The effects of introducing psychoeducational programs in patients with stroke in post-acute care

Summary

Background: Stroke is not only a very common cause of death, but also the most common cause of disability and long-term health problems with a significant impact on patients‘ quality of life. The present study aimed to assess the effects of a psychoeducational program delivered simultaneously with standard rehabilitation care to patients in the post-acute phase of stroke on their health-related quality of life (HRQoL), dignity, levels of depression, levels of self-sufficiency in activities of daily life, and also pain. Methods: The randomized study involved adult patients after their first stroke occurrence who were admitted to post-acute inpatient rehabilitation care due to persistent neurological deficits. At the same time, they were partially self-sufficient and did not present with dementia or a phatic disorder or severe visual or hearing impairment. In addition to standard care, the intervention group was provided with multi-component psychoeducation. Data collection took place at patient enrollment and 3 months later using standardized questionnaires for health-related quality of life (EQ-5D-5L), depression (Beck‘s Depression Inventory [BDI-II]), dignity (The Patient Dignity Inventory [PDI]), coping with activities of daily living (Barthel index [BI]) and pain (Visual Analogue Scale [VAS]). Statistical evaluation was performed using univariate and multivariate analyses. Results: Of the 221 randomized patients, 201 (91%) completed the study; 102 in the intervention group (65 men, age 60 ± 13.6 years) and 99 in the control group (58 men, age 63 ± 13.4 years). After 3 months, there was a statistically significant difference in the change in EQ-5D-5L/domains (2.77 ± 2.08 vs. 0.93 ± 1,81), EQ-VAS (13.77 ± 12.06 vs. 4.23 ± 15.51), PDI (9.50 ± 8.33 vs. 2.47 ± 8.18), BI (14.94 ± 11.02 vs. 8.96 ± 9.16) and BDI (3.15 ± 3.61 vs. 0.40 ± 4.19) in the intervention group compared to the control group (for all P < 0.0001). Post-hoc analysis showed that the independent predictors of higher HRQoL were, apart from applied psychoeducation, greater degrees of self-sufficiency, less severe depression levels and lower intensity of pain. Conclusion: Psychoeducation is a suitable supplement to post-acute rehabilitation care for post-stroke patients leading to improvements in HRQoL, greater independence in activities of daily life, reduction of depression load and increased sense of dignity.

Keywords:

stroke – depression – health-related quality of life – dignity – psychoeducation – self-suffi ciency

This is an unauthorised machine translation into English made using the DeepL Translate Pro translator. The editors do not guarantee that the content of the article corresponds fully to the original language version.

 

Introduction

Stroke is a neurological disease representing a major global cause of severe long-term disability in adults with a significant impact on their quality of life [1]. The most common consequences of stroke are neuropsychiatric disorders involving a wide range of symptoms such as anxiety, depression, fatigue, apathy or emotionality, in addition to altered mobility that limits an individual's ability to perform activities of daily living (ADLs) [2]. In this context, monitoring and assessment of health-related quality of life (HRQoL) is becoming increasingly important as an indicator of health service needs and a way to assess health status very effectively [1]. Of importance is the extent to which an individual experiences his or her life as manageable and meaningful [4] and how he or she perceives his or her personal dignity, which is closely linked to respect, recognition, self-esteem and pride [5].

Thanks to significant advances in the treatment of acute cerebrovascular events, patients are now surviving longer, but less attention is being paid to care management in the post-acute phase and in the return to the community phase, particularly in the area of a comprehensive psychosocial approach [6-8]. The European Stroke Action Plan has therefore set strategic goals for the coming years aimed at optimising the continuum of care, including a greater emphasis on quality of life [9].

Recent studies have revealed that personalized psychoeducational interventions targeting the specific needs of stroke survivors can positively impact a number of important outcomes throughout the recovery trajectory [10-12]. To our knowledge, no study has been conducted to date that has tested the effect of a psychoeducational programme as part of post-acute rehabilitation care in Czech patients after stroke.

