Applied Nursing Research 32 (2016) 233–240

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

The effect of the support program on the resilience of female family

caregivers of stroke patients: Randomized controlled trial☆,☆☆
Fadime Hatice İnci, PhD, RN a,⁎,1, Ayla Bayik Temel, PhD, RN b,2
a
Pamukkale University, Faculty of Health Sciences, Department of Public Health Nursing, 20100, Denizli, Turkey
b
Ege University Faculty of Nursing, Department of Public Health Nursing, 35040, İzmir, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Aim: The purpose of the study was to determine the effect of a support program on the resilience of female family
Received 18 January 2016 caregivers of stroke patients.
Revised 5 August 2016 Methods: This is a randomized controlled trial. The sample consisted 70 female family caregivers (34 experimen-
Accepted 7 August 2016 tal, 36 control group). Data were collected three times (pretest–posttest, follow-up test). Data were collected
Available online xxxx
using the demographical data form, the Family Index of Regenerativity and Adaptation-General.
Results: A significant difference was determined between the experimental and control group's follow-up test
Keywords:
Caregiver
scores for relative and friend support, social support and family-coping coherence. A significant difference was
Resilience determined between the experimental group's mean pretest, posttest and follow-up test scores in terms of family
Support program strain, relative and friend support, social support, family coping–coherence, family hardiness and family distress.
Stroke Conclusions: These results suggest that the Support Program contributes to the improvement of the components
of resilience of family caregivers of stroke patients.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction from resilience factors such as intra-family communication, social sup-

Stroke is the third leading cause of death and the leading cause of
adult disability in the world (Towfighi & Saver, 2011). In Turkey, stroke,
with its 15.0% mortality rate, ranks second among the causes of death
(Başara, Dirimeşe, Özkan, & Varol, 2007). It also ranks second as the
cause of providing care at home in Turkey accounting for 15.4%
(Subaşı & Öztek, 2006). Of the patients having suffered stroke, 50% are
discharged from the hospital, 20% die or 30% are in need of long-term
home or institutional care (Karakurt & Kaşıkçı, 2008). Therefore, stroke
patients need emotional, informational and instrumental support pro-
vided by family members to maintain their daily life (Schure et al.,
2006). Stroke patients usually receive support from the family, spouse
or friends (Greenwood & Mackenzie, 2010). Difficulties due to care-
giving are not suffered by all caregivers in the same way, which stems
☆ Conflict of interest: No conflict of interest has been declared by the authors.
☆☆ Funding: This research received no specific grant from any funding agency in the pub-
lic, commercial, or not-for-profit sectors.
⁎ Corresponding author at: Pamukkale University, Faculty of Health Sciences. Tel.: +90
258 2964352; fax: +90 258 2962559.
E-mail addresses: hemel@pau.edu.tr (F.H. İnci), aylabayik@ege.edu.tr (A.B. Temel).
1
Postal Addresses: Pamukkale Üniversitesi Salic Bilimleri Fakültesi Kinikli Kampüsü
20,100 Denizli, Türkiye. Tel.: +905,055,914,032.
2
Tel.: +905,053,562,575.
port, spending time with family members, religion, spirituality and loy-
alty (Jonker & Greeff, 2009).
2. Background
Resilient families can grow stronger from stressful and difficult con-
ditions they face (McCubbin, McCubbin, & Thompson, 2003). Masten
(2001) defined resilience as being able to successfully adapt even to
high risk conditions and to revert to normal. On the other hand, family
members' ability to cope with stressful life cycles in the family and to
ensure family cohesion is defined as family resilience (Black & Lobo,
2008). Family resilience is a systemic concept indicating the presence
of harmful and beneficial processes that affect the family and the func-
tions of the family members mutually within a specific purpose
(Gardner, Huber, Steiner, Vazquez, & Savage, 2008).
It is possible to improve a family's support systems, communication
and compliance or other resilience factors through a therapeutic or
group intervention program in the family (Schure et al., 2006; Van
Den Heuvel, Witte De, Nooyen-Haazen, Sanderman, & Meyboom-De
Jong, 2000; Van Den Heuvel et al., 2002). Studies conducted on the
issue indicate that families in constant contact with the social environ-
ment including their relatives, friends and neighbors have high levels
of resilience. In addition, support obtained from social sources such as
health services contributes to the family's resilience (Greenwood &
Mackenzie, 2010, Simon, Murphy, & Smith, 2005). There are many in-
terventional studies conducted on caregivers of stroke patients. These

