Abstract

Background - Family members play important role in recovery of stroke

patient.As stroke is a common, chronic condition with high morbidity, mortality
and disability.The aim of study was to estimate stress level in family members of
stroke patients.
Method - It was a observational study, including 100 caregivers of patients with
stroke. PSS-10 scale was used to assess level of stress in family members. Online
survey was done by making Google forms.
Result - 57% of family members of stroke patient perceived moderate level of
stress, this affects the mental health and quality of life of caregivers.
Conclusion - This study concludes that the stress was more in wives, sons,
daughters in first relation where as in second relation stress was more in daughter
in law. Some interventions should be structured to reduce the level of stress in
family members.
Key words - Stress, stroke, caregivers, perceived, PSS.
 INTRODUCTION

Stress can be defined as “a condition or feeling experienced when a person

perceives that the demands placed on them exceed the resources the individual has
available.” Stress can therefore be understood as a perceived imbalance between
the demands encountered in daily living and a person’s capability to respond.6

Stress can affect all aspects of your life, including your emotions,
behaviors,thinking ability and physical health. Prolonged stress is associated with
poor physical and mental health outcomes7, and this can arouse feeling of fear,
uselessness, anger, incompetence and guilt which ultimately results in headache,
low energy, constant worrying, forgetfulness, inability to focus, poor judgements,
depression, anxiety, personality disorders, etc.

Stroke (Cerebrovascular accident (CVA)) can be defined as sudden loss of

neurological function caused by an interruption of blood flow to brain.1 Stroke is
the second leading cause of death globally.2 The incidence of stroke increases with
age, doubling after the age of 55 years.2 Stroke is a common chronic disease with
high morbidity, mortality and disability in worldwide.

Stroke can be classified into 2 categories :-

Ischemic stroke - Ischemic stroke contributes about 85% of patients. And is

caused by the deficient blood and oxygen supply to the brain.2 Which
further classified into –

 Thrombotic stroke
 Embolic stroke

Hemorrhagic stroke - Hemorrhagic stroke accounts for 10-15% of patients. And

is caused by bleeding or leaky blood vessels in the brain.2 It is further classified
into -
 Intracerebral hemorrhage
 Subarachnoid hemorrhage

The pathogenesis of stroke is as follows, clots form in brain and interrupts blood
flow which results in clogging arteries and causing blood vessels to break leading
to bleeding results in sudden death of brain cells owing to lack of oxygen which
leads to loss of neuronal function.2 which results in presence of symptoms such as
weakness in arm/leg, speech difficulties, facial drop, vision difficulties,
dizziness, memory loss.4

The clinical staging of stroke is generally as follows

 Acute phase is an initial phase, which lasts upto 2 weeks after the onset of the
lesion.5
 Subacute phase begins 3-11 weeks after the stroke.5
 Chronic phase starts after the 12-24 weeks of stroke and this is referred as early
chronic stage while more than 24 weeks post stroke is termed as chronic stage.5

Like other disabling conditions the onset of the stroke is sudden, leaving individual
and family ill prepared to deal with its consequences.8 Most people(25%-50%)
with stroke are being cared for at home by family members.16 Giving care is
stressful and family members are predisposed to care related complications such as
life changes and perceives stress.16 Informal caregivers are defined as individuals
who provide some type of unpaid ongoing assistance with activities of daily living
or instrumental activities of daily living for individuals with a chronic illness or
disability.20 Informal relatives (such as spouse, Husband, child) are backbone of
services provided to surviving stroke patients.9

Informal caregivers play an important role in post stroke care, the stress factors
amongest family members are as follows –

 Patients factors which are predictors for caregivers strain are as follows –
1) Severe disabilities such as hemiplegia, speech disability, facial drop, poor
vision, etc
2) Poor cognition
3) Depression
4) Recurrent stroke10
 Caregivers factors which are associated with considerable caregivers strain are
as follows –
1) Changed employment status
2) Help from formal caregivers
3) Anxiety, depression, stress10
At least 50-70% of stroke patients suffer from chronic neurological or cognitive
impairment creating significant burden on patients family.11 This makes patients
and their families to fall into troubles of “ adaptations” and “ care” causes huge
impact on mental health of caregivers.3 Caregivers stress is common and is caused
by ongoing emotional and physical strain of caregiving.20

It is reported that the main caregivers of stroke patients have an equal or greater
incidence of having psychological issues such as increase in perceived stress,
anxiety and depression, etc.3 This affects daily routine work and responsibilities of
caregivers, this results in disturbance in emotional and physical state of the person.
This is also a one of the reason of why psychological issues occur in the caregivers
of stroke patients.

