, shoulders, and heel) in taking care of pressure ulcers, concluded that implementation of this protocol significantly decreases the incidence and prevalence of bedsore and shortens the healing time of pressure ulcers (24).
Moody et al. investigated the effect of skincare program training of hospital staff on the progression of bedsore in cases above 65 years old. They observed that this training can mitigate progression of bedsore by up to 63%. It can also cause saving time of occupation of beds at the ICU and saving time and costs for patients and their families (25). In contrast to the results of the above studies, which were congruent with the current study, Jamand et al. concluded that constant presence of one of the family members on the patient’s bedside did not have any significant relationship with incidence of bedsore (26), which was incongruent with the conclusion of the present study. Possibly, the reason for this lack of effect brought by constant care on mitigation of bedsore can be attributed to not receiving any special training about preventing bedsore. In the present study, this training was given to the main caregiver, yet in the mentioned study, no special training had been provided by the researcher to the patient or caregiver.
Since stroke is a debilitating disease, the basis of controlling the disease is by enhancing the knowledge and function of caregivers about preventing incidence of complications. The family caregivers, who are aware of the causes of development of stroke, its complications, and ways to prevent complications, participate in care provision for the patient with greater motivation. Also, as mentioned in the present study and other studies, home-based training to caregivers and patients can significantly decrease the incidence of bedsore in stroke patients.
Lack of cooperation of some family members in receiving home-based training and difficulty of coordination for holding subsequent educational sessions at the patients’ home were among the limitations of this plan. By explaining the possible benefits of this plan and making the patients and their caregivers aware before starting the plan, attempts were made to resolve these issues.
5.1. Conclusion
According to the results of the present study, one of the practical and economical methods for reducing bedsore is training family caregivers of patients, especially the main caregiver. It can be considered an effective solution to be implemented by nurses and physicians at the hospital to decrease the incidence of bedsore in stroke patients. It is suggested that further studies should be conducted about the effect of home-based training on bedsore in other patients with a high risk of bedsore.