http://dx.doi.org/10.1016/j.apnr.2016.08.002
0897-1897/© 2016 Elsevier Inc. All rights reserved.
234 F.H. İnci, A.B. Temel / Applied Nursing Research 32 (2016) 233–240

interventional studies have been usually performed through face-to-
face interactive personal training, telephone communications, group
training or Web based telephone conferences (Grant, Elliott, Weaver,
Bartolucci, & Giger, 2002; Oupra, Griffiths, Pryor, & Mott, 2010; Shyu,
Chen, Chen, Wang, & Shao, 2008; Steiner et al., 2009). The content of in-
terventions includes provision of information about the disease and
stroke, skills training, coping with stress, problem solving and social
support (Bakas et al., 2009; Clark, Rubenach, & Winsor, 2003; Grant
et al., 2002; Oupra et al., 2010; Pierce, Steiner, Khuder, Govoni, &
Horn, 2009; Temizer & Gözüm, 2012; Van Den Heuvel et al., 2000). On
the other hand, there is a gap in the research literature related to the
studies on meeting multi-dimensional needs of caregivers of stroke pa-
tients such as information on stroke, care skills regarding the activities
of daily living of the patient provided healthcare, stress-coping
methods, problem solving, intra-family interaction and social support.
2.1. Conceptual framework
This current study drew on “The Resiliency Model of Family Stress,
Adjustment, and Adaptation” (McCubbin & McCubbin, 1996). The resil-
ience model, which places its primary focus on family change and adap-
tation over time, emerged from studies of war induced family crises
(McCubbin et al., 2003). It is a resilience-focused process, with specific
focus on several post-crisis or adaptation-oriented elements in an effort
to explain the family's behavior and functioning in the process of adap-
tation. The adaptation process is determined by the pile-up of demands,
interacting with the family's vulnerabilities, resources, appraisal pro-
cesses, social support, patterns of functioning, coping and problem solv-
ing, as well as processes that explain the relational processes involved in
family adaptation (McCubbin & McCubbin, 1996). Family adaptation is
the end product of the family processes in response to the crisis and
pile-up of demands. The concept of family adaptation is used to describe
a continuum of outcomes reflecting family efforts to achieve a balance in
functioning. The positive end of continuum is called bonadaptation, and
the negative end of the continuum is maladaptation. As can be seen in
Fig. 1, this study entailed those variables related to Mccubbin's resil-
ience model.
2.2. Aim of the study
The purpose of the study was to determine the effect of a support
program on the resilience of female family caregivers of stroke patients.
3. Method
3.1. Design
The study utilized a randomized controlled design, with pre-test,
post-test and a 6-month follow-up evaluation. Fig. 2 is the CONSORT
flow diagram of this study. The target population of the study comprised
female family caregivers of stroke patients registered in Denizli State
Hospital, Clinic of Home Care Services.
3.2. Sample size
To detect a medium effect size of differences between control and
experimental groups at a 0.05 level of significance and the power of
0.80, 26 subjects are normally required in each group (Cohen, 1992).
It was decided that both groups should include 40 caregivers consider-
ing similar studies and the possibility of caregivers abandoning the
study (Oupra et al., 2010; Smith, Egbert, Dellman-Jenkins, Nanna, &
Palmieri, 2012; Temizer & Gözüm, 2012). Six caregivers from the exper-
imental group and four caregivers from the control group were exclud-
ed from the study due to reasons such as moving to another city,
withdrawing from the study and death of stroke patients. Therefore,

The Resiliency Model of Family Stress, Adjustment, and Adaptation

Mccubbin’s resilience Empirical indicators

Theoretical structure
model concepts

Stressor Family Stressors Index

Family stressors
(A)

Pile-up Family strains The Family Strains Index

(AA)

Patterns of function Family Hardiness Index

Family Hardiness
(TT)

Family resources
(BB) Social Support Social Support Index

Situational appraisal Coherence The Family Coping-

(CC) Coherence Index

Problem solving and coping The Relative and Friend

Problems olving and coping Support Index
(PSC)

Adaptation Family Adaptation Family Distress Index

(XX)

Fig. 1. Conceptual, theoretical, empirical structure of resilience of female family caregivers.