Therefore, the aim of our study was to examine the effect of a psychoeducational program provided simultaneously with standard rehabilitation care to patients in the post-acute phase of stroke on their quality of life, dignity, level of depression, level of self-sufficiency in activities of daily living, and pain compared to patients in the control group who had standard rehabilitation care.

 

Subjects and methods

Design studies

We conducted a prospective randomized controlled trial (RCT) that was registered prior to first responder enrollment in the study at ClinicalTrials.gov (Identified: NCT05501275).

 

Patients

The target population was defined by the following entry criteria:

a) age ≥ 18 years;

b) confirmed diagnosis of stroke;

c) first stroke;

d)
persistent neurological deficit with a National Institutes of Health Stroke Scale (NIHSS) score of 5-15;

e)
partial self-sufficiency with Barthel Index (BI) ≥ 45 points;

(f) hospitalization in a rehabilitation institution;

(g) signing the informed consent.

Patients who were unable to cooperate because of dementia (Mini-Mental State Examination score [MMSE] ≤ 24 points) or severe visual and hearing impairment and/or fatal impairment were excluded from the study.

 

Data collection

Data collection took place in the largest rehabilitation institute Hrabyně in the Moravia region of the Czech Republic from September 2022 to March 2023. Hospitalized patients after stroke who were indicated for post-acute rehabilitation care were recruited into the study. Only patients who met the entry and exclusion criteria and signed informed consent were included according to the Consolidated Standards of Reporting Trials (CONSORT) recommendations, as shown in Figure 1. No later than 24 h after inclusion in the study , patients were randomized to intervention and control groups. A pair of trained research assistants recorded baseline sociodemographic (age, sex, education, marital status) and clinical data (active and past medical conditions) based on a standardized interview. For each enrolled patient, the research assistants administered a set of assessment tools in the Czech version (table 1) [13-24] at the start of the study (T1 phase) and after 3 months (T2 phase). At the end of the follow-up period, the patients in the control group were offered a psychoeducational intervention for ethical reasons.

 

Randomization

The statistician performed randomization into two parallel groups in a predefined ratio of 1:1. The randomization scheme was generated by the Randomization.com web application using the random permuted block method with a size of 4. Each patient was randomly assigned to either the standard rehabilitation care group (control) or the intervention group, where a psychoeducational program was added to the standard rehabilitation care.

 

Psychoeducational programme

In addition to standard post-acute rehabilitation care, patients in the intervention group also received a group (4-8 patients) psychoeducational programme with a multi-component focus (nursing, psychology, social care). The program consisted of six structured face-to-face educational sessions that lasted 60-90 min and were held once a week for 6 weeks. The content of each session is shown in Table 2.

 

Statistical analysis

The calculation of the research sample size was based on data from the pilot study. From the results, we determined the significant difference between the groups to be a mean difference in the EQ Visual Analogue Scale (EQ-VAS) of 5 points with a standard deviation of measurement of 8.4 points. The calculation showed that 70 patients needed to be included in each group to demonstrate a significant difference at a statistical significance level of 5% (a = 0.05) and a test power of 90% (power = 0.9).

Shapiro-Wilk normality tests verified that most variables do not have a normal distribution. Quantitative variables are presented by means of means and standard deviations, minimum and maximum values and medians. The Mann-Whitney U test was used to compare two independent samples. Qualitative variables were described using absolute and relative frequencies. Comparisons between groups were made using Fisher's exact test or chi-square test.

As part of the post hoc analysis, multiple linear regression was used to identify predictors of HRQoL changes using a stepwise forward method. All factors of interest were selected for analysis. The significance level was set ata = 0.05 for all tests. SPPS Statistics for Windows, Version 23.0 statistical software (IBM, Armonk, NY, USA) was used for statistical processing.

 

Results

Characteristics of patients

A total of 221 stroke patients (mean age 63 ± 14 years; 132 [59.7%] men) were randomized to the intervention (n = 111) and control (n = 110) groups for this study. Of the total randomized patients, 20 did not complete the study (Figure 1).