The rationale of this study was to identify the level of perceived stress among the
family members of stroke patients and hence to help family members to tackle
stress by perceiving different coping strategies and improve their personal life.
RESEARCH QUESTION

What is the prevalence of perceived stress in family members of stroke patients?

AIM AND OBJECTIVES

AIM

The aim of study is to estimate the stress level in family members of

stroke patients.

OBJECTIVES

1) To know the level of perceived stress in family members of stroke

patients.
2) To evaluate perceived stress level in male and female members of stroke
patients.
3) To find out stress level in various relations with stroke patient.
NEED OF STUDY

The study will estimate the level of perceived stress in family members
of stroke patients. As high stress levels in family members of stroke patients not
only reduce their quality of life but also directly affect patients attitude towards
treatment protocol which ultimately increases stress and depression in patient
itself. So retrieving knowledge about presence of stress is therefore important in
itself and if found should be given attention for timely interventions. So, the
appropriate intervention strategies must be proposed to reduce stress and enhance
caregivers abilities.
REVIEW OF LITERATURE

1) The study performed by Babitha Rajan, Suman G, et al; on “Assessment

of stress among caregivers of the stroke survivors : community based study”
concludes that there is an increase in strain on the caregivers of stroke
survivors which impacted the personal life as well as the quality of care
offered by them.

2) A study performed by Michael O. Ogunlana msc,et al; on “Quality of life

and burden of informal caregivers of stroke survivors” concluded that the
caregivers of stroke survivors had moderately low quality of life and level of
caregiving burden.

3) A study done by Azar Kazemi, Jalil Azimian, et al; on “ Caregiver burden

and coping strategies in caregivers of older patients with stroke” concludes
that caregivers with higher burden of care used more negative coping
strategies, such as escape, avoidance, and distancing. In order to encourage
caregivers to utilize effective coping skills, appropriate programs should be
designed and implemented to support caregivers.

4) A study performed by Eeeseung Byun, Lois Evans, et al; on “Depressive

symptoms in caregivers immediately after stroke” concludes that the
caregivers and stroke survivors characteristics may help identify caregivers
at highest risk for early depressive symptoms and guide interventions aimed
at their resolution.
5) A study performed by Gianluca Pucciarelli, Davide Ausili ,et al; on
“Quality of life, anxiety, depression and burden among stroke caregivers : A
longitudinal, observational multicentre study” concluded that the first 9
months of caregiving are particularly problematic for caregivers. The
trajectories of the above variables and their predictors may be useful for
policy makers, clinicians, investigators and educators to give better care to
stroke caregivers and their survivors.

6) A study done by Tatiana Ferreira da Costa, Claudia Jeane, et al; on

“Burden on caregivers of patients with sequelae of Cerebrovascular
accident” concludes that the results allow us to reflect on the need to create a
policy aimed at family caregivers to reduce the impact of care delivery.
SOCIAL RELEVANCE

To study the impact of stress level in family members of stroke patients

and estimating perceived stress so the family members would apply different stress
relieving strategies on self and reduce their stress level which may impact their
life.
METHODOLOGY

 Study design - Observational study

 Source of data - Among all stroke patients relatives

 Study setting - Aurangabad city

 Study population - Stroke patients relatives

 Sample size - 100. Formula;- n=([Z1]^2{P(1-P))/d^2

 Sampling method - Convenient sampling method

 Duration of sampling - 3 months

 Materials used - Perceived stress scale (PSS-10)

INCLUSION CRITERIA

1) It should be main family members of stroke patients.

2) Both male and female family members of stroke patients.
3) Family members aged between 18-50 years.
4) Family members willing to participate in study.

EXClUSION CRITERIA

1) Not wiling to participate in the study.

2) Any paid caregiver.
3) Family member who have diagnosed for any major medical condition.