 F.H. İnci, A.B. Temel / Applied Nursing Research 32 (2016) 233–240 235

Assessed for eligibility

(met the inclusion criteria, n=195)
Enrolment

Declined to participate (n=115)

Randomization (n=80)

Allocation
Experimental group (n=40) Control group (n=40)

Support program Routine

based on resilience home care
model services

Routine home
care services
Follow-up

Lost to follow-up (n=6) Lost to follow-up (n=4)

Death of stroke patient (n=3) Death of stroke patient (n=2)
Moved (n=1) Moved (n=1)
Discontinued intervention (n=2) Discontinued intervention (n=1)

Analysis

Analysed (n=34) Analysed (n=36)

Excluded from analysis (n=0) Excluded from analysis (n=0)

Fig. 2. CONSORT diagram showing flow of participants through the study.

70 people were included in the study. Of them, 34 were assigned to the
experimental group and 36 to the control group.
3.3. Randomization
Female family caregivers were assigned randomly, using a comput-
erized random number generator, to one of two parallel groups: an ex-
perimental or a control group. Half of the participants were randomized
to the experimental group (n: 40) and the other half to the control
group (n: 40). Participants were blinded to treatment allocation. The in-
vestigator delivered the intervention and, therefore, could not be
blinded to allocation. Therefore, this study is a single-blinded design.
The group assignments will remain blinded to participants throughout
the study period.
3.3.1. The inclusion criteria
The inclusion criteria for the caregivers were as follows: being fe-
male and aged 18 and over, having at least primary school graduate,
having no hearing problem by the self report, having no known cogni-
tive impairments or mental health problems severe enough to interfere
with answering the questions accurately, having provided care to the
stroke patient at least 12 months, living in the same house with the pa-
tient, not having any health problems to prevent her from providing
care ability, to be able to speak, read and write in Turkish.
3.3.2. The exclusion criteria
The exclusion criteria were as follows: being male, having received
training about the same topic before.
3.4. Data collection
Data were collected three times between March 2013 and February
2014 through a pretest given at one month before intervention, a post-
test given at one month after intervention and a follow-up test at six
months after intervention. Data were collected by researcher at
caregiver's home.
3.5. Intervention processes
In the present study, the experimental group was given a support
program alongside routine home care, while the control group received
solely routine home care. The routine home care consists of all nursing,
medical and follow-up services.
The content of support program was prepared by evaluating the pre-
test data collected from caregivers, pertinent literature and the main
components of “The Resiliency Model of Family Stress, Adjustment,
and Adaptation”. The support program consisted of two sections: edu-
cation sessions and social support sessions. The content of the support
program is given in Table 1.
3.5.1. Implementation of the support program
A ten-session support program (five education sessions, five social
support sessions) was prepared for the experimental group.
Education sessions: Education sessions were held once a week for
five weeks. Each session took 90 minutes. While four of the education
sessions were held in groups, one was held as an individualized pro-
gram carried out through home visits. The caregivers were assigned to
three groups during the group-program sessions. Each group consisted
of 10–12 caregivers. During the education sessions, caregivers were pro-
vided with written education material.
236 F.H. İnci, A.B. Temel / Applied Nursing Research 32 (2016) 233–240
Table 1
Contents of support program.
Sessions Topics
1st week 1 session Introduction - Stroke
2 session Social support
2nd week 3 session The burden of caregivers
4 session Social support
3rd week 5 session Care of patients with stroke
6 session Social support
4th week 7 session Stress and coping
8 session Social support
5th week 9 session Intra-family interaction
10 session Social support
3.5.2. Social support sessions
Each group attending in social support sessions consisted of 10–12
people. Social support group meetings were conducted as semi-
structured. Learning activities to enable caregivers in groups to learn
about and socialize with each other were performed. The participants
were encouraged to share the challenges they encountered while pro-
viding care for stroke patients mostly, and to express their feelings
about caregiving. Then, they were asked to express their opinions on
how to solve the problems they faced and to discuss it with other mem-
bers of the group. The researcher informed the participants on topics
that they lacked of knowledge.
3.6. Data collection tools
Data were collected using demographical data form, the Family
Index of Regenerativity and Adaptation-General.
3.7. Demographical data form
This questionnaire included seven questions about caregiver's age,
