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Self-management and self-efficacy in stroke survivors: Validation of the

Italian version of the Stroke Self-Efficacy Questionnaire

Article  in  European journal of physical and rehabilitation medicine · December 2016

DOI: 10.23736/S1973-9087.16.04451-8

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© 2016 EDIZIONI MINERVA MEDICA European Journal of Physical and Rehabilitation Medicine 2018 February;54(1):68-74
Online version at http://www.minervamedica.it DOI: 10.23736/S1973-9087.16.04451-8

ORIGINAL ARTICLE

Self-management and self-efficacy in stroke survivors:

validation of the Italian version of the
Stroke Self-Efficacy Questionnaire
Laura DALLOLIO  1 *, Rossella MESSINA 1, Simona CALUGI  1, Stefania FUGAZZARO  2,
Roberta BARDELLI  2, Paola RUCCI  1, Maria P. FANTINI  1, Enrica CAVALLI  3,
Mariangela TARICCO  3 on behalf of Look After Yourself Project

1Sectionof Hygiene and Biostatistics, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of
Bologna, Bologna, Italy; 2IRCCS Arcispedale Santa Maria Nuova, Reggio Emilia, Italy; 3University Hospital Policlinico Sant’Orsola
Malpighi, Bologna, Italy
*Corresponding author: Laura Dallolio, Section of Hygiene and Biostatistics, Department of Biomedical and Neuromotor Sciences, University of Bologna,
Via San Giacomo 12, Bologna, Italy. E-mail: laura.dallolio@unibo.it

ABSTRACT
BACKGROUND: Self-efficacy is an important mediator of the adaptation process after stroke. However, few studies have attempted to measure
self-efficacy in a stroke population. The most recently developed scale is the Stroke Self-Efficacy Questionnaire that measures self-efficacy rat-
ings in specific domains of functioning relevant for a stroke survivor.
AIM: The aim of this study was to validate the Italian version of Stroke Self-efficacy Questionnaire in stroke survivors.
DESIGN: Cross-sectional study.
SETTING: Three Physical Medicine and Rehabilitation Units located in public hospitals.
POPULATION: 149 adult patients recruited after their first stroke.
METHODS: Patients were assessed using the Self-efficacy in stroke survivors questionnaire, the Modified Barthel Index, the Geriatric Depres-
sion Scale and the Short Form Health Survey.
RESULTS: Patients (38.3% female, mean age 69.3 years) completed the Self-efficacy in stroke survivors questionnaire with the help of an
interviewer. Using confirmatory factor analysis two factors were identified (activity and self-management). The factor score ‘activity’ was sig-
nificantly associated with the Modified Barthel Index and with the physical component of the Short Form Health Survey, but uncorrelated with
the mental component of the Short Form Health Survey and with the Geriatric Depression Scale, supporting the convergent/discriminant validity
of the instrument. The ‘self-management’ factor was weakly associated with the Modified Barthel Index, the physical and mental components
of the Short Form Health Survey and uncorrelated with the Geriatric Depression Scale, suggesting that it measures a different construct. When
we categorized patients according to their walking status, we found that the walking group had significantly higher scores on the activity factor
than the non-walking group, while no significant differences were found concerning the self-management factor.
CONCLUSIONS: The findings supported the validity of the Italian version of the Stroke Self-efficacy questionnaire . It measures two dimen-
sions of self-efficacy, activity and self-management, strongly related to independence and recovery after stroke and therefore it represents a
useful tool to assess self-efficacy.
CLINICAL REHABILITATION IMPACT: The Italian version of the Stroke Self-efficacy questionnaire is a valid and reliable measure of self-
efficacy. Clinicians can use this instrument to target rehabilitation interventions according to patients’ individual confidence in their functional
and self-management capacity and in order to set realistic goals.
(Cite this article as: Dallolio L, Messina R, Calugi S, Fugazzaro S, Bardelli R, Rucci P, et al.; Look After Yourself Project. Self-management and
self-efficacy in stroke survivors: validation of the Italian version of the Stroke Self-Efficacy Questionnaire. Eur J Phys Rehabil Med 2018;54:68-74.
DOI: 10.23736/S1973-9087.16.04451-8)
Key words: Stroke - Validation studies as topic - Self care - Self efficacy - Surveys and questionnaires.