Finally, 201 patients were included in the final analysis, of whom 102 were in the intervention group (mean age 60.6 ± 13.6 years; 65 [63.7%] men) and 99 in the control group (mean age 63.5 ± 13.4 years; 58 [58.6%] men). The patient groups differed only in family situation, i.e., with whom the patients lived (p = 0.024), and in the method of financial provision (p = 0.016). Other characteristics are shown in Table 3.

 

Effect of the psychoeducation programme

Patient groups were compared in values measured before the intervention (T1), after 3 months (T2) and in the final difference (T1 - T2). At baseline (T1), the only difference between the groups was in perceived dignity (The Patient Dignity Inventory [PDI] total score), which was rated worse by patients in the intervention group (p = 0.033). At the 3-month follow-up measure (T2), patients in the intervention group rated their current health status more positively (p = 0.009) and had lower levels of depression (p = 0.019). There were statistically significant differences in the final difference in the values (T1 - T2) of each variable in the quality of life (EQ-5D-5L domains), current health status perception (EQ-VAS), sense of dignity (PDI), level of self-sufficiency (BI), and depression (Beck's Depression Inventory [BDI-II]), all p < 0.0001. Only in the assessment of pain intensity (Visual Analog Scale [VAS]) was the difference not statistically significant (p = 0.091). Compared with the control group, patients who completed the psychoeducation program had a greater difference between the baseline (T1) and second assessment (T2) in HRQoL (in the domains of quality of life, subjectively perceived current health status), dignity, assessment of level of self-sufficiency, and level of depression. The results are shown in Table 4.

 

Predictors of changes in HRQoL (2^nd measurement) - multicollinear regression analysis

In the post hoc analysis, a polynomial regression model was used to search for predictors that had a significant effect on the difference between HRQoL scores at the time of T1 and T2 measurements. The results are shown in Table 5.

Four significant factors influenced the change (improvement) in HRQoL as measured by the EQ-5D-5L (quality of life/domain): Higher levels in independence in ADL (standard beta = 0.318; p < 0.0001), applied psychoeducation (standard beta coefficient = 0.246; p < 0.0001), lower levels of depressive symptoms (standard beta coefficient = 0.237; p < 0.0001), and lower pain (standard beta coefficient = 0.184; p < 0.001). The multiple linear regression model explained 39% (R² = 0.395) of the variability in the dependent variable (quality of life/domain).

Furthermore, multivariate analysis revealed that higher HRQoL measured by EQ-VAS (perceived health status) significantly predicted: offered psychoeducation (standard beta coefficient 0.248; p = 0.0004), less depression (standard beta coefficient = 0.205; p = 0.003) and subjectively perceived lower pain intensity (standard beta coefficient = 0.142; p = 0.031). The polylinear regression model explained only 16% (R² = 0.167) of the variability in the dependent variable (perceived level of current health status).

 

Discussion

The results of the study demonstrate the positive effect of a psychoeducational programme integrated into post-acute rehabilitation care after stroke. The results showed that after 3 months there was a significant difference between the study groups in EQ-5D-5L, EQ-VAS, PDI, BDI and BI in favour of the intervention group, indicating a significant improvement in quality of life, sense of dignity, depression level and self-sufficiency. Post hoc analysis further showed that higher HRQoL was dependent on receiving psychoeducation, greater degree of self-sufficiency, less severity of depression, and lower pain intensity.