OUTCOME MEASURE

1) Perceived stress scale (PSS-10)

Perceived stress scale (PSS-10) was used to evaluate levels of stress. It

is a brief and easy-to-use tool. It measures the degree to which situations in ones’
life are appraised as stressful. It has been proven to possess substantial reliability
and validity. The questions in this scale ask about the feelings and thoughts of the
participants during the last one month. In each case, they will be asked to indicate
how often they felt or thought a certain way. It is a 10 item questionnaire with
responses in the form of how often they experienced certain situations from 0-
never to 4- very often.12
PROCEDURE:
The purpose of the study was explained to the participants. This an observational
study was done on the family members of stroke patients. The participants were
included in study on the basis of inclusion and exclusion criteria. The outcome
measures Perceived Stress Scale were used.

Perceived stress scale is a measure of the degree to which situations in one’s life
are appraised as stressful. Items were designed to tap how unpredictable,
uncontrollable, and overloaded respondents find their lives. It is brief and easy to
administer tool. The scale includes questions about the feelings and thoughts of the
individual during the last one month. It is a 10 item questionnaire with responses in
the form of often they experience certain situation from 0-never to 4-very often.

The scale and questionnaire were converted into Google form

(http://play.google.com/store/apps/details?id=com.heartfull.forms) so it
became convenient for participants to fill the form without any difficulty in
the COVID-19 outbreak. Filled questionnaire and scales were collected in
Google form responses and items were analysed for perceived stress level
of the participants.
RESULT

The study was conducted by using PSS-10 scale for estimating perceived
stress level in family members of stroke patients. The number and percentage of
stressed cases were calculated according to demographic data. The statistical
analysis was done by the statistician.
TABLE NO. 1
Gender of Frequency Percentage
relatives

Male 50 50%

Female 50 50%

Chart Title
60

50

40

30

20

10

0
1 2

Gender of relatives Frequency

FIGURE 1
The above bar diagram in figure no.1 shows distribution of relatives on the basis of
their gender. In this study 50% individuals are males and 50% individuals are
females.
 TABLE NO. 2

Relationship with Percentage

patient
Wife 17%
Husband 8%
Son 35%
Daughter 11%
Daughter in law 14%
Mother in law 2%
Mother 3%
Father 5%
Brother 3%
Sister 2%

Frequency
40
35
30
25
20
15
10
5
0
Wife Husband Son Daughter Daughter Mother Mother Father Brother Sister
in law in law

FIGURE 2
The above bar diagram in figure no. 2 shows distribution of relatives on the basis
of their relation with stroke patients. In this study 17% are Wives, 8% are
Husbands,35% are Son, 11% are Daughters, 14% are Daughter in law, 2% are
Mother in law, 3% are Mothers, 5% are Fathers, 3% are Brothers and 2% are
Sisters.
PERCEIVED STRESS LEVEL

1) In the last month, how often have you been upset because of something
that happened unexpectedly?

TABLE NO. 3
Option Responses

0 3

1 3

2 23

3 36

4 35

Responses

3%
3% 0
35% 23% 1
2
3
4
36%

FIGURE 3
Out of 100 caregivers, 3% subjects choose never, 3% have almost never, 23%
sometimes, 36% fairly often, and 35% very often have been upset because of
something that happened unexpectedly.
2)In the last month how often have you felt you were unable to control the
important things in your life?

TABLE No. 4

Option Responses

0 15

1 6

2 31

3 39

4 9

Responses

9% 15% 0
1
6% 2
3
39% 4
31%

FIGURE 4

Out of 100 caregivers,15% have never, 6% have almost never, 31% sometimes,
39% fairly often and 9% very often, have felt they were unable to control the
important things in their life.
3)In the last month how often have you felt nervous and stressed?

TABLE NO. 5

Option Responses

0 3

1 7

2 18

3 36

4 36

Responses

3%7% A
36% B
18%
C
D
E

36%

FIGURE 5

Out of 100 caregivers,3% have never felt,7% almost never felt,18% sometimes
felt,36% fairly often felt and 36% very often, have felt they were nervous and
stressed.
4)In the last month how often have you felt confident about your ability to handle
your personal problems?

