Development of a Self-Managemet Support Model for Stroke Patients Receiving Warfarin through Family Involvement at Yangsisurat Hospital,Maha Sarakham Province.

Abstract

      This action research aimed to study the situation and existing problems, develop a self-management support model, and evaluate the model. The study was conducted from July 2023 to September 2024, applying the Kemmis and McTaggart action research process (two cycles) in conjunction with Creer’s self-management concepts and Glasgow’s self-management support concepts. Participants included 25 multidisciplinary team members and network personnel, 40 stroke patients receiving warfarin, and 40 primary caregivers or family members, all selected via purposive sampling. Research instruments included the self-management support model, a self-management behavior assessment form, a family participation assessment form, a clinical outcome and complication record form, a satisfaction assessment form, and interview/focus group guidelines. Quantitative data were analyzed using frequency, percentage, mean, standard deviation, and paired t-tests, while qualitative data were analyzed using content analysis.

      The results revealed that the developed model comprised six components: 1) individual assessment of patients and families; 2) enhancement of self-management knowledge and skills; 3) collaborative goal setting and care planning; 4) support for decision-making and implementation; 5) monitoring of risks and complications; and 6) follow-up, evaluation, and coordination of continuing care. Following the implementation of the model... Patients' self-management behavior scores increased from 28.60 ± 4.52 to 38.75 ± 3.08 (statistically significant, p < .001), and family participation scores rose from 30.15 ± 4.20 to 42.20 ± 3.12. The proportion of patients with INR levels within the target range increased from 55.00% to 80.00%; medication adherence improved from 77.50% to 95.00%; appointment attendance rose from 85.00% to 97.50%; and warfarin-related complications decreased from 30.00% to 7.50%. Patients and their families expressed the highest level of satisfaction with the model, with mean scores of 4.46 ± 0.40 and 4.50 ± 0.36, respectively.