S
or other proprietary information of the Publisher.

troke is the second leading cause of death and the of stroke, but progress after stroke, as with any other
first cause of long-term neurological disability chronic disease, is complex.
worldwide.1 Several rehabilitative interventions have Stroke survivors often experience depressive symp-
proven their effectiveness in acute and postacute phases toms, functional impairment and reduction in mobil-

68 European Journal of Physical and Rehabilitation Medicine February 2018

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SELF-MANAGEMENT AND SELF-EFFICACY IN STROKE SURVIVORS DALLOLIO
ity.2 The process of adjustment to stroke includes both
biomedical and psychosocial adaptation processes, in
which the physical, psychosocial and emotional aspects
of the adaptation are obviously interlinked.3, 4 Recent
studies highlighted that patients often feel unprepared
to deal with long-term disabilities, especially at the end
of the rehabilitation program.
Stroke survivors often have their own personal bench-
marks for recovery, which may include aspects related
to both physical and psychosocial outcomes.5 Neverthe-
less, rehabilitation is frequently oriented to functional
improvement, and, despite a move towards more per-
son-centred goal setting, often professionals decide the
content and direction of rehabilitation.6, 7
One psychological construct, which has recently been
found to predict both quality of life and disablement post-
stroke, is self-efficacy.8 The concept of self-efficacy orig-
inates from “Social Learning Theory” and is defined as
“the belief in one’s capabilities to organise and execute
the courses of action required to produce given attain-
ments”.9 Moreover, self-efficacy has been found to pre-
dict mood, quality of life and functional independence
for patients with other chronic conditions.10-12
A growing literature investigating self-management
in stroke survivors indicated that self-management
programmes are associated with several outcomes, in-
cluding quality of life, depression, activities of daily
living (ADL) and physical functioning and a reduced
incidence of falls.13-16 For these reasons, there is an
increasing interest in supporting stroke survivors and
their caregivers in self-managing the long-term conse-
quences of stroke. Self-efficacy influences the initiation
of behavior change,9 so it is considered the main out-
come measure of many stroke self-management pro-
grammes.17, 18
Coping and self-efficacy have been proposed as im-
portant determinants of the adaptation process in indi-
viduals after stroke.19, 20 Few studies have attempted to
measure self-efficacy in a stroke population. The most
recently developed scale is the Stroke Self-Efficacy
Questionnaire (SSEQ) 21 that measures self-efficacy
ratings in specific domains of functioning relevant to a
person. Items include common self-management tasks
or other proprietary information of the Publisher.
in stroke suggested by the guidelines by Lorig et al.22
The SSEQ is a 13-item self-report scale designed to as-
sess the confidence levels of stroke individuals in rela-
tion to functional performance and self-management. 21
Vol. 54 - No. 1 European Journal of Physical and Rehabilitation Medicine 69
Following the authors’ indications SSEQ has been de-
veloped in order to identify “those individuals that re-
quire more targeted support from practitioners in order
to build self-confidence with an associated beneficial
reduction of mood disorders and life dissatisfaction in
the longer term”.21 The SSEQ, in its original version,
demonstrated good internal consistency and criterion
validity.21 Moreover, a principal component analysis
provided evidence that the instrument is unidimension-
al. This finding has been recently disconfirmed by Riazi
et al.23 who, using Rasch analysis, identified two dis-
tinct constructs: self-management self-efficacy and ac-
tivity self-efficacy. Therefore, there is a need to clarify
whether the scale has a uni- or bidimensional structure.
The primary aim of this study was to validate the Ital-
ian version of the SSEQ, and to assess its psychometric
properties in stroke survivors. The secondary aim is to
examine how self-efficacy is associated with patients’
walking status.
Materials and methods
Participants
The study sample included consecutive adult patients
recruited after their first stroke at the Physical Medicine
and Rehabilitation Unit of St. Orsola Malpighi Hospital,
Bologna (Italy), Physical Medicine and Rehabilitation
Unit of IRCCS Arcispedale Santa Maria Nuova, Reggio
Emilia (Italy) and Rehabilitation Medicine Unit of St.
Agostino-Estense Baggiovara New Hospital, Modena
(Italy) from to October 2014 to March 2016.
Inclusion criteria were 1) age >18; 2) a confirmed
first-ever diagnosis of stroke according to the World
Health Organization’ definition;24 3) having a caregiver
as reference person, sent to mild communication dis-
ability (Communication Disability Scale <3); 4) pa-
tient’s willingness to sign the informed consent form.
Exclusion criteria were previous stroke episodes, se-
vere cognitive impairment (Mini-Mental State Exami-
nation MMSE<15/30, Communication Disability Scale
≥3), life threatening diseases (i.e. severe heart failure,
respiratory insufficiency, advanced cancer, sepsis).
Procedures