TABLE NO. 6

Option Responses

0 18

1 28

2 28

3 13

4 13

Responses

13% 18% 0
1
13%
2
3
28% 4
28%

FIGURE 6
Out of 100 caregivers, 18% have never, 28% almost never, 28% have sometimes,
13% have fairly often and 13% very often have felt they were confident about their
ability to handle their personal problems.
5)In the last month how often have you felt that things were going your way?
 TABLE NO. 7

Option Responses

0 7

1 11

2 22

3 38

4 22

Responses

7%
22% 11% 0
1
2
22% 3
4
38%

FIGURE 7

Out of 100 caregivers, 7% have never, 11% almost never, 22% have sometimes,
38% fairly often and 22% have very often felt that things were going their way.

6)In the last month how often have you found that you could not cope with all the
things that you had to do?
 TABLE NO. 8

Option Responses

0 20
Option Responses
1 0 9 14
2 1 34 24
3 2 22 27
4 3 15 10

4 25
Responses

15% 20% 0
1
2
22% 9%
3
4

34%

FIGURE 8

Out of 100 caregivers, 20% have never, 9% almost never, 34% have sometimes,
22% have fairly often and 15% very often have found that they could not cope with
all the things that they had to do.

7)In the last month how often have you been able to control irritations in your life?
TABLE NO. 9
 Responses

14% 0
25%
1
2
24% 3
10%
4

27%

Figure 9

Out of 100 caregivers, 14% have never, 24% almost never, 27% have sometimes,
10% fairly often and 25% very often have been able to control irritations in their
life.

8)In the last month how often have you felt that you were on top of the things?
TABLE NO. 10
 Option Responses

0 13

1 34

2 14

3 23

4 16

Responses

16% 13% 0
1
2
23% 3
34%
4
14%

FIGURE 10

Out of 100 caregivers, 13% have never, 34% almost never, 14% have sometimes,
23% have fairly often and 16% very often have felt that they were on top of the
things.

9)In the last month how often have you been angered because of things that were
outside of your control? Option Responses

0 31 TABLE NO. 11
1 3

2 29

3 26

4 11
 Responses

11% 0
31% 1
2
26%
3
3% 4

29%

FIGURE 11

Out of 100 caregivers, 31% have never, 3% almost never, 29% have sometimes,
26% fairly often and 11% very often have been angered because of things that
were outside of their control.

10)In the last month how often have you felt difficulties were piling up so high that
you could not overcome them?
TABLE NO. 12
Option Responses

0 19
 1 9

2 33

3 28

4 11

Responses

11% 19% 0
1
9% 2
28%
3
4
33%

FIGURE 12

Out of 100 caregivers, 19% have never, 9% almost never, 33% sometimes, 28%
have fairly often and 11% very often have felt difficulties were piling up so high
that they could not overcome them.

TABLE NO. 13 (PSS-10 Outcomes)

 Stress Frequency Percentage
level

Low 12 12%

Moderate 57 57%

High 31 31%

Frequency
57

31

12

Low Moderate High

FIGURE 13
Above bar diagram, figure no.13 shows Perceived stress level among all
caregivers. Among 100 caregivers 12% perceived Low level of stress, 57%
perceived Moderate level of stress and 31% perceived High level of stress.

TABLE NO. 14 (Represents perceived stress level of Gender of relatives)

 Gender of Perceived stress level Total
relatives Low Moderate High
No. % No. % No. % No. %
Male 05 10 32 64 13 26 50 100

Female 07 14 25 50 18 36 50 100

Chart Title
120
100
80
60
40
20
0
No. % No. % No. % No. %
Low Moderate High
Perceived stress level Total

Male Female

FIGURE 14

The above bar diagram, figure no.14 shows perceived stress level in gender of
relatives. In 50 male caregivers – 10% male caregiver perceived Low level of
stress, 64% perceived Moderate level of stress and 26% male caregivers perceived
High level of stress and in 50 female caregivers – 14% perceived Low level of
stress, 50% perceived Moderate level of stress and 36% female caregiver perceived
High level of stress.