education, marital status, relationship with the stroke patient, caregiv-
ing duration, family support for patient care, chronic disease.
3.8. The Family Index of Regenerativity and Adaptation-General
The Family Index of Regenerativity and Adaptation-General (FIRA-
G) was developed by Hamilton McCubbin to provide a brief set of mea-
sures which have reliability and validity and can be used to test the
major dimensions of the resiliency model of family stress, adjustment
and adaptation. The FIRA-G is designed to obtain seven indices of family
functioning. The indices include family stressors, family strains, relative
and friend support, social support, family coping–coherence, family har-
diness, and family distress.
3.8.1. Family Stressors Index
The index consists of 10 items selected to record those life events
and changes which can render a family vulnerable to the impact of a
subsequent stressors or change. The index includes the addition of a
member, changes in the work situation, deaths and illnesses. The scores
for the index range from 0 to 50.1. The psychometric properties of the
Family Stressors Index include a validity coefficient (correlation with
family inventory of life events and changes) of 0.60. Internal consistency
of the index is 0.81 (McCubbin & McCubbin, 1996). The index was
adapted into Turkish by Inci and Bayık Temel (İnci & Bayık Temel,
2013). The internal consistency of the Turkish version is 0.77.
3.8.2. The Family Strains Index
The index measures additional events that are known to contribute
to family vulnerability. The Family Strains Index consists of ten items
and measures stressor pile-ups resulting in family strain that is caused
by family conflict, financial hardships, and increased family care bur-
dens (McCubbin & McCubbin, 1996). The scores for the index range
Time Method
90 Min. Group education
60 Min. Group meeting
90 Min. Group education
60 Min. Group meeting
90 Min. Individual education
60 Min. Group meeting
90 Min. Group education
60 Min. Group meeting
90 Min. Group education
60 Min. Group meeting
from 0 to 51.8. Internal consistency score was 0.81 based on
Crohnbach's alpha calculation. The index was adapted into Turkish by
Inci and Bayık Temel. The Cronbach's alpha of the Turkish version of
the Family Strain Index was 0.78 (İnci & Bayık Temel, 2013).
3.8.3. The Relative and Friend Support Index
The index measures the extent to which the family uses the support
of relatives and friends as a coping strategy to manage stressors and
strains. The scale consists of eight items that focus on the sharing of
problems and asking for advice from friends and family. The respon-
dents indicate an answer on a five-point Likert scale. The scores for
the index range from 0 to 40. The internal reliability of the scale is
0.82 (McCubbin & McCubbin, 1996). The index was adapted into
Turkish by Inci and Bayık Temel. The Cronbach's alpha of the Turkish
version of the Relative and Friend Support Index was 0.85 (İnci &
Bayık Temel, 2013).
3.8.4. Social Support Index
The index was used to evaluate the degree to which families are in-
tegrated into the community and view the community as a source of
support, in that the community can provide emotional support, esteem
support, and network support. This scale consists of 17 statements,
which are rated on a five-point scale of agreement, ranging from
“strongly disagree” to “strongly agree”. The scores for the index range
from 0 to 68. The higher scores indicate higher perceived received sup-
port. The index has an internal reliability of 0.82 (McCubbin &
McCubbin, 1996). The index was adapted into Turkish by Inci and
Bayık Temel. The Cronbach's alpha of the Turkish version of the SSI
was 0.88 (İnci & Bayık Temel, 2013).
3.8.5. The Family Coping–Coherence Index
The index measures the concept of family resources by determining
the family's perception of their ability to overcome stressful life events.
The scale consists of four items. The scores for the index range from 0 to
20. Internal reliability ranged between 0.86 and 0.87. Coping and
coherence is viewed as a buffer for stressors and demands and helps
the family to adjustment and adaptation (McCubbin & McCubbin,
1996). The index was adapted into Turkish by Inci and Bayık Temel.
The Cronbach's alpha of the Turkish version of the index was 0.79
(İnci & Bayık Temel, 2013).
3.8.6. Family Hardiness Index
The index measures the family hardiness that protects the family
against the effects of stressful situations. Family hardiness refers to a
feeling of control over certain events and difficulties. The scale consists
of 20 items that involve the basic strengths that families employ when
confronted with a transition, a crisis or a stressor. Families with a low
hardiness score are described as being vulnerable. The scores for the
index range from 0 to 60. A higher score indicates greater family hardi-
ness or internal strength. The internal consistency of this index is 0.82
(McCubbin & McCubbin, 1996). The index was adapted into Turkish
by Inci and Bayık Temel. The Cronbach's alpha of the Turkish version
 F.H. İnci, A.B. Temel / Applied Nursing Research 32 (2016) 233–240 237