Participants were recruited for a non-randomized
controlled trial aimed to evaluate the efficacy of a stan-
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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use i
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(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
©
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DALLOLIO SELF-MANAGEMENT AND SELF-EFFICACY IN STROKE SURVIVORS
dardized therapeutic education patient (TPE) program
for stroke survivors. The present study is focused on
baseline assessments including the SSEQ, the Modified
Barthel Index (MBI), the Geriatric Depression Scale
(GDS) and the Short Form Health Survey (SF-12). The
Ethics Committee of the Hospital Trust Sant’Orsola
Malpighi of Bologna (registration number: 29/2014/O/
Sper), the Ethics Committee of the Hospital Trust Santa
Maria Nuova of Reggio Emilia (registration number:
2014/0008420) and the Provincial Ethics Committee
of Modena approved the study (registration number:
44/2014). All eligible patients provided a written in-
formed consent after receiving an explanation of study
procedures and aims and after having an opportunity to
ask questions.
Measures
The SSEQ is a 13-item self-report scale measuring
self-efficacy after stroke in specific domains of func-
tioning. The purpose of the SSEQ is to measure the
strength of confidence that stroke survivors have about
regaining activities lost after their stroke. Each item is
rated on a 0-3 scale, where 0 indicates absolutely no
confidence and 3 complete confidence about accom-
plishing the task.
The Italian version was translated from the original
English version 21 and back-translated to English by a
bilingual person of English mother tongue.
In order to improve the comprehensibility, items were
discussed by the investigators’ team and a final version
was agreed. The final Italian version of the SSEQ was
then administered to a pilot sample of 30 stroke sur-
vivors in a real-world setting in order to evaluate the
face validity of items. Results of the supervised pilot
administration of the instrument indicated that patients
had difficulties rating items 7 (�����������������������
dress and undress your-
self even when you feel tired), 8 (prepare a meal you
would like for yourself) ������������������������������
and 11 (����������������������
cope with the frustra-
tion of not being able to do some things because of your
stroke). Regarding item 7, it was therefore decided to
instruct patients to answer whether they could dress or
undress in some way, using strategies if needed. Re-
or other proprietary information of the Publisher.
garding meal preparation (item 8), if patients were not
used to cook in daily life, they were asked to answer by
imagining to do it. The term ‘frustration’ included in the
item 11 that someone did not understandwas clarified
70 European Journal of Physical and Rehabilitation Medicine February 2018
using words like “emotional distress” and “suffering”.
Moreover, item 6 was modified to make it appropriate
for patients with hemiplegia (“use your hands for eat-
ing your food” instead of “use both your hands”). The
time of administration of SSEQ ranged from 10 to 20
minutes.
To test the convergent/discriminant validity of SSEQ,
the following instruments were administered: ���������
the Modi-
fied Barthel Index (MBI) 25 was used to assess the abil-
ity to perform activities of daily living. It is the modified
form of the original Barthel Index 26 with 10 items that
explore functional and motor abilities. The total score
ranges from 0 to 100. Scores from 0 to 20 indicate total
dependence, 21-60 severe dependence, 61-90 moderate
dependence, 91-99 slight dependence and 100 total in-
dependence.
The SF-12 27 is a validated and widely used health-re-
lated quality of life measure. It consists of 12 items that
are aggregated into two summary measures of physical
health (PCS) and mental health (MCS), expressed as T-
scores (mean=50, SD=10), where higher scores denote
a better health-related quality of life.
The Geriatric Depression Scale (GDS) 28 was used to
measure the presence and severity of depression. Scores
of 0 to 5 indicate the absence of depression, 6 to 8 in-
dicate mild depression, and ≥9 indicate moderate to se-
vere depression.
To examine the criterion validity of SSEQ, patients
were categorized according to their walking status. Sub-
jects currently able to walk with or without assistance
were those scoring>0 on BMI Mobility item and non-
walking were those not able to walk in any capacity
(BMI Mobility item score =0).
Sample size
Sample size was determined to perform a Confirma-
tory Factor Analysis (CFA), for which at least a ten-to-
one ratio between patients and items is recommended.29
Statistical analysis
The convergent/discriminant validity of SSEQ versus
the MBI, the SF-12 and the GDS was tested by using
Pearson’s correlation coefficient. The criterion validity
was examined by comparing the mean SSEQ Score of
patients who were currently able to walk and with that
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, log
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use i
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
©
COPYRIGHT 2018 EDIZIONI MINERVA MEDICA
SELF-MANAGEMENT AND SELF-EFFICACY IN STROKE SURVIVORS DALLOLIO