TABLE NO. 15 (Represents perceived stress level in various relations of

stroke patients)
Relation with Perceived stress level Total
stroke patients
Low Moderate High
No. % No. % NO. %
Wife 3 17.64 9 52.94 5 29.4 17
Husband 2 25 2 25 4 50 8
Son 3 8.57 24 68.57 8 22.85 35
Daughter 1 9.09 5 45.45 5 45.45 11
Daughter-in-law 1 7.14 7 50 6 42.85 14
Mother-in-law 0 0 1 50 1 50 2
Mother 1 33.33 1 33.33 1 33.33 3
Father 0 0 4 80 1 20 5
Brother 0 0 3 100 0 0 3
Sister 1 50 1 50 0 0 2

Chart Title
120
100
80
60
40
20
0
if e nd So
n er w w he
r er he
r er
ba ht -la - la ot th ot st
W s ug
-r in -r in F a r Si
Hu Da te
M B
he
ugh ot
M
Da

Perceived stress level Low No. Perceived stress level Low % Perceived stress level Moderate %
Perceived stress level Moderate No. Perceived stress level Moderate % Perceived stress level High NO.
Perceived stress level High % Total NO. Total %

FIGURE 15
The above bar diagram shows perceived stress level in various relations of stroke
patients.

DISCUSSION
 We conducted a study to find out the prevalence of perceived stress in
family members of stroke patients. The present study had 100 caregivers (both
male and female), with various relationship to the stroke patients, who responded
to our questionnaire which was based on stress that they perceived. Most of the
stroke survivors who are taken care at home , directly or indirectly places burden
on the caregivers. Stroke patients have poor cognition, altered mood, decreased
functional status and affected quality of life. The patient is dependent on his/her
family members which results in burden on caregivers both economically(80%)
and mentally at individual and family level. As mentioned above, the questionnaire
used in this study is perceived stress scale (PSS-10). This questionnaire contains
four positive stated items and six negative stated items . The questions in this scale
asks about the feelings and thoughts during the last month i.e how often you felt or
thought in a certain way.
Results depicted that moderate level of stress perceived in family members of
stroke patients. Among 100 participant, 12% perceived low levels of stress, 57%
perceived moderate levels of stress and 31% perceived high levels of stress. As
mentioned in our results, participants who participated in study were 50% males
and 50% females, in that 10% male perceived low stress, 64% male perceived
moderate stress and 26% male perceived high level of stress where as 14% females
perceived low stress, 50% females perceived moderate stress level and 36% female
caregiver perceived high stress levels. Maximum number of relations we found in
our study were wives, sons, daughter, daughter in law to stroke patients, who
perceived moderate level of stress.
A study done on assessment of stress among caregivers of stroke survivors:
community based study states that all caregivers participated in study were going
through financial difficulties, physical strain, family and emotional adjustments
and sleep disturbance were found to have contributed to their stress. So our study is
concurrence with the study done by Babitha Rajan, Suman G, et al. In this study
authors found that 88.7% caregivers were upset and 50.7% were feeling confined
which is in accordance with our study where 94% caregivers found upset and 71%
subjects thought they were not able to cope with all things that they had to do.
A study done on female caregivers and stroke severity determines caregiver stress
in stroke patients,found that 90% caregivers were underwent in mood disturbances
such as forgetfulness, sadness,confusion, anger, irritated. They concluded that
caregiving burden was predominantly shouldered by female caregivers.So this
research is in parallel to the current study where 62% and 66% caregivers thought
that they were irritated and angered.15
A study performed on family functioning and depression in primary caregivers of
stroke patients in china, found SD(2.12 +-0.38) for behaviour control and
SD(2.37+-0.30) for problem solving ability in stroke survivors family. They stated
that it is necessary to improve the assessment of stroke survivor families and the
effectiveness of family based interventions.11 Other than that, in current study 90%
and 54% subjects thought that they were nervous and stressed and were confident
about their ability to handle personal problems respectively.
The caregivers of stroke patients were undergoing in stress due to heavy
responsibility, uncertainty of patients care needs, restraints in social life and feeling
that patients entirely relies on their care. The financial difficulties can be increased
if the stroke survivor is sole bread winner of family, the emotional disturbance can
be occur due to the unexpected event which was happened in their life for which
they were not prepared. So to lower the incidence of stress in family members of
stroke patients proper interventions should be structured.