of the index was 0.90. The Turkish version of the index was Table 2
unidimentional (İnci & Bayık Temel, 2013). Descriptive characteristics of experimental and control group caregivers of stroke patients.

Variables Experimental group Control group p value

3.8.7. Family Distress Index (n = 34) (n = 36) of χ2
Family Distress Index was used to measure family adaptation. The Age group
index consists of five items selected to record those major difficulties 20–29 2 (5.9) 2 (5.6)
which may be experienced by families and reflect deterioration in the 30–39 5 (14.7) 4 (11.1)
40–49 12 (35.3) 8 (22.2)
family's stability. The index includes family members with emotional
50–59 9 (26.5) 13 (36.1) 0.702
problems, the abuse of alcohol or drugs, physical or psychological vio- ≥60 6 (17.6) 9 (25.0)
lence, separation or divorce and deterioration in the marital relationship Education status
(McCubbin & McCubbin, 1996). The scores for the index range from 0 to Primary school 22 (64.7) 26 (72.2)
33.6. The index was adapted into Turkish by Inci and Bayık Temel. The Middle school 3 (8.8) 4 (11.1) 0.796
High school 6 (17.6) 4 (11.1)
Cronbach's alpha of the Turkish version of the index was 0.68 (İnci &
University 3 (8.8) 2 (5.6)
Bayık Temel, 2013). Marital status
Married 29 (85.3) 31 (86.1)
3.9. Data analysis Single 5 (14.7) 5 (13.9) 1.000
Relationship
Daughter 17 (50.0) 15 (41.7)
Data were analyzed using SPSS (Statistical Package for Social Sci- Daughter in law 9 (26.5) 10 (27.8)
ences) version 15.0. Chi-square tests were used to determine differ- Grandchild 5 (14.7) 3 (8.3) 0.408
ences in descriptive characteristics between the groups. The two-way Spouse 3 (8.8) 8 (22.2)
repeated measures analysis of variance and Friedman analysis of vari- Caregiving duration
1–4 year 18 (52.9) 14 (38.9)
ance were used to compare the resilience components of experimental
5–9 year 8 (23.5) 14 (38.9)
and control groups. In further analysis, paired sample t-tests with 10–14 year 5 (14.7) 6 (16.7) 0.499
Bonferroni adjustments and Wilcoxon signed ranks test with Bonferroni 15 and over year 3 (8.8) 2 (5.6)
adjustments were used. The significance level was established at 0.05. Family support for
patient care
Effect sizes of 0.20 were considered small, 0.50 medium and 0.80 large
Yes 28 (82.4) 22 (61.1) 2.895
(Cohen, 1992). It was targeted medium effect size at resilience compo- No 6 (17.6) 14 (38.9) 0.089
nent of experimental group in this study. Chronic illness
Yes 15 (44.1) 13 (36.1) 0.193
3.10. Ethical considerations No 19 (55.9) 23 (63.9) 0.660