The significantly greater increase in HRQoL in our intervention group is in line with, for example, the results of the study by Tielemans et al. [25], where patients with stroke who received self-management and educational interventions focused on social-psychological aspects of life also showed favourable trends in HRQoL. This confirms the importance of including these interventions in the standard follow-up care provided after stroke. The importance of focusing on psychological factors in terms of HRQoL trajectory in patients after stroke has also been described, for example, by van Mierlo et al [26]. In contrast, Minshall et al. [27] did not demonstrate the influence of psychoeducational programs on HRQoL. Also, in an earlier study [28], no statistically significant improvement in QoL was found in home-care patients after stroke who received the intervention of a specialized interprofessional team (nurse, physiotherapist, occupational therapist, speech therapist, dietician, social worker and personal assistant) compared to patients who received only standard home care. This may be related to differences in the content of the intervention offered, in the composition of the team delivering the intervention, in the form of the intervention applied and the location where it was delivered, and differences between the participants enrolled. Our study had only post-MP patients in the intervention group; other studies provided psychoeducational interventions for post-MP patients and their family caregivers simultaneously [25,27]. Another difference was the form of intervention received. In our study, we chose face-to-face groups, because in a group of people with similar fate and life situation, individuals' self-esteem and motivation for treatment are more enhanced than in individual therapy. Therapists create a space for questions and expression of physical and emotional experiences [29]. In a study by Minshall et al [27], participants (stroke patients and their caregivers) received a structured workbook and a professional facilitator (psychologist). They could choose the mode of support delivery (in person, by telephone, via Skype). Couples (patient and caregiver) could participate in the intervention individually or together. Patients in the study by Markle-Reid et al [28] received the intervention individually. There was also a difference in the setting where the intervention took place. In our study, the psychoeducational program was part of the post-acute rehabilitation care implemented during hospitalization in a rehabilitation facility. In the study by Mishall et al [27], stroke patients and their caregivers could choose between a hospital visit and a home environment. The study by Markle-Reid et al [28] was conducted in the home setting only. Finally, the composition of the specialist team, which was related to the nature of the intervention provided, may have influenced the different outcomes. In our study, this included a nurse, a psychologist and a social worker. In other studies, it was only a psychologist [27] or an interprofessional team without a psychologist [28].

Regarding the evaluation of self-esteem, it seems that the completion of the multicomponent psychoeducational intervention also had a positive effect on the evaluation of dignity-related problems in patients after a stroke. A similar study for comparison has not yet been conducted. However, communication is key to creating dignified encounters in care, which allows the patient to emerge as a unique person and provides the basis for preserving and maintaining absolute dignity [30].

Depression after stroke is a major risk factor for impaired HRQoL [31] and prolonged recovery [32]. Psychoeducational strategies, as reported by Bakas et al [33], are a more effective alternative than psychotherapy alone in the treatment of mental illness. In our study, we observed a significant trend towards a reduction in depression after the application of psychoeducation compared to the control. These findings are consistent with the results of several RCTs [10,34,35]. However, this is not consistent with a recently published comparative study by Verberne et al [36], which did not confirm this effect. This may be due to the fact that targeted awareness of the risks, course and causes of stroke is likely to make sufferers more aware of the potential consequences, recurrence and length of illness, which in turn exacerbates their psychological distress [37].

In the context of stroke, the occurrence of adverse complications such as pain is associated with worse HRQoL, loss of independence in ADL [38] and sleep disturbances [39]. In addition to pharmacotherapy, non-pharmacological interventions are recommended in the management of pain after stroke [40]. For example, a recent Swiss RCT [41] testing the efficacy of a psychoeducational intervention on pain in hospitalized cancer patients suggested a beneficial analgesic effect. However, this does not correspond with the results of our study, in which no significant difference (improvement) in pain dynamics was observed after the application of multicomponent psychoeducation compared to the control group. This may have been due to the fact that pain intensity may be variable during the course of the illness, as patients after stroke experience pain more often in the subacute and chronic phases than in the acute phase [42]; moreover, thalamic pain syndrome (post-stroke pain), which is the main cause of neuropathic pain, is difficult to treat [39].

Loss of self-sufficiency, which prevents the provision of ADLs, appears to be another very important problem after stroke [43]. Minshall et al [27] report that improvements in physical functioning are less likely to be achieved in stroke survivors using psychosocial or educational intervention approaches alone. In contrast, the results of our study support the hypothesis that offering psychoeducation can significantly improve functional independence in ADL in the short term. This effect has been demonstrated, for example, in a recent RCT [44] or in the conclusions of a recently published meta-analysis [45]. However, people of younger age [43] and those who do not have severe neurological deficits [46] and are less depressed [47] are more likely to regain self-sufficiency after stroke. However, each individual's self-care is closely related to his or her own beliefs (self-efficacy), self-confidence and life role [48].