Table I.—Demographic, clinical characteristics and scales meas- of non-walking patients using the independent-samples
uring functional status, health-related quality of life and depres-
sion of study participants (N.=149). t-test. Four patients had missing data on Modified Bar-
thel Index, the SF-12 and or Geriatric Depression Scale
Characteristics N. (%) or mean±SD
and were excluded from these analyses.
Gender
Males 92 (61.7%)
Confirmatory Factor Analysis (CFA) was performed
Female 57 (38.3%) to compare the goodness of fit of the the two-factor so-
Age (years) 69.3±12.7 lution identified by Riazi et al. 2014 in 118 stroke survi-
Living alone 31 (20.8%)
Type of stroke
vors with that of the one-factor solution proposed in the
hemorrhagic 27 (18.1%) original version by Jones et al.21
ischemic 122 (81.9%) In this analysis items were used as categorical vari-
Days post stroke 16.6±12.7
Cumulative Illness Rating Scale
ables and factors were estimated using a robust weight-
Severity Index 1.5±0.3 ed least squares estimator.
Comorbidity Index 2.0±1.9 Model fit was evaluated using the Comparative Fit
MMSE 24.6±4.9
Barthel Index Modified* 36.8±20.9
Index (CFI), Tucker-Lewis Index (TLI) and the root
SF-12† Mean Square Error of Approximation (RMSEA).
PCS 34.7±8.6 TLI and CFI values >0.90 reflect acceptable fit and
MCS 44.0±12.9 values >0.95 imply very good fit. RMSEA values <0.05
Geriatric Depression Scale‡ 7.0±2.0
indicate close model fit; values up to 0.08 suggest a rea-
MMSE: Mini-Mental State Examination; SF12: Short Form health survey; PCS:
Physical Component Score; MCS: Mental Component Score. sonable error of approximation in the population, and
*1 missing value; †1 missing value; ‡2 missing values.
values >0.10 indicate poor fit.

1: into bed 2: exit bed 3: walk few steps inside 4: move around inside 5: walk outside

6: eat food 7: dress 8: prepare meal

9: make progress 10: own exercise 11: cope 12: do things 13: get faster
or other proprietary information of the Publisher.

Figure 1.—Frequency distribution of responses to the 13 SSEQ item. Items are rated 0 to 3, with 0 indicating not at all confident, 1 some confidence,
2 moderate confidence, 3 very confident. Legend to the items from left to right: item 1: into bed; item 2: exit bed; item 3: walk few steps inside; item
4: move around inside; item 5: walk outside; item 6: eat food; item 7: dress; item 8: prepare meal; item 9: make progress; item 10: own exercise;
item 11: cope; item 12: do things; item 13: get faster. Grey: items measuring activity (1-8); dark gray: items measuring self-management (9-13).

Vol. 54 - No. 1 European Journal of Physical and Rehabilitation Medicine 71

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, log
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use i
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
©
COPYRIGHT 2018 EDIZIONI MINERVA MEDICA
DALLOLIO SELF-MANAGEMENT AND SELF-EFFICACY IN STROKE SURVIVORS

were males and 20.8% were living alone before stroke.

