Psychosocial well-being after stroke
No change was detected in the SOC after the inter-
vention. However, the results indicated that a higher
SOC level might have a protective effect against the
potentially stressful situation imposed by a stroke. The
SOC is considered to be strongly related to perceived
health (16). Despite the adverse health experiences
after a stroke, participants with higher SOC scores
had higher odds of a normal mood and higher scores
regarding health-related quality of life at T2. This result
is consistent with Antonovsky’s (16) theory on saluto-
genesis, which explains how some people manage well
despite adverse health experiences. This finding is also
supported by a recent study on how personal factors,
such as proactive coping, influence stroke outcomes,
seem to be stable over time (33) and demonstrated
that in the period from 2 months to 2 years after stroke
personal factors did not improve naturally.
Our results differed from those reported in a com-
parable study that evaluated the effect of motivational
interviewing on mood (11). Watkins and colleagues
reported a significant difference between the interven-
tion and control groups at 3 months, with 49% of the
participants in the intervention group and 39% of the
participants in the control group having normal mood
at 3 months. At 12 months, the difference between the
groups remained significant, with 48% of participants
in the intervention group and 37% of participants in the
control group reporting normal mood. Watkins’ study
was conducted in a hospital with a different and shorter
intervention, and the data were primarily collected by
mail. Comparably, a substantially higher percentage of
participants in both groups (59.6%) had normal mood
at 6 months in our study. Although the results failed to
demonstrate effectiveness of this dialogue-based inter-
vention for promoting psychosocial well-being after
stroke, conducting an RCT in a complex setting with
face-to-face data collection imposes several factors that
may explain the neutral results obtained in this study.
The Norwegian authorities have encouraged re-
habilitation services delivered in the municipalities
through the Coordination Reform (12) and through the
clinical guidelines for treatment and rehabilitation after
stroke (19). A considerable proportion of participants
reported receiving rehabilitation services post-stroke
(66% at T1 and 55% of T2). Therefore, the rehabilita-
tion needs of some participants may have already been
met through usual care. No standardized psychological
support exists in the follow-up after stroke in Norway
and we lack a complete overview of the content of
the follow-up that the participants received. However,
since the participants lived in more than 70 different
municipalities, we must assume that the follow-up
varied substantially.
563
The most frequently reported follow-up was physical
therapy (59% at T1, 36% of T2). This finding was sup-
ported by a recently conducted study comparing stroke
rehabilitation in Norway and Denmark, suggesting that
follow-up focuses more on physical rehabilitation in
Norway, while psychological support is better organi-
zed and implemented in Denmark (34).
We experienced that some of the participants strugg-
led to distinguish ordinary healthcare services from
the intervention, and participants in the control group
perceived the study participation and the structured as-
sessment interviews as a form of intervention. Conduc-
ting face-to-face assessments ensured high compliance
and complete data during collection, but also had some
disadvantages. Face-to-face interviewing is a form of
social interaction and merely being involved in these
interviews may have positively affected the patients’
psychosocial well-being. Having an interviewer visit
their homes 1 and 6 months after discharge may have
also led to the perception of having received an inter-
vention, even by those in the control group.
Social desirability bias (35) is another factor that
potentially affected the results. If the respondents
had acted in ways or held attitudes that they felt were
undesirable, their answers might have been affected.
Consequently, they might have underreported socially
undesirable attitudes and behaviours while enhancing
attitudes and behaviours they believed were expected
in coping with their life after stroke.
Stroke recovery is multifaceted. Finding the optimal
instrument to capture the impact of a psychosocial
intervention rather than the expected natural recovery
after stroke was challenging. Recovery depends on dif-
ferent mechanisms and treatments at different phases
after the acute injury, which range from hours to many
months. Although improvement varies among indivi-
duals, most patients improve during the first period
following the stroke because of acute care treatment
and post-lesional plasticity (36).
Another issue is a possible ceiling or floor effect
of the outcome measures, which is a known risk with
instruments addressing aspects of psychosocial well-
being (37). Many participants had no or minor stroke
symptoms and limited adverse effects on their daily
living activities after their stroke. This outcome resul-
ted in maximum scores on several questions, especially
on the SAQOL-39g.
Furthermore, well-being is a subjective phenome-
non. Physical sequelae, side-effects of medication,
and overall spontaneous improvement may affect how
patients answer questions immediately after a stroke
compared with 6 months post-stroke. This personal
reporting of subjective appraisal introduces the possibi-
J Rehabil Med 51, 2019