Should Patients Be Confident in Their Efficacy in Improving Their Functional Abilities After a Stroke?

Background Patients’ self-confidence in their abilities needs to be improved to achieve functional abilities after a stroke. Self-efficacy is a prerequisite for self-management after a stroke. This study aimed to analyze the relationship between self-efficacy and the functional abilities of post-stroke patients. Methodology This was an analytical cross-sectional study conducted over two months. A total of 145 respondents were recruited using the convenience sampling method. Respondents were post-stroke patients who had undergone the post-stroke phase during the first three to six months since the acute stroke. Data collection was performed through questionnaire interviews. Data were analyzed using descriptive analysis and Spearman correlation. Results There was a significant positive relationship between self-efficacy and functional independence (p < 0.05). Conclusions Self-efficacy influences motivation to perform activities of daily living, which can increase the achievement of functional abilities.


Introduction
Achieving independent functional abilities after stroke is important in the care of post-stroke patients.Achieving functional independence can be seen in the patient's ability to perform daily activities.Basic activities of daily living (ADLs) function as an important prognostic factor of functional independence during early post-stroke recovery [1].The inability of post-stroke patients to perform physical activities can result in death.The death of post-stroke patients is closely related to physical dependence, lack of activity, worsening of the disease, and disturbances in body balance [2].The results of a meta-analysis showed that post-stroke patients who performed physical activity have a 27% lower risk of recurrent stroke and death compared to individuals who were not active [3].Physical activity can improve cardiovascular capacity, mobility, balance, walking ability, muscle strength, and overall quality of life, thereby reducing disability and the risk of recurrent stroke [4].
Longitudinal studies showed that most functional recovery occurs within the first month after stroke, but recovery declines between three and six months post-stroke [5,6].Another study reported that post-stroke patients who were independent in the first three months could become dependent within one year if they did not do physical activity with a decline rate of 3% per year [7].Therefore, it is necessary to achieve functional independence.Efforts to achieve functional independence are part of self-management.Poststroke patients require ongoing self-management to restore lost functional abilities.Applying selfmanagement principles in inpatient rehabilitation can support the development of internally motivated thought patterns and behavior to increase patient engagement [8].Previous research has found that involving patients in their care is significantly related to achieving functional independence [9].However, to improve the self-management abilities of post-stroke patients, self-efficacy is needed.Self-efficacy is a prerequisite for the success of effective self-management [10].
Self-efficacy relates to "belief in one's ability to organize and carry out the actions necessary to produce certain achievements" [1].Studies on chemotherapy patients found that better self-efficacy was associated with better quality of life and lower fatigue [11].Confidence in one's ability to manage oneself well is an important aspect of ongoing care [12].Individuals with high self-efficacy after a stroke usually have greater confidence to participate in ADLs, a higher ability to overcome obstacles in their recovery, and usually have better psychosocial functioning and well-being compared to those with low self-efficacy [1].Self-efficacy increases cancer patients' confidence in performing self-care behavior during chemotherapy [11].For this reason, this study aims to analyze the relationship between self-efficacy and patients' functional abilities in the first three to six months after a stroke.

Study design, sample, and setting
This analytical cross-sectional study was conducted over two months.Patient data were obtained from Bahteramas Hospital.A total of 145 respondents were recruited using convenience sampling methods.This method was carried out based on the accessibility and availability of researchers, where the sample was recruited from the hospital that had the largest number of stroke patients and the location of the respondents' homes where they could be reached by researchers.Inclusion criteria were patients aged 25-65 years, who had experienced the post-stroke phase during the first three to six months since the acute ischemic stroke, did not experience cognitive impairment, were willing to participate in the research, were in a stable condition, did not experience post-stroke depression as proven by measurements using the Patient Health Questionnaire-9 (PHQ-9), and lived with their family (partner and/or children) who could act as caregivers.Patients with severe weakness and aphasia were excluded from this study.Respondents were recruited at the Bahteramas Hospital Rehabilitation Unit and then assessed at home to measure their functional abilities.Researchers explained the objectives and rights of respondents during the study, including explanations relating to confidentiality, anonymity, and confidentiality of their personal data.

Study instrument
The instruments used in this research were the Stroke Self-Efficacy Questionnaire (SSEQ) and the Modified Barthel Index (MBI).The SSEQ is used to measure respondents' self-efficacy.The SSEQ contains 13 questions that assess self-efficacy beliefs related to daily tasks and self-management (e.g., mobility, ambulation, dressing, coping with stroke frustration, and exercise adherence).The SSEQ has high internal consistency (Cronbach's alpha = 0.90) [1,13].It uses a 10-point scale, where 0 implies not confident at all to 10 implies very confident [14].
The MBI is used to measure behavior related to daily living activities and includes 10 items, namely, feeding, grooming, bathing, dressing, toilet transfer, bladder control, bowel control, chair/bed transfer, stair climbing, and ambulation.It is recommended for clinical and research applications because it has better test-retest reliability and relatively lower random measurement error than the native Barthel Index (BI) [15].The MBI is also recommended for clinical and research use as an outcome measure for stroke patients [16].It has better sensitivity and reliability (Cronbach's alpha = 0.93) [17].The total MBI assessment score ranges from 0 to 100.A lower score indicates less independence, whereas a higher score indicates greater independence [18].A maximum score of 100 indicates the patient is completely independent in performing basic ADLs, whereas a score of 0 indicates total dependence [18].The MBI score is divided into five categories: 0-20 (total dependence), 21-60 (severe dependence), 61-90 (moderate dependence), 91-99 (slight dependence), and 100 (independence) [19].