Other clinical characteristics are reported in Table I.
The frequency of response to the 13 items is provided
in Figure 1.
Items 1-5 and 8 were skewed to the right, and the
modal answer was “not at all confident”, indicating that
a large percentage of patients did not feel confident in
walking around, going to bed, prepare meals. On the
contrary, items 6, 9-13 were skewed to the left, sug-
gesting that patients felt confident in improving, eat-
ing using their hands, following the exercise program
and overcome frustration of not being able to do some
things because of the illness.
A confirmatory factor analysis was carried out to
identify the latent structure of the SSEQ items. Results
indicate that the two-factor model proved to have a bet-
ter fit compared to the one-factor model (CFI=0.934,
TLI=0.918, RMSEA=0.195 vs. CFI= 0.991, TLI=0.989,
RMSEA=0.073).
The results of CFA are depicted in Figure 2, in which
factor loadings are listed on along the arrows connect-
ing items to factors.
Items 3, 4, 5 had the highest loadings on factor 1,
and item 6, measuring the ability to eat independently,
had the lowest loading. This first factor was named
“activity”.
Items 9 and 10 had the highest loading on factor 2,
Figure 2.—Structure of the SSEQ resulting from CFA. The two factors
identifies are activity and self-management. Numbers above two-sided
arrows denote correlations. Numbers above directed arrows indicate Activity
item loadings. Loadings range from 0 to 1. The higher the loadings the 2 factor score
stronger the association of the item with the factor. Self-
management
1 factor score

The fit indices were assessed collectively, so that a

single index that fell just outside the acceptable range 0

was not necessarily considered to reflect poor model fit,

provided that the other statistics indicated good model fit. -1

The significance level was set at P<0.05. IBM SPSS

Statistics (version 20, Chicago, USA) and Mplus Ver- -2

sion 7 (http://www.statmodel.com) were used for the

analyses. -3

-4
Results
or other proprietary information of the Publisher.

Not walking Walking

One hundred forty-nine patients completed the Walking status
SSEQ. Participants had a mean age of 69.3 (SD=12.7) Figure 3.—Boxplot of the SSEQ factor scores by walking status. Walk-
years, were on average 16.6 days poststroke, 61.7% ing patients have significantly higher scores on activity factor.