Before the study was started, ethical approval was obtained from the
Ege University Nursing Faculty Ethics Committee. Prior to data collec-
tion, in order to get the permission of the participants they were provid-
ed with both written and verbal information about the study purpose
and procedure. The participants were informed that their participation
was voluntary and that they could withdraw from the study at any time.
4. Results
4.1. Descriptive characteristics of caregivers
The descriptive characteristics of the caregivers in the experimental
and control groups in this research were tested for homogeneity to con-
firm that there were no differences. The experimental and control
groups were statistically similar (p N 0.05) and homogenous (Table 2).
4.2. Findings on FIRA-G
The mean pretest, posttest and follow-up test scores obtained from
the experimental and control groups were compared in terms of the
components of resilience. Statistically significant differences were
found between the mean social support, family hardiness and family
distress scores obtained in the pre-test, the mean family strains scores
obtained in the post test and the mean relative and friend support, social
support and family coping–coherence scores obtained in the follow-up
test by the participants in the experimental and control groups
(Table 3).
A significant difference was determined between the experimental
group's mean pretest, posttest and follow-up test scores in terms of
family strain, support from relative and friend, social support, family
coping–coherence, family hardiness and family distress. Family hardi-
ness mean scores of the two groups obtained from the pretest, posttest
and follow-up test were significantly different (p b 0.01) (Table 4). The
effect sizes of the components of resilience measured in the pretest and
posttest of the experimental group were determined to be moderate
and high respectively (d N 0.50 or d N 0.80). However, the effect sizes of
the control group are small or negligible (d b 0.20) (Table 4).
5. Discussion
That the differences between the experimental and control groups
and changes with time in terms of family stressors were not statistically
significant after the support program might be due the fact that the
Family Stressors Index addresses a wide range of time as long as 12
months and that life events investigated were not controlled by the
participants.
Since family stressors are observed at any period of life and are un-
controllable, absence of differences was considered; as expected the
support program seems to haven't been effective in reducing family
stressors. Since it is not possible to eliminate risk factors from a person's
life, increasing the person's ability to cope with and adapt to difficult
conditions despite increased risk factors is very important.
The support program seems to be effective in reducing family strain
on caregivers. While the effect size between the pretest and posttest in
the experimental group was medium it was small between the pretest
and follow-up test, which means that the goal was achieved at the post-
test but not stable and the effect size decreased. Thus continuity of the
intervention was proved to be important. In addition, this gradual de-
crease in the effect size may have been due to the fact that the research-
er discontinued interventions in this process and that interventions
were aimed only at caregivers.
The support program seems to have increased the relative and friend
support. This change shows that the support program encouraged the
caregivers to utilize support from relative and friend in problem solving
and coping more. The questions in the index may have aroused the in-
terest of the control group caregivers and contributed to their under-
standing of the importance of support from relative and friend by
raising their awareness. Although the difference between the pretest
and posttest scores of the caregivers in the experimental group was
238 F.H. İnci, A.B. Temel / Applied Nursing Research 32 (2016) 233–240

Table 3
Pretest, posttest and follow-up resilience components scores in experimental and control groups.

Variables Pretest Posttest Follow-up p value of χ2/F

Mean ± SD Mean ± SD Mean ± SD

Family stressors
Experimental group 7.05 ± 7.75 6.64 ± 7.63 6.11 ± 7.66 0.764
Control group 7.38 ± 7.57 7.57 ± 7.18 8.92 ± 7.90 0.749
p value of U 0.663 0.512 0.069
Family strains
Experimental group 15.26 ± 9.89 11.02 ± 5.14 12.89 ± 5.01 0.021
Control group 14.66 ± 6.21 14.14 ± 5.82 13.04 ± 6.29 0.382
p value of U 0.887 0.010 0.718
Relative/Friend support
Experimental group 15.71 ± 7.78 19.71 ± 6.53 21.85 ± 7.70 0.015
Control group 16.22 ± 7.70 17.69 ± 7.32 18.25 ± 4.88 0.192
p value of U 0.777 0.331 0.046
Social support 0.554a
Experimental group 42.85 ± 7.22 51.44 ± 9.10 52.82 ± 8.10 0.001b
Control group 47.14 ± 8.90 48.75 ± 8.47 48.05 ± 8.37 0.001c
Family coping–coherence
Experimental group 15.65 ± 3.52 17.21 ± 1.79 17.97 ± 1.80 0.001
Control group 16.61 ± 1.82 16.31 ± 1.77 16.86 ± 2.02 0.211
p value of U 0.298 0.050 0.026
Family hardiness
Experimental group 40.59 ± 8.22 46.97 ± 5.95 47.44 ± 5.93 0.001
Control group 45.47 ± 5.77 46.44 ± 6.37 45.56 ± 6.57 0.009
p value of U 0.003 0.832 0.262
Family distress
Experimental group 8.65 ± 7.61 4.53 ± 4.23 4.73 ± 4.63 0.015
Control group 5.20 ± 5.40 6.08 ± 7.45 6.36 ± 6.56 0.874
p value of U 0.028 0.924 0.428