The presented study has some limitations that should be pointed out. Firstly, its monocentric nature. Second, the results may have been influenced by other variables, such as stroke subtypes and revascularization techniques, which were not considered in this study. Third, we also see limitations in the follow-up period, which was relatively short, and therefore no conclusions can be drawn for longer-term effects. Fourth, the results cannot be generalized to other populations because the transcultural validity was limited to the Czech population, but we hope that these advantages will allow some transferability of the results.

 

Conclusion

Applied psychoeducational intervention is becoming increasingly important for patients after stroke, as it helps to improve not only their quality of life, but also their independence in ADL, depression and sense of dignity. The negative impact of the consequences of stroke on patients' lives can be minimized with this intervention. The findings have direct implications for clinical practice with implications for the education of health and social service professionals.

 

Ethical principles

The work was carried out in accordance with the Helsinki Declaration of 1975 and its revisions in 2004 and 2008. The study protocol was approved by the Ethics Committee of the Faculty of Health Sciences of Palacký University in Olomouc, Czech Republic (UPOL-117270/1030S-2020, 14 July 2020). Data were collected according to ethical principles in accordance with the Declaration of Helsinki. Informed consent for participation in the study was obtained from all patients.

 

Conflict of interest

The authors declare that they have no conflict of interest in relation to the subject of the study.

 

Tables

Table 1. Assessment tools used.

Variables	Evaluation tool	Domains/items/scores	Psychometric properties
			Cronbach's alpha	validity, reliability	suitability of use
Health-related quality of life	European Quality of Life 5 Dimensions 5 Level (EQ-5D-5L) [13]	1) DESCRIPTION PART EQ-5D-5L (quality of life dimensions) 5domains: mobility, self-care, usual activities, pain/trouble, anxiety/depression, scored on a five-point scale (1 - no difficulty; 2 - mild difficulty; 3 - moderate difficulties; 4 - severe difficulties; 5 - extreme difficulties 2) VISUAL PART of EQ-VAS (horizontal line) score 0-100 (0 - worst condition; 100 - best condition		construct and criterion validity, sensitivity of items to change [14]	in patients with stroke [15]
Dignity	Patient Dignity Inventory (PDI) [16	25 items (score: 25-125) 4 domains (Czech version) lower scores indicate a better perception of dignity	0,58-0,90 Czech version [17]		in elderly oncologically and non-cancer patients [17]
Self-sufficiency in activities of daily living)	Barthel index of daily activities (Barthel Index, BI) [18]	10 items (score: 0-100) Score 96-100 independence; Score 65 needing help with ADLs; Score≤ 40 high		excellent reliability [19]	in patients with stroke [19]
Pain	Visual Analogue Scale (VAS) [20]	10 cm horizontal line (at the left end no pain = 0; at the right end extreme pain = 10)		high reliability [20]	in patients with stroke [21]
Depression	Beck Depression Inventory Scale - II (BDI-II) [22]	21 items (score: 0-63)                 lower score indicates lower severity of depression	0,85-0,92 Czech version [23]	very good internal consistency [23]	in patients with stroke [24]

 

 

Table 2. Content of the psychoeducational programme (in individual weeks).

Sessions	Area	Table of Contents
1	Nursing	Management in CMP (etiology, initial symptoms, early and late complications)
	Psychology	basic principles of human functioning (bio-psycho-social-spiritual approach); introduction to the relaxation/imagination technique according to Jacobson
	Social care	information on available community services (home care, nursing care)
2	Nursing	Long-term consequences of stroke; the nature of stroke treatment; compliance with the treatment regimen; possibilities of patient influence
	Psychology	work with own emotions (sharing experiences of emotions), relaxation training (autogenic training according to Jacobson)
	Social care	outpatient social services (day/weekly residential care, day service centres, emergency care, respite services).
3	Nursing	Self-risk of falls; safe home environment; healthy lifestyle; non-pharmacological pain management options
	Psychology	Acceptance of stigmatization of disability; relationship issues (functioning in relationships); interpersonal communication, relaxation (autogenic training according to Jacobson)
	Social care	coping with life events (personal/professional) related to changes in health due to disability; possibilities and ways of retraining disabled people
4	Nursing	short re-education from previous meetings (self-management in CMP); contacts to patient organisations (printed materials provided)
	Psychology	adaptation to disabilities after stroke, cognitive processing of information by the patient, relaxation (autogenic training according to Jacobson)
	Social care	social benefits (application for state social assistance benefits, disability pension, material hardship benefits, mobility allowance, exceptional benefits, disability benefits, care allowance); registration with the Labour Office
5	Nursing	education in selected areas of secondary prevention of stroke (self-monitoring of BP, risk factors for dyslipidemia including treatment and adherence); patients provided with printed material
	Psychology	value orientation and personal attitudes of the patients, goals and possibilities in the next life, orientation to the possibilities of their development, relaxation (autogenic training according to Jacobson)
	Social care	help with filling in application forms for individual social benefits
6	Final group session: feedback (semi-structured interviews with patients)
	Nursing	expected changes in lifestyle, consolidation of acquired skills according to individual needs of the patient
	Psychology	changes in the patient's personal attitudes, consolidation of the acquired skills according to the patient's individual needs, relaxation (autogenic training according to Jacobson)
	Social care	consolidation of the acquired skills according to the individual needs of the patient