72 European Journal of Physical and Rehabilitation Medicine February 2018

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, log
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use i
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
©
COPYRIGHT 2018 EDIZIONI MINERVA MEDICA
SELF-MANAGEMENT AND SELF-EFFICACY IN STROKE SURVIVORS DALLOLIO
that was named self-management. Notably, the two fac-
tors were correlated to each other (r=0.45, P<0.001).
The SSEQ ‘activity’ factor score was significantly
associated with MBI (r=0.46, P<0.001) and with the
physical component of the SF-12 (r=0.25, P=0.002), but
it was uncorrelated with the mental component of the
SF-12 (r=0.09, P=0.262) and with the GDS (r=-0.10,
P=0.234). The SSEQ ‘self-management’ factor score
was weakly associated with MBI (r=0.21, P=0.009), the
physical component of the SF-12 (r=0.21, P=0.012), the
mental component of the SF-12 (r=0.18, P=0.033) and
uncorrelated with the GDS (r=-0.08, P=0.364).
Moreover, walking patients had significantly higher
mean scores on SSEQ activity factor than non-walking
patients (t=5.4, P<0.001), while no significant differ-
ences were found concerning the SSEQ self-manage-
ment factor (t=1.5, P=0.124) (Figure 3).
Discussion
The aim of this study was to validate the Italian ver-
sion of the SSEQ, and to analyze the factor structure
of the questionnaire. Our results, based on stroke survi-
vors recruited in a real-world setting, indicate an excel-
lent fit of the two-factor model and are consistent with
those of Riazi et al.23 The two SSEQ factors measure
two dimensions of self-efficacy, activity and self-man-
agement, strongly related to independence and recov-
ery after stroke. These two dimensions are conceptually
different. In fact, as argued by Bandura,30 self-efficacy
in functional activity in not necessarily linked to self-
efficacy in self-management. This seems reasonable
as stroke survivors may have different levels of self-
efficacy in performing activities of daily living as they
would in self-managing illness. These two aspects are
conceptually distinct, thus someone with high self-ef-
ficacy in performing daily activities may not have high
self-efficacy in the self-management of illness.
Moreover, our SSEQ factor “activity” showed a good
convergent validity with the Modified Barthel score and
with the physical component of the quality of life, con-
firming previous results.21 Notably, mean SSEQ activity
scores of walking patients were higher than those of non-
or other proprietary information of the Publisher.
walking patients. This is in line with the previous study
by Jones et al.21 and with the self-efficacy theory which
postulates a relationship between self-efficacy and other
health behaviors, such as mobility and activity.14, 31
Vol. 54 - No. 1 European Journal of Physical and Rehabilitation Medicine 73
Moreover, the mental component of quality of life
and geriatric depression were unrelated with SSEQ
“activity” factor, confirming that this factor measures a
conceptually different construct.23
The main strength of this study is that it was carried
out in a large sample of stroke survivors. Clinicians
can use SSEQ to target rehabilitation interventions for
stroke survivors according to patients’ individual con-
fidence in functional activity and self-management and
using it to set realistic goals. Moreover, SSEQ may also
assist clinicians in the identification of patients at risk
of difficulty coping with stroke consequences and the
transition phases (e.g. from hospital to home).
The SSEQ can also be used as a primary outcome
measure in stroke patient education programs or to
monitor response to specific physical rehabilitation in-
terventions.
Limitations of the study
Our results should be interpreted keeping in mind
some limitations.
First, our sample includes patients who were assessed
from few days to few weeks post-stroke and this large
time frame may affect the participants’ judgment about
their capacity and confidence in performing specific ac-
tivities of daily living. Furthermore, we did not attempt
to verify whether the SSEQ was able to distinguish stroke
survivors during the rehabilitation phase from patients
who had already completed the rehabilitation process.
Our results cannot be generalized to patients with at least
one previous stroke and/or severe cognitive impairment.
Conclusions
Our results suggest that the Italian version of the
SSEQ is a valid and reliable tool for assessing self-ef-
ficacy in stroke survivors. The instrument can be used
to identify strengths to be leveraged in targeting per-
sonalized interventions. Future perspectives include the
conduction of prospective studies assessing how self-
efficacy varies as a result of specific educational or mo-
tivational interventions.
References
  1. World Health Organization. The World Health Report: 2003: shaping
the future. Geneva: World Health Organization; 2003.
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DALLOLIO SELF-MANAGEMENT AND SELF-EFFICACY IN STROKE SURVIVORS

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Contributors.—The Look After Yourself Project includes the following investigators: Mariangela Taricco, Enrica Cavalli, University Hospital Policlinico
Sant’Orsola Malpighi, Bologna, Italy; Claudio Tedeschi, Stefania Fugazzaro, Bardelli Roberta, Monia Allisen Accogli, Alessandra Altavilla, Gennaro Maisto,
Monica Denti, Giovanni Gallo, Mirco Piccinini, IRCCS Arcispedale Santa Maria Nuova, Reggio Emilia, Italy; Stefano Cavazza, Azienda USL di Modena,
Nuovo Ospedale Civile S. Agostino – Estense Baggiovara, Modena, Italy; Donatella Pagliacci, Azienda USL 6 Livorno, Italy; Maria Pia Fantini, Paola Rucci,
Laura Dallolio, Simona Calugi, Rossella Messina, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna,
Italy.
Funding.—This paper was developed with a grant from the “Progetto-Regione Università”, Emilia-Romagna Region (Italy), ‘Research for Clinical Gover-
nance’ 2013, for the project: “Patient Therapeutic Education (PTE) in the rehabilitation process of stroke patients: improving self-management and fostering
transition from hospital to community”. The Emilia-Romagna Region had no role in the definition of the study design; in the collection, analysis and inter-
pretation of data; in the writing of the report; and in the decision to submit the article for publication.
Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.
Article first published online: December 19, 2016. - Manuscript accepted: December 5, 2016. - Manuscript revised: November 28, 2016. - Manuscript re-
ceived: August 5, 2016.
or other proprietary information of the Publisher.

74 European Journal of Physical and Rehabilitation Medicine February 2018

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