SD = standard deviation.
a
Indicates significant effect of group.
b
Time.
c
Interaction of group and time.

not significant, the medium effect size targeted by the researchers was changes in social support levels. In a study conducted by Van Del Heuvel
achieved. The difference between the pre-test and follow-up test not et al. in 2000, they observed improvements both in the group program
only is statistically significant but also has an effect size very close to and in the home visit program in terms of relying on their own knowl-
the highest effect size. Although a statistically significant difference be- edge about patient care, and using coping strategies and social support
tween the posttest and follow-up test results was not an expected situ- effectively (effect size 0.26) (Van Den Heuvel et al., 2000). Van Del
ation, the effect of the support program continued to increase even after Heuvel et al. conducted a similar study in 2002 and obtained results
six months and demonstrated a small effect size, which suggests that similar to those of their previous study (Van Den Heuvel et al., 2002).
the caregivers gained skills to make use of support from relative and
friend. Grant et al. (2002) provided a 3-hour face-to-face discharge ed- Table 4
ucation to 74 caregivers. The first session of the education was given in Inter-Measurements Resilience Components Scores of caregivers.
the hospital. Grant et al. reported that at the end of the attempts to gain
Variables Experimental group Control group
the participants problem-solving skills through phone calls, problem-
d p value of t/z d p value of t/z
solving skills of the participants in the experimental group were better
than those of the participants in the control group (Grant et al., 2002). Family strain
Upon the completion of the education program on how to improve Pretest–Posttest 0.54 0.037 0.09 0.649
Pretest–Follow Up 0.30 0.281 0.26 0.064
intra-family communication and problem solving skills given to families Posttest–Follow Up −0.37 0.023 −0.18 0.041
of patients with depressive disorder in 2009, Bester reported that the Relative and friend support
program was not effective in improving communication and problem Pretest–Posttest −0.56 0.032 −0.20 0.132
solving skills (Bester, 2009). The results of this present study are similar Pretest–Follow Up −0.79 0.005 −0.31 0.102
Posttest–Follow Up −0.30 0.114 −0.09 0.777
to those of Grant et al.'s study, but different from those of Bester's study.
Social support
This difference between the studies might be due to the fact that pa- Pretest–Posttest −1.05 0.001 −0.19 0.128
tients given care had different illnesses, that different intervention Pretest–Follow Up −1.30 0.001 −0.10 0.415
methods and measurement tools were used, and that the participants Posttest–Follow Up −0.16 0.119 0.08 0.382
were from different cultural backgrounds. Family coping–coherence
Pretest–Posttest −0.56 0.019 −0.17 0.385
At the end of the support program carried out by a nurse in this
Pretest–Follow Up −0.83 0.001 −0.13 0.322
study, social support levels of the female family caregivers increased. Posttest–Follow Up −0.42 0.027 −0.29 0.109
The difference between the effect sizes of the pretest and posttest and Family hardiness
between the pretest and follow-up test in the experimental group was Pretest–Posttest −0.89 0.001 −0.16 0.076
Pretest–Follow Up −0.96 0.001 −0.01 0.114
quite high, which suggests that the support program helped increase
Posttest–Follow Up −0.08 0.024 0.14 0.590
the use of social support, and the effect size was a lot higher than that Family distress
of the researcher's intended effect size of 0.50. That the caregivers Pretest–Posttest 0.67 0.010 −0.14 0.273
shared their experiences with each other in the group, that they posi- Pretest–Follow Up 0.62 0.015 −0.20 0.258
tively affected each other, and that they established positive communi- Posttest–Follow Up −0.045 0.684 −0.21 0.936