 

 

Table 3. Patient characteristics.

Variable		Group		The value of p
		with intervention (n =102)	without intervention (n = 99)
		M ± SD (median); min-max	M ± SD (median); min-max
age (years)		60.6±13.6 (60), 24-85	63.5±13.4 (66), 22-86	0,113b
		number (%)	number (%)
Gender	man	65 (63,7)	58 (58,6)	0,473a
	Woman	37 (36,3)	41 (41,4)
Education	Basic	10 (9,8)	14 (14,1)	0,487b
	Trained	41 (40,2)	36 (36,4)
	Secondary	34 (33,3)	38 (38,4)
	College	17 (16,7)	11 (11,1)
family situation (who he lives with)	myself	23 (22,5)	27 (27,3)	0,024*a
	with my husband	42 (41,2)	55 (55,6)
	with a partner	8 (7,8)	5 (5,1)
	with relatives	28 (27,5)	11 (11,1)
	Other	1 (1,0)	1 (1,0)
financial security	Wage	53 (52,0)	37 (37,4)	0,067a
	pension benefits	44 (43,2)	60 (60,6)	0,016*a
	social contributions	3 (3,0)	6 (6,1)	0,166a
	family support	4 (3,9)	1 (1,0)	0,369a
	Other	4 (3,9)	3 (3,0)	1,000a
Comorbidities	Hypertension	33 (32,4)	35 (35,4)	0,658a
	ICHS	12 (11,8)	11 (11,1)	1,000a
	DM	24 (23,5)	29 (29,3)	0,334a
	Other	4 (3,9)	8 (8,1)	0,289a
acute problems	Yes	57 (55,9)	48 (48,5)	0,324a
	No	45 (44,1)	51 (51,5)

*p < 0.05; ^aFisher's exact test; ^bMann-Whitney U test (significant values in bold)

DM - diabetes mellitus: IHD - ischemic heart disease; M- mean; n - number; SD - standard deviation

 

 

Table 4. Comparison of intervention and control groups (2nd measurement) - univariate regression analysis.

