ABSTRACT

Objective:

To evaluate the effect of educational videos to improve the practical skills and knowledge of stroke patients' informal caregivers.

Materials and methods:

Pretest/posttest study. The participants were 10 caregivers aged 18 to 65 years and of both sexes of patients in the subacute phase of stroke. We developed eight educational videos related to positioning, mobilizations and transfers, which were implemented in the caregivers’ and/or patients’ homes along three days (on the first day, three videos; second day, three videos; and third day, two videos). Each video was viewed on a tablet for 30 minutes. We evaluated skills and knowledge before and after each video, and finally, the caregivers’ satisfaction. We used three instruments, a checklist to assess practical skills, a questionnaire to assess knowledge, and another for satisfaction.

Results:

The practical skills score increased from 21,6 to 56,1 points (p <0,001) and knowledge from 11,6 to 21,6 points (p <0,001). 7/10 of the caregivers were very satisfied with the videos, 7/10 considered the words easy, 7/10 considered easy to put the indications into practice, 9/10 would definitely recommend the videos, and everyone considered them useful.

Conclusion:

Educational videos improve the practical skills and knowledge of stroke informal caregivers. Developed educational videos could be successful in training caregivers on the management of these patients.

Keywords:
Stroke; Subacute Care; Home Care Services; Caregivers; Physical Therapy Specialty; Instructional Film and Video; Aptitude, Knowledge; Patient Satisfaction

INTRODUCTION

Patients who have suffered a cerebrovascular accident (CVA) and survived have sequelae, more than 80% of which are motor, including hemiplegia ¹1. Hewer RL. Motor loss and swallowing difficulty after stroke: frequency, recovery, and prognosis. Acta Neurol Scand. 1987;76(1):50-4. doi:10.1111/j.1600-0404.1987.tb03543.x.
https://doi.org/10.1111/j.1600-0404.1987... . Therefore, they will be dependent patients and will require a caregiver, who is often a family member who adapts his or her own responsibilities and assumes that role even without adequate training (informal caregiver). Caregivers play a very important role, especially after hospital discharge ²2. Zawawi NSM, Aziz NA, Fisher R, Ahmad K, Walker MF. The Unmet Needs of Stroke Survivors and Stroke Caregivers: A Systematic Narrative Review. J Stroke Cerebrovasc Dis. 2020;29(8):104875. doi:10.1016/j.jstrokecerebrovasdis.2020.104875.
https://doi.org/10.1016/j.jstrokecerebro... ^,33. Málaga G, De La Cruz-Saldaña T, Busta-Flores P, Carbajal A, Santiago-Mariaca K. La enfermedad cerebrovascular en el Perú: estado actual y perspectivas de investigación clínica. Acta Med Peru. 2018;35(1):51-4., which usually coincides with the subacute phase and is the stage when patients achieve most of their recovery ⁴4. Levin PG. Stronger after stroke: your roadmap to recovery [Internet]. 3o ed. New York: Springer; 2018 [citado el 5 de noviembre de 2018]. Disponible en: https://books.google.com.pe/books?id=Vt1JDwAAQBAJ&pg=PA146&dq=stroke+phases+acute+subacute+chronic&hl=es&sa=X&ved=0ahUKEwj-8fyS6L3eAhUm0FkKHVKND8UQ6AEIJzAA#v=onepage&q=stroke phases acute subacute chronic&f=false.. Caregiver education is crucial to reduce risks to their own physical and mental health ⁵5. Brereton L, Carroll C, Barnston S. Interventions for adult family carers of people who have had a stroke: A systematic review. Clin Rehabil. 2007;21(10):867-84. doi:10.1177/0269215507078313.
https://doi.org/10.1177/0269215507078313... ⁾ and to prevent complications and promote patient recovery ⁶6. Pitthayapong S, Thiangtam W, Powwattana A, Leelacharas S, Waters CM. A Community Based Program for Family Caregivers for Post Stroke Survivors in Thailand. Asian Nurs Res (Korean Soc Nurs Sci). 2017;11(2):150-7. doi:10.1016/j.anr.2017.05.009.
https://doi.org/10.1016/j.anr.2017.05.00... .

