Developing an intervention to enhance the engagement and motivation of stroke patients with cognitive impairment in physiotherapy rehabilitation programmes in Saudi Arabia

Abstract

Introduction Globally, a stroke occurs every two seconds, making it the second leading cause of death after ischemic heart disease. Strokes reduce quality of life and increase disabilities and are often associated with cognitive impairment (CI) with an increased dependency, risk of mortality, development of depression and poor quality of life. Indeed, the incidence of CI after stroke is relatively high, reported to affect 40-70% of stroke survivors, therefore CI after stroke is an important research priority as agreed by stroke patients, caregivers, as well as health professionals. Post-stroke rehabilitation promotes functional recovery and independence of stroke survivors but CI after stroke is negatively associated with poorer functional outcomes. The presence of CI after a stroke can also affect the rehabilitation process as such stroke survivors may be less motivated and interested in rehabilitation programmes and engage in fewer therapy sessions. The concept of engagement and motivation is identified as a cognitive state, therefore, motivation and engagement in the physiotherapy treatment programme tend to be insufficient in stroke survivors with CI. This thesis aimed to develop an intervention to improve engagement and motivation in physiotherapy treatment for stroke survivors with CI in the Kingdom of Saudi Arabia. Methods A mixture of methods approach with three interlinked studies was conducted within the development stage of the Medical Research Council (MRC) framework for the development of complex interventions. A scoping review (study one) was conducted to explore the engagement and motivation strategies used in physical therapy practice for stroke patients with cognitive impairment. Qualitative interviews (study two) with physiotherapists were conducted to identify the individuals and environmental facilitators and barriers to applying engagement and motivation strategies in the Saudi physiotherapy rehabilitation context. These findings were combined with the use of a theoretical domain framework to develop a behaviour change intervention. The intervention was presented in programme theory using a logic model to demonstrate the visual pipeline consequence, highlighting the evidence-based findings, facilitators and barriers, selected behaviour change techniques, mechanism of action and intervention outcomes. After designing the logic model and explaining the intervention components, stakeholders were engaged using the nominal group technique (study three) to discuss the applicability of the behaviour change intervention in the local rehabilitation context and refine the logic model. Results The scoping review included 17 studies and indicated a lack of robust evidence on strategies used in physical therapy practice and how these strategies were applied and improved the level of engagement and motivation of stroke patients with CI during treatment. The engagement and motivation strategies identified were therapeutic interactions and communication, an enriched environment, the use of technology, and applying strategy training. The qualitative interviews conducted with twelve physiotherapists identified five facilitators, “Promising impacts”, “Professional responsibilities and treatment priority”, “Positive connections with patients and their families”, “Training and educational support”, and “Physiotherapists self-attitude” and four barriers, “Information and case identification”, “Organisational culture”, “Patient belief and circumstances”, and “Physiotherapists` awareness and self-confidence”. The stakeholder engagement activity was conducted with fifteen stakeholders including physiotherapists, heads of departments, quality managers and clinical researchers. The participants agreed that educational workshops and restructuring the physiotherapy department environment were extremely important (67%) or important (33%) behaviour change techniques to enhance professionals' skills and improve stroke rehabilitation services. Regarding changing protocols, more than a quarter of the participants (27%) were not sure that changing protocols would be an effective strategy to enhance physiotherapists' skills and stroke patient outcomes. They attributed this to physiotherapists' negative attitude regards using the rehabilitation protocols, the long process to change protocols, frequent changes in the rehabilitation protocols and organisational pressure to develop protocols for accreditation purposes. These responses were used to amend the logic model and intervention. Conclusion This thesis highlighted the complexity of patient engagement and motivation, as well as the role of individual and environmental factors in supporting stroke patients with CI engagement and motivation in rehabilitation programmes. The study explored the facilitators and barriers to applying engagement and motivation strategies in the Saudi rehabilitation context and acknowledged the individual and organisational barriers. Consequently, a theoretically driven behaviour change intervention was developed to improve the engagement and motivation of stroke patients with CI in physiotherapy rehabilitation programmes. The thesis concluded with recommendations and suggestions regarding improving the rehabilitation services for stroke patients with CI, considering engagement and motivation and further researching different strategies to support them. It also provided recommendations for policymakers in the Saudi rehabilitation context to improve the services provided for stroke patients with CI and the importance of multidisciplinary collaboration to support patients' outcomes and treatment services. Following the intervention development, research is needed to deliver and evaluate the behaviour change intervention for improving the engagement and motivation of stroke patients with CI.