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However, few dialogue-based psychosocial inter-
ventions to support stroke survivors’ coping and life
skills have been conducted by primary healthcare
professionals in the municipalities. In Norway, imple-
mentation of the Coordination Reform in 2012 (12)
resulted in a shift in focus from primarily treating pa-
tients in hospitals to a focus on prevention, improving
coordination between different care levels, integrating
care in the community, and strengthening healthcare in
the municipalities. The overriding aim of the reform
was to direct more investment towards primary care in
order to curb increasing hospital expenditure. As part of
this shift, providing rehabilitation near patients’ homes
in the municipalities was encouraged.
The dialogue-based intervention was developed and
feasibility tested in accordance with the United King-
dom Medical Research Council (UK MRC) guidance
on developing and evaluating complex interventions
(13, 14). The intervention was found to be feasible to
conduct in the municipalities, was tailored for stroke
survivors and designed to be delivered in the early
rehabilitation phase starting 4–6 weeks after stroke
onset (15). A guiding topical outline and worksheets
were developed to support the dialogues. The topics
included emotions, social relationships, bodily chan-
ges, dynamic problem-solving, daily activities and
identity (14, 15).
The theoretical perspectives underpinning the inter-
vention included Antonovsky’s (16) theory on saluto-
genesis, sense of coherence (SOC), narrative theory
(17) and ideas from guided self-determination (18).
Based on the theoretical foundation and feasibility
work, we hypothesized that support during the early
adjustment phase following a stroke could lead to
improvements in mood, reduced depression, enhanced
health-related quality of life and improved understan-
ding, manageability and meaning in their lives after
stroke (14, 15).
The present study evaluated the effect of a dialogue-
based intervention in addition to usual care on psycho-
social well-being 6 months after stroke.
MATERIALS AND METHODS
Trial design and participants
This study was a multicentre, prospective, randomized control-
led trial (RCT). Participants were recruited from 11 acute stroke
or rehabilitation units in eastern Norway between November
2014 and November 2016.
Patients who met these criteria were invited to participate:
aged >18 years and had had an acute stroke within the past
month, were medically stable, had sufficient cognitive functio-
ning to provide informed consent and participate, and under-
stood and spoke Norwegian. Exclusion criteria were: severe
dementia, other serious somatic or psychiatric diseases or severe
www.medicaljournals.se/jrm
aphasia. Recruiting personnel assessed the cognitive function
and aphasia, which were discussed with the rehabilitation team
at the recruiting institutions.
Interventions
All participants received usual care. Usual care included acute
treatment at stroke units and rehabilitation centres or in the
municipality. All participants were followed up by their phy-
sicians in accordance with the Norwegian clinical guidelines
for treatment and rehabilitation after stroke (19) in addition to
nursing and therapy input (e.g. through a multidisciplinary team)
based on need and availability.
The dialogue-based intervention consisted of 8 individual
sessions involving the participant and a registered nurse (RN)
or occupational therapist (OT) recruited via the recruiting
institutions, other stroke rehabilitation units or the community
healthcare. All intervention personnel (IP) were required to
complete a 3-day training programme. Group seminars led by
members of the research team were arranged for the IP during
the study. The seminars were an arena for guidance and supervi-
sion and allowed the research team to reinforce IP training and
compliance to protocol in order to promote intervention fidelity.
The same RN/OT worked with the participant through all
sessions. Interventions were delivered mainly in the partici-
pants’ homes. The first of the 8 sessions began shortly after
randomization (4–8 weeks post-stroke), and the final session was
completed within 6 months. The number of sessions was chosen
to balance the ideal with the realistic (i.e. as few encounters as
possible, but enough to provide adequate support).
The sessions` content addressed feelings, thoughts and reflec-
tions related to the patients’ experiences after stroke, and were
based on topics highlighted as significant issues in the stroke
literature and in the development and feasibility studies (14, 15).
Theoretically, experiences of chaos and a lack of control were
perceived as potential threats to well-being following stroke. It
was assumed that sense of coherence (SOC) could be promoted
by experiencing diverse life events as comprehensible, mana-
geable and meaningful. To promote SOC, the participants were
encouraged to relate their experiences. Narrative theories em
phasize that human beings create meaning in their lives through
telling stories. By guided self-determination, the intervention
sought to empower the participants to make decisions on issues
related to well-being based on their values and perspectives (14).
More details on the topics of the dialogue-based sessions are
provided in the Table SI and Table SII 1 . Further details regar-
ding the development and adjustments of the intervention were
provided in previous research (15).
Outcomes
The stroke aetiology, side localization of the stroke symptoms,
cognitive function, and language difficulties were recorded at
baseline after obtaining informed consent. Neurological deficits
were evaluated using the National Institutes of Health Stroke Sca-
le (NIHSS) upon admittance to the hospitals (20). Information
regarding cognitive function (Mini Mental Status Evaluation;
MMSE) was collected from the participant’s medical record.
Participants were assessed prior to randomization using struc-
tured outcome measures 1 month post-stroke (T1). In addition,
the data collector recorded the patient’s age, sex, living situation,
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