For most caregivers and patients, discharge from the hospital is one of the most difficult times. The caregiver feels unprepared to return home, mainly due to lack of knowledge in dealing with the sequelae. In addition, they have reported the need for training in specific caregiving tasks, such as positioning, mobilizations and transfers ²2. Zawawi NSM, Aziz NA, Fisher R, Ahmad K, Walker MF. The Unmet Needs of Stroke Survivors and Stroke Caregivers: A Systematic Narrative Review. J Stroke Cerebrovasc Dis. 2020;29(8):104875. doi:10.1016/j.jstrokecerebrovasdis.2020.104875.
https://doi.org/10.1016/j.jstrokecerebro... ^,77. Pesantes MA, Brandt LR, Ipince A, Miranda JJ, Diez-Canseco F. An exploration into caring for a stroke-survivor in Lima, Peru: Emotional impact, stress factors, coping mechanisms and unmet needs of informal caregivers. eNeurologicalSci. 2017;6:33-50. doi:10.1016/j.ensci.2016.11.004.
https://doi.org/10.1016/j.ensci.2016.11.... . Correct positioning, mobilizations and transfers protect joints, provide comfort and prevent complications such as respiratory problems, pressure ulcers, pain, contractures, shortening and swelling. They also promote recovery and maximize patient function through modulation of muscle tone, adequate sensory information, enhanced spatial perception, stabilization of body segments and neuromuscular activation ⁸8. Chatterton HJ, Pomeroy VM, Gratton J. Positioning for stroke patients: A survey of physiotherapists' aims and practices. Disabil Rehabil. 2001;23(10):413-21. doi:10.1080/09638280010008825.
https://doi.org/10.1080/0963828001000882... ^,99. Gillen G. Stroke Rehabilitation: A Function-based Approach [Internet]. 4o ed. United States of America: Elsevier; 2015 [citado el 22 de enero de 2021]. Disponible en: https://books.google.com.pe/books?id=Id4vCgAAQBAJ&printsec=frontcover&dq=Stroke+Rehabilitation:+A+Function-based+Approach&hl=es-419&sa=X&ved=0ahUKEwiY6by83cLmAhVRA9QKHSvPDDoQ6wEILzAA#v=onepage&q=Stroke Rehabilitation%3A A Function-based Approach&f=false.
https://books.google.com.pe/books?id=Id4... .

In Latin America, most patients have several limitations in accessing health services ¹⁰10. Avezum Á, Costa-Filho FF, Pieri A, Martins SO, Marin-Neto JA. Stroke in Latin America: Burden of Disease and Opportunities for Prevention. Glob Heart. 2015;10(4):323-31. doi:10.1016/j.gheart.2014.01.006.
https://doi.org/10.1016/j.gheart.2014.01... . In Peru, especially in rural areas, health systems are saturated, have limited coverage and delayed access, the number of specialists is limited, and social inequity exists ¹¹11. Lazo-Gonzales O, Alcalde-Rabanal J, Espinosa-Henao O. El sistema de salud en Perú: situación y desafíos [Internet]. Lima: Colegio Médico del Perú, REP; 2016 [citado el 18 de enero de 2021]. Disponible en: http://web2016.cmp.org.pe/wp-content/uploads/2016/12/libroSistemaSaludPeru-.pdf.
http://web2016.cmp.org.pe/wp-content/upl... . One study reported that in Lima none of the caregivers of patients who had suffered a stroke had received guidance on the care of their patients after hospital discharge ⁷7. Pesantes MA, Brandt LR, Ipince A, Miranda JJ, Diez-Canseco F. An exploration into caring for a stroke-survivor in Lima, Peru: Emotional impact, stress factors, coping mechanisms and unmet needs of informal caregivers. eNeurologicalSci. 2017;6:33-50. doi:10.1016/j.ensci.2016.11.004.
https://doi.org/10.1016/j.ensci.2016.11.... . This situation is aggravated in rural areas, where the percentage who know about and use rehabilitation services is lower, and the problem of accessibility related to transportation, distance and physical barriers is greater ¹²12. Miranda JJ, Moscoso MG, Yan LL, Diez-Canseco F, Málaga G, Garcia HH, et al. Addressing post-stroke care in rural areas with Peru as a case study. Placing emphasis on evidence-based pragmatism. J Neurol Sci. 2017;375:309-15. doi:10.1016/j.jns.2017.02.027.
https://doi.org/10.1016/j.jns.2017.02.02... .