CONCLUSION
 Our study showed that, caregivers perceived overall 57% moderate level
of stress. The burden was more in wives, son, daughters, daughter in law. This
influenced both personal life of caregivers and quality of care experienced by
stroke survivor. This study suggests that some interventions should be structured to
help caregivers cope with their perceived level of stress.
LIMITATION

1) The sample size is less, if the study can be done in large sample size
then proper results can be find out.
2) The perceived stress scale (PSS-10) can be corelate with other scale, to
know the level of limitation in caregivers.
3) In this study, online survey was done so personal interview with
caregiver was not taken.
 REFERENCE
1) Susan B, O’Sullivan Thomas J. Schmitz. George D. Fulk,Physical
Rehabilitation ,6th edition
2) Kuriakose D, Xiao Z. Pathophysiology and treatment of stroke: present
status and future perspectives. International journal of molecular sciences.
2020 Jan;21(20):7609.
3) Hu P, Yang Q, Kong L, Hu L, Zeng L. Relationship between the
anxiety/depression and care burden of the major caregiver of stroke patients.
Medicine. 2018 Oct;97(40).
4) Faiz KW, Sundseth A, Thommessen B, Rønning OM. Patient knowledge on
stroke risk factors, symptoms and treatment options. Vascular health and
risk management. 2018;14:37.
5) Wu P, Zeng F, Li YX, Yu BL, Qiu LH, Qin W, Li J, Zhou YM, Liang FR.
Changes of resting cerebral activities in subacute ischemic stroke patients.
Neural regeneration research. 2015 May;10(5):760.
6) Heinen I, Bullinger M, Kocalevent RD. Perceived stress in first year medical
students-associations with personal resources and emotional distress. BMC
medical education. 2017 Dec;17(1):1-4.
7) Liu S, Lithopoulos A, Zhang CQ, Garcia-Barrera MA, Rhodes RE.
Personality and perceived stress during COVID-19 pandemic: Testing the
mediating role of perceived threat and efficacy. Personality and Individual
differences. 2021 Jan 1;168:110351.
8) Rajan B, Suman G, Pruthvish S, Radhika K. Assessment of stress among
caregivers of the stroke survivors: community based study. International
Journal of Community Medicine and Public Health. 2016;4(1):211-5.
9) Ogunlana MO, Dada OO, Oyewo OS, Odole AC, Ogunsan MO. Quality of
life and burden of informal caregivers of stroke survivors. Hong Kong
Physiotherapy Journal. 2014 Jun 1;32(1):6-12.
10) Hung JW, Huang YC, Chen JH, Liao LN, Lin CJ, Chuo CY, Chang
KC. Factors associated with strain in informal caregivers of stroke patients.
Chang Gung Med J. 2012 Sep 1;35(5):392-401.
11) Guo YL, Liu YJ. Family functioning and depression in primary
caregivers of stroke patients in China. International Journal of Nursing
Sciences. 2015 Jun 1;2(2):184-9.
12) Cohen S, Kamarck T, Mermelstein R. Perceived stress scale.
Measuring stress: A guide for health and social scientists. 1994;10(2):1-2.