cation within the group may have been effective in creating positive d = effect size; p = adjusted significance level 0.016 (0.05/3).
 F.H. İnci, A.B. Temel / Applied Nursing Research 32 (2016) 233–240
Smith et al. conducted a study with the relatives of stroke patients in 2012
but did not find a significant difference between social support levels of
the caregivers in the experimental and control groups, and the effect
size they determined was negligible (Smith et al., 2012). The results of
this present study are similar to those of Van Del Heuvel et al.'s studies
(2000–2002), but different from those of Smith et al.'s study (2012).
The difference may have stemmed from the methods used in the studies,
because, while Van Den Heuvel et al. (2000, 2002) used group education
and home visits, Smith et al. utilized the Web in their studies.
Although there was an increase in family coping–coherence in both
groups, this increase was statistically significant only in the experimen-
tal group. Although the difference between the pretest and posttest
scores in the experimental group was not significant, the effect size
was medium. The difference between the pretest and follow-up test
scores in the same group was statistically significant and the effect
size was large. These effect size values were higher than the effect size
of 0.50 targeted by the researcher. What is promising is that this effect,
although not statistically significant, continued to increase during the
time between the posttest and follow-up test. In several studies on the
issue, it is reported that education/counseling programs reduce anxiety
and depressive symptoms of patients and care burden of caregivers, en-
able them to learn appropriate coping methods, increase their satisfac-
tion with care and improve their quality of life (Kalra et al., 2004;
Pierce, Finn, & Steiner, 2004).
The support program applied to the experimental group increased
the caregivers' family hardiness. The effect size of the family hardiness
was large between the pretest and posttest measurements and between
the pretest and follow-up test measurements, but negligible between
the posttest and follow-up test measurements in the experimental
group. The effect size obtained in the pretest–posttest and pretest-
follow up measurements was larger than the targeted effect size of
0.50. The impact of the support program on family hardiness, though
not much, continued to increase at six months after the program. The
support program also improved the family's inner strengths and re-
sources. In Clark et al.'s interventional study (2003) providing education
and counseling to stroke patients and their spouses in which family
functions of the experimental and control groups were compared, it
was observed that while the family functions of the experimental
group increased, those of the control group decreased (Clark et al.,
2003). In a study conducted by Holtzkamp in 2010, at the end of the
program aimed at women, their resilience levels were evaluated, and
the difference was considered significant in terms of group and time,
but insignificant in terms of group*time interaction. Similar to those in
the literature, this study revealed that programs aimed at caregivers
promoted family resilience in other words, increased the family's
inner strengths.
The support program seems to have been effective in reducing the
family distress on the caregivers. While the effect size of family distress
between the pretest and posttest measurements and between the pre-
test and follow-up measurements was medium in the experimental
group, it was negligible between the posttest and follow-up test mea-
surements. It can be said that the support program positively contribut-
ed to the reduction of family distress experienced by the female family
caregivers of stroke patients and to the development of their adaptation,
and that the effect size was medium. These results indicate that the
targeted effect size of 0.50 was achieved. In a study conducted by
Holtzkamp in 2010, at the end of the program aimed at women, family
coherence was evaluated, and the difference was considered significant
in terms of group and time, but insignificant in terms of group*time in-
teraction (Holtzkamp, 2010). The findings of this present study can be
said to be similar to the findings of the Holtzkamp's study.
6. Conclusions
A significant difference was determined between the experimental
group's and control group's follow-up test scores for caregiver burden,
239
support from relative and friend, social support and family coping co-
herence. A significant difference was determined between the experi-
mental group's mean pretest, posttest and follow-up test scores in
terms of family strain, support from relative and friend, social support,
family coping–coherence, family hardiness and family distress. These
results suggest that the Support Program contributes to the improve-
ment of the resilience of female family caregivers of stroke patients. In-
dividuals who perceive problems encountered as a part of daily life,
struggle to solve them believing that they can do so and trying to
solve these problems by talking and sharing with the family, relatives
and friends will not let problems accumulate, improve their problem-
solving capacity and strengthen themselves. This study could provide
a reference for clinicians and clinical researchers when planning and
implementing support programs for family caregivers of stroke patients.
Although the results of this study are promising, we recommend further
testing of the model of resilience to generalize the results beyond that of
our sample.
7. Limitations
The limitations of this study may be outlined as follows: Because of
small sample size and the design of the study the findings of this
study can only be generalized to the study group; the short follow-up
period could be considered as another limitation. Additionally, due to
the study being managed for a doctoral thesis, data collection and inter-
vention were carried out by the same researcher who was not therefore
blinded to group assignment.
Ethical approval
Ege University Nursing Faculty Ethics Committee, Reference
No.2012–30.
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