The development of technology represents new opportunities to improve healthcare. Thus, mHealth or mobile health interventions such as telemedicine, videoconferencing, text messaging, mobile applications, among others, have been developed ¹²12. Miranda JJ, Moscoso MG, Yan LL, Diez-Canseco F, Málaga G, Garcia HH, et al. Addressing post-stroke care in rural areas with Peru as a case study. Placing emphasis on evidence-based pragmatism. J Neurol Sci. 2017;375:309-15. doi:10.1016/j.jns.2017.02.027.
https://doi.org/10.1016/j.jns.2017.02.02... . In addition, videos have shown to be effective educational tools. Videos aimed at patients with chronic obstructive pulmonary disease (COPD) have improved knowledge and technique in the use of inhalers ¹³13. Mulhall AM, Zafar MA, Record S, Channell H, Panos RJ. A Tablet-Based Multimedia Education Tool Improves Provider and Subject Knowledge of Inhaler Use Techniques. Respir Care. 2017;62(2):163-71. doi:10.4187/respcare.05008.
https://doi.org/10.4187/respcare.05008... . Similarly, videos have increased the knowledge of stroke patients ¹⁴14. Denny MC, Vahidy F, Vu KYT, Sharrief AZ, Savitz SI. Video-based educational intervention associated with improved stroke literacy, selfefficacy, and patient satisfaction. PLoS One. 2017;12(3):e0171952. doi:10.1371/journal.pone.0171952.
https://doi.org/10.1371/journal.pone.017... , caregivers of asthma patients ¹⁵15. Riera A, Ocasio A, Tiyyagura G, Thomas A, Goncalves P, Krumeich L, et al. A web-based educational video to improve asthma knowledge for limited English proficiency Latino caregivers. J Asthma. 2017;54(6):624-31. doi:10.1080/02770903.2016.1251597.
https://doi.org/10.1080/02770903.2016.12... , children with epilepsy ¹⁶16. Saengow VE, Chancharoenchai P, Saartying W, Pimpa W, Chotichanon N, Lewsirirat T, et al. Epilepsy video animation: Impact on knowledge and drug adherence in pediatric epilepsy patients and caregivers. Clin Neurol Neurosurg. 2018;172:59-61. doi:10.1016/j.clineuro.2018.06.031.
https://doi.org/10.1016/j.clineuro.2018.... and patients in intensive care units ¹⁷17. Krewulak KD, Bull MJ, Wesley Ely E, Davidson JE, Stelfox HT, Fiest KM. Effectiveness of an intensive care unit family education intervention on delirium knowledge: a pre-test post-test quasi-experimental study. Can J Anesth. 2020;67(12):1761-74. doi:10.1007/s12630-020-01810-5.
https://doi.org/10.1007/s12630-020-01810... .

On the other hand, face-to-face training among caregivers themselves or with actors who act as patients, together with feedback from the health professional, have increased the knowledge and self-competence of caregivers of patients with dementia ¹⁸18. Tan ZS, Soh M, Knott A, Ramirez K, Ercoli L, Caceres N, et al. Impact of an Intensive Dementia Caregiver Training Model on Knowledge and Self-Competence: The Improving Caregiving for Dementia Program. J Am Geriatr Soc. 2019;67(6):1306-9. doi:10.1111/jgs.15821.
https://doi.org/10.1111/jgs.15821... , and the self-efficacy and preparedness for care of caregivers of cancer patients ¹⁹19. Hendrix CC, Bailey DE, Steinhauser KE, Olsen MK, Stechuchak KM, Lowman SG, et al. Effects of enhanced caregiver training program on cancer caregiver's self-efficacy, preparedness, and psychological well-being. Support Care Cancer. 2016;24(1):327-36. doi:10.1007/s00520-015-2797-3.
https://doi.org/10.1007/s00520-015-2797-... , as well as the knowledge and practices reported in caregivers of patients with stroke ²⁰20. Choi JS, Seo YM, Kwon IS. Effects of education on knowledge and practice of caregivers of the stroke patient. J Korean Acad Nurs. 2006;36(7):1175-1182. doi:10.4040/jkan.2006.36.7.1175.
https://doi.org/10.4040/jkan.2006.36.7.1... .

Although there is evidence demonstrating the efficacy of caregiver education, both face-to-face and with educational videos, most studies evaluate knowledge, self-efficacy or self-competence, not techniques or practical skills, especially related to positioning, mobilizations or transfers of patients who have suffered a stroke. In addition, there is a need to develop and evaluate culturally focused interventions that can serve as new forms of healthcare. The aim of the study was to evaluate the effect of educational videos to improve the practical skills and knowledge of informal caregivers of stroke patients.