Data collection
Data collection was performed from May to June 2023 through visits to respondents' homes.Data on selfefficacy and functional abilities of respondents were studied through questionnaire interviews.The researcher explained each question item to the respondent.Validation of the respondent's functional ability data was also done by asking the respondent's family or caregiver who lived at home with them about their functional ability achievements.
The majority of the respondents were over 50 years old (57.2%) and female (53.8%), high school graduates (44.8%), married (58.6%), experienced hemiparesis on the left side of the body (60%), and right-handed (89.0%).All patients had weakness in at least one muscle group, mostly on the left side (left arm = 79.3%).The majority of the muscle strength groups displayed active movement against gravity and resistance (Medical Research Council grade = 4).The most common comorbidity was hypertension (41.4%).
Based on the National Institutes of Health Stroke Scale scores, most respondents had moderate stroke severity (71%).Most respondents also had moderate dependence in performing ADLs (42.1%) and good selfefficacy (53.1%) (Table 1).Determining the self-efficacy category using a cut-off point, the median value was 84.0.

DM = diabetes mellitus
Table 2 shows that self-efficacy had a significant relationship with the patient's functional independence in performing daily activities (p = 0.000).The correlation test results showed a very strong relationship between self-efficacy and functional independence.This relationship was also positive, meaning that the higher the self-efficacy, the higher the respondent's achievement of functional independence.

TABLE 2: Relationship between self-efficacy and functional independence.
Table 3 shows that among the 13 dimensions of respondents' self-efficacy, the highest dimension was "Do your own exercise program every day" (mean = 6.31,SD = 1.357) and the lowest dimensions were "Prepare the food you want for yourself" and "Continue to get faster at tasks that have become slower since your stroke" (mean = 5.77).Regarding functional independence, the highest was "Chair/bed transfer ability" (mean = 9.84, SD = 4.231) and the lowest was "Bathing ability" (mean = 2.99, SD = 1.470).

Discussion
Based on the results of this study, there was a significant relationship between self-efficacy and functional independence (p < 0.05).This is in line with other research that there is a relationship between functional independence and self-efficacy, where functional independence strongly predicts the quality of life of stroke sufferers and high self-efficacy determines the quality of life [20].Stroke sufferers with a higher level of selfefficacy have the potential to recover gradually during the rehabilitation process [21].Physical activity stimulates neuroplasticity and improves patient function [13].
In this study, 57.1% of good self-efficacy respondents experienced moderate dependence.Achieving this ability is closely related to the individual's motivation to perform physical activity.Motivation is closely related to self-efficacy, which refers to an individual's desire to perform certain behaviors to achieve their goals [1].Motivation is a process where self-efficacy influences individual function and has an impact on post-stroke rehabilitation outcomes [1].The dimension "do exercise program every day" is the dimension that is highest owned by respondents, which shows the high motivation that respondents have.A person's level of self-efficacy influences their motivation to achieve their goals, determines how long the individual persists when facing challenges, and determines their resilience to failure [1].Motivation can be provided by family or people closest to the patient.In this study, respondents lived with their families who could act as a support system for respondents so that they could increase their self-efficacy.
However, 42.1% of respondents experienced moderate dependence in this study.This percentage is higher than respondents who experienced severe dependence and slight dependence.Recovery of post-stroke activity limitations mostly occurs within a certain duration, especially the first 12 months after stroke [22].
Respondents in this study were in the first three to six months of recovery after a stroke.Although several studies state that slow recovery occurs in the first three to six months after a stroke, this study showed an increase in the respondents' physical activity abilities.This can be related to the degree of stroke severity experienced by the respondent.Patients who experience mild strokes on average experience better recovery than stroke patients with severe deficits [23].As many as 71.0% of respondents in this study experienced moderate stroke severity.
In the functional independence dimension, the ability "chair/bed transfer ability" was the highest achievement item (mean = 9.84) in this study.In performing ADLs for stroke patients, moving between bed and wheelchair is not as difficult as walking [24].Functional recovery is relatively better when compared to motor recovery [25].Transferability is included in functional recovery.Transfer is considered one of the skills acquired through motor learning [24].Self-efficacy develops due to the learning process.Individual self-efficacy plays a major role in the approach to goals, tasks, and challenges [26].This can have a positive impact on self-confidence and belief in one's ability to do something.Self-efficacy is a mediator of the relationship between driving performance and activity participation after stroke, so the contribution of selfefficacy is crucial [21].
The findings from this study have several practical implications for improving patient self-efficacy.Providing information to patients and families can improve their ability to care for themselves and their families.In addition, it is necessary to provide positive reinforcement for the patient's achievements so that they increase their confidence in their abilities.However, this study had several limitations, including the limited sample because the recruitment duration was only two months and the heterogeneity of hemiparesis experienced by respondents.This study only applies to ischemic stroke patients.Future research needs to add a larger sample size, the duration of sample recruitment needs to be increased to at least six months, and the homogeneity of stroke lesions needs to be considered.

Conclusions
Self-efficacy contributes to improving the functional abilities of post-stroke patients.This shows improved recovery after a stroke.Self-efficacy is influenced by the motivation to perform certain behaviors, in this case, daily life activities.Performing daily living activities can increase the achievement of functional abilities.Achieving this functional ability cannot be separated from the patient's involvement in self-care.
In patient-centered care, as individuals, patients play an active role and as a resource that contributes to their care.Increasing the patient's knowledge, skills, and awareness of their ability to provide care for themselves is crucial.Apart from that, there is a need for support from various parties (health workers, family, and peers) to increase self-confidence in patient self-efficacy.