Variables		Intervention group (n = 102)		Group without intervention (n = 99)		The p-value
		M ± SD (median)	min-max	M ± SD (median)	min-max
Health-related quality of life (HRQoL)	EQ-5D-5L descriptive part/ dimensions/domains  (T1 score)	11,86 ± 4,14 (12)	5-21	11,30 ± 4,04 (11)	5-20	0,344b
	EQ-5D-5L dimensions/domains  T2 score	9,09 ± 2,94 (9)	5-16	10,37 ± 4,05 (10)	5-21	0,051b
	EQ-5D-5L domain (difference T1 - T2)	2,77 ± 2,08 (3)	0-9	0,93 ± 1,81 (1)	-4 to 7	< 0,0001***b
	EQ-VAS visual part/ level of health. condition (T1 score)	59,37 ± 19,86 (60)	10-95	60,36 ± 21,99 (60)	5-98	0,755b
	EQ-VAS level of health. condition (T2 score)	73,15 ± 17,39 (80)	25-99	64,60 ± 22,21 (65)	5-97	0,009**b
	EQ-VAS level of health. Healt (difference T1 - T2)	13,77 ± 12,06 (10)	-15 to 45	4,23 ± 15,51 (2)	-60 to 60	< 0,0001***b
Dignity	PDI (scoreT1)	49,11 ± 16,58 (46)	25-100	44,84 ± 16,83 (42)	25-95	0,033*b
	PDI (T2 score)	39,61 ± 12,57 (37)	25-88	42,36 ± 16,16 (38)	25-91	0,532b
	PDI (difference T1 - T2)	9,50 ± 8,33 (8)	-13 to 32	2,47 ± 8,18 (1)	-24 to 28	< 0,0001***b
Self-sufficiency	BI (T1 score)	67,45 ± 19,60 (65)	40-95	70,35 ± 18,74 (70)	45-95	0,292b
	BI (T2 score)	82,39 ± 13,54 (85)	50-100	79,31 ± 16,77 (85)	45-100	0,332b
	BI (difference T1 - T2)	14,94 ± 11,02 (15)	-5 to 40	8,96 ± 9,16 (5)	0-35	< 0,0001***b
Pain	VAS (T1 score)	2,12 ± 1,68 (2)	0-7	1,89 ± 1,56 (2)	0-7	0,275b
	VAS (T2 score)	1,62 ± 1,27 (1)	0-7	1,59 ± 1,26 (2)	0-5	0,980b
	VAS (difference T1 -T2)	0,50 ± 1,42 (0)	-4 to 4	0,30 ± 1,22 (0)	-3 to 4	0,091b
Depression	BDI (T1 score)	7,96 ± 7,50 (5)	0-34	6,82 ± 5,49 (5)	0-21	0,808b
	BDI (T2 score)	4,81 ± 5,11 (2)	0-20	6,41 ± 6,35 (3)	0-28	0,019*b
	BDI (difference T1 - T2)	3,15 ± 3,61 (1)	-2 to 16	0,40 ± 4,19 (0)	-12 to 19	< 0,0001***b

*p < 0.05; **p < 0.01;***p < 0.001; ^bMann-Whitney U test (significant values are in bold)

BDI-II - Beck Depression Inventory Scale; BI - Barthel Index of Daily Activities; EQ-5D-5L - European Quality of Life 5 Dimensions 5 Level Questionnaire; EQ-VAS - European Quality of Life Questionnaire/Visual Analogue Scale (European Quality of Life - Visual Analogue Scale); M - mean; PDI - Patient Dignity Inventory; SD - standard deviation; VAS - Visual Analogue Scale; T1 - first measurement (at baseline); T2 - second measurement (at 3 months)

 

 

Table 5 Predictors of changes (improvements) in health-related quality of life of EQ-5D-5L after psychoeducation

- Multivariate analysis.

Predictor	Health-related quality of life (HRQoL)
	EQ-5D-5L (domains)		EQ-VAS (health status level)
	standard beta coefficient (95% CI)	The p-value	standard beta coefficient (95% CI)	The value of p
self-sufficiency (BI) change of 1 point	0,318 (0,041; 0,089)	< 0,0001***
psychoeducation (group with intervention vs. without intervention)	0,246 (0,544; 1,573)	< 0,0001***	0,248 (3,267; 11,220)	0,0004***
depression (BDI-II) change of 1 point	0,237 (0,063; 0,185)	< 0,0001***	0,205 (0,243; 1,208)	0,003**
pain (VAS) change by 1 point	0,184 (0,120; 0,120)	< 0,001**	0,142 (0,147; 2,995)	0,031*
model quality R2 adjust. R2	0,395; 0,383		0,167; 0,154
Assumptions of the Durbin-Watson test/ VIF model	2,193/1,118		2,203/1,088

*p < 0.05; **p < 0.01; ***p < 0.001; significant values are in bold

BDI-II Beck Depression Inventory Scale; BI-Barthel Index of Daily Activities; CI-confidence interval; VAS- Visual Analogue Scale; VIF-variance inflation factor