13) Em S, Bozkurt M, Caglayan M, Ceylan Cevik F, Kaya C, Oktayoglu

P, Nas K. Psychological health of caregivers and association with functional
status of stroke patients. Topics in stroke rehabilitation. 2017 Jul
4;24(5):323-9.
14) Efi P, Fani K, Eleni T, Stylianos K, Vassilios K, Konstantinos B,
Chrysoula L, Kyriaki M. Quality of life and psychological distress of
caregivers’ of stroke people. Acta Neurol Taiwan. 2017 Dec 15;26(4):154-
66.
15) Menon B, Salini P, Habeeba K, Conjeevaram J, Munisusmitha K.
Female caregivers and stroke severity determines caregiver stress in stroke
patients. Annals of Indian Academy of Neurology. 2017 Oct;20(4):418.
16) Peyrovi H, Mohammad-Saeid D, Farahani-Nia M, Hoseini F. The
relationship between perceived life changes and depression in caregivers of
stroke patients. Journal of Neuroscience Nursing. 2012 Dec 1;44(6):329-36.
17) Sutter-Leve R, Passint E, Ness D, Rindflesch A. The caregiver
experience after stroke in a COVID-19 environment: a qualitative study in
inpatient rehabilitation. Journal of Neurologic Physical Therapy. 2021
Jan;45(1):14.
18) Akosile CO, Banjo TO, Okoye EC, Ibikunle PO, Odole AC. Informal
caregiving burden and perceived social support in an acute stroke care
facility. Health and quality of life outcomes. 2018 Dec;16(1):1-7.
19) Byun E, Evans L, Sommers M, Tkacs N, Riegel B. Depressive
symptoms in caregivers immediately after stroke. Topics in stroke
rehabilitation. 2019 Apr 3;26(3):187-94.
20) Kazemi A, Azimian J, Mafi M, Allen KA, Motalebi SA. Caregiver
burden and coping strategies in caregivers of older patients with stroke.
BMC psychology. 2021 Dec;9(1):1-9.
21) Long NX, Pinyopasakul W, Pongthavornkamol K, Panitrat R. Factors
predicting the health status of caregivers of stroke survivors: A cross‐
sectional study. Nursing & health sciences. 2019 Jun;21(2):262-8.
22) Pucciarelli G, Ausili D, Galbussera AA, Rebora P, Savini S, Simeone
S, Alvaro R, Vellone E. Quality of life, anxiety, depression and burden
among stroke caregivers: A longitudinal, observational multicentre study.
Journal of advanced nursing. 2018 Aug;74(8):1875-87.
23) Costa TF, Pimenta CJ, Nóbrega MM, Fernandes MD, França IS,
Pontes MD, Costa KN. Burden on caregivers of patients with sequelae of
cerebrovascular accident. Revista Brasileira de Enfermagem. 2020 Aug
10;73.
24) Liu J, Liu Q, Huang Y, Wang W, He G, Zeng Y. Effects of personal
characteristics, disease uncertainty and knowledge on family caregivers'
preparedness of stroke survivors: a cross‐sectional study. Nursing & Health
Sciences. 2020 Dec;22(4):892-902.
25) Pucciarelli G, Vellone E, Savini S, Simeone S, Ausili D, Alvaro R,
Lee CS, Lyons KS. Roles of changing physical function and caregiver
burden on quality of life in stroke: A longitudinal dyadic analysis. Stroke.
2017 Mar;48(3):733-9.
26) McLennon SM, Bakas T, Jessup NM, Habermann B, Weaver MT.
Task difficulty and life changes among stroke family caregivers: relationship
to depressive symptoms. Archives of physical medicine and rehabilitation.
2014 Dec 1;95(12):2484-90.
PARTICIPANTS CONSENT FORM
Title of the study : “Evaluation of perceived stress in family members of stroke patients ” Name

of the participant:

Age:

E-mail of the participant:

Contact no.:

I have read the information in this form (or it has been read to me). I was free to ask any
questions and they have been answered. I am over 18 years of age and, hereby give my consent
to be included as a participant in this study.

1) I have read and understood consent form and the information provided to me.
2) I have had the consent document explained to me.
3) My identity will be kept confidential if my data are publicly presented.
4) I have had my questions answered to my satisfaction.

By signing this consent form, I attest that the information given in this document has been clearly
explained to me and apparently understood by me.

PARTICPANT’S SIGN WITNESS SIGN

DATE DATE
 APPENDIX 2: OUTCOME MEASURE

PERCEIVED STRESS SCALE

The questions in this scale ask you about your feelings and thoughts during the last month.
In each case, you will be asked to indicate by circling how often you felt or thought a
certain way.
Name :-
Date :-
Age :-
Gender :-
Other :-

0= Never. 1= Almost Never. 2= Sometimes. 3= Fairly often 4= very often

1)In the last month, how often have you been

upset because of something that happened 0 1 2 3 4
unexpectedly?

2)In the last month, how often have you felt

you were unable to control the important 0 1 2 3 4 things in
your life?

3)In the last month, how often have you felt

nervous and stressed? 0 1 2 3 4

4)In the last month, how often have you felt

confident about your ability to handle your 0 1 2 3 4
personal problems?
5)In the last month, how often have you felt
that things were going your way? 0 1 2 3 4

6)In the last month, how often have you

found that you could not cope with all the 0 1 2 3 4
things that you had to do?

7)In the last month, how often have you

been able to control irritations in your life? 0 1 2 3 4

8)In the last month, how often have you felt

that you were on top of the things? 0 1 2 3 4

9)In the last month, how often have you

been angered because of things that were 0 1 2 3 4
outside of your control?

10)In the last month, how often have you

felt difficulties were piling up so high that 0 1 2 3 4
you could not overcome them?