MATERIALS AND METHODS

Study design and population

A pretest/posttest study was carried out. Participants were recruited from the hospitalization and emergency services of the Cayetano Heredia Hospital, Lima, Peru. The inclusion criteria considered subjects that were informal caregivers (family members) of patients who had suffered an ischemic stroke, were in the subacute phase (from the first seven days of symptom onset to the first three months) ⁴4. Levin PG. Stronger after stroke: your roadmap to recovery [Internet]. 3o ed. New York: Springer; 2018 [citado el 5 de noviembre de 2018]. Disponible en: https://books.google.com.pe/books?id=Vt1JDwAAQBAJ&pg=PA146&dq=stroke+phases+acute+subacute+chronic&hl=es&sa=X&ved=0ahUKEwj-8fyS6L3eAhUm0FkKHVKND8UQ6AEIJzAA#v=onepage&q=stroke phases acute subacute chronic&f=false., were stable and had hemiplegia. Also, the age of the caregivers should be greater than 18 and less than 65 years. Caregivers were excluded if they had severe cognitive, hearing or visual problems or if their patients were uncooperative due to their cognitive, neurological or psychiatric conditions; and/or had comorbidities affecting mobility, such as other neurological, orthopedic or trauma disorders.

Educational videos

The educational videos included activities related to positioning, mobilizations and transfers for good management of patients in the subacute phase of stroke. The scripts for the videos were developed based on specialized literature ⁸8. Chatterton HJ, Pomeroy VM, Gratton J. Positioning for stroke patients: A survey of physiotherapists' aims and practices. Disabil Rehabil. 2001;23(10):413-21. doi:10.1080/09638280010008825.
https://doi.org/10.1080/0963828001000882... ^,99. Gillen G. Stroke Rehabilitation: A Function-based Approach [Internet]. 4o ed. United States of America: Elsevier; 2015 [citado el 22 de enero de 2021]. Disponible en: https://books.google.com.pe/books?id=Id4vCgAAQBAJ&printsec=frontcover&dq=Stroke+Rehabilitation:+A+Function-based+Approach&hl=es-419&sa=X&ved=0ahUKEwiY6by83cLmAhVRA9QKHSvPDDoQ6wEILzAA#v=onepage&q=Stroke Rehabilitation%3A A Function-based Approach&f=false.
https://books.google.com.pe/books?id=Id4... ^,2121. Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, et al. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47(6):e98-169. doi:10.1161/STR.0000000000000098.
https://doi.org/10.1161/STR.000000000000... ^,2222. Davies PM, Torres Lacomba M. Pasos a seguir: tratamiento integrado de pacientes con hemiplejía. 2 ed. Madrid: Me´dica Panamericana; 2008. and the advice of seven experts: four medical technologists in physical therapy and rehabilitation, a geriatrician, a neurologist and a communicator. Scripts were recorded, followed by videos, cast with two characters: the study investigator acting as the caregiver and a professional actor as the patient. Three medical technologists in physical therapy and rehabilitation evaluated the videos and provided feedback for improvement. Finally, we obtained eight educational videos lasting between 1 minute 15 seconds and 2 minutes 44 seconds, as well as an introductory video of 1 minute 15 seconds to explain mainly which side was considered affected (video 0).

The eight videos correspond to the following activities: video 1 - alignment of the patient in the prone position; video 2 - alignment in the prone position on the affected side; video 3 - alignment in the prone position on the healthy side; video 4 - how to elevate the patient’s hips when lying on the back; video 5 - how to turn the patient on his affected and healthy side; video 6 - how to sit the patient on the edge of the bed from the prone position; video 7 - how to transfer the patient from a bed to a chair; video 8 - alignment of the patient when sitting in a chair. These videos are available at: https://www.youtube.com/playlist?list=PLXlX1w9QhG15NPlTb0TqSkeYvbp3NzFT_

Instruments

For evaluating practical skills (Supplementary Material 1), a 68-item checklist was used and administered by the researcher. For evaluating knowledge (Supplementary Material 2), a questionnaire with 27 single-choice closed-ended questions was completed by the caregiver. In both instruments, one point was assigned for each item/correct answer and zero for each item/incorrect answer. To assess satisfaction (Supplementary Material 3), a questionnaire with 7 single-choice closed-ended questions and 3 open-ended questions was used and completed by the caregiver. The instruments were developed from the specialized literature used for the elaboration of the videos. Subsequently, the instruments were evaluated by five medical technologists in physical therapy and rehabilitation, according to the criteria of sufficiency, relevance and clarity, after which the respective corrections were made. Finally, the instruments to assess knowledge and satisfaction were applied to five potential caregivers in order to improve the semantics of the questions and alternatives, corrections were made and the final instruments were obtained.

Procedures

Cases of patients with ischemic stroke were identified in the hospitalization and emergency services of the Cayetano Heredia Hospital and assessed to see if they met the selection criteria, and if so, a family member was contacted personally or by telephone to find out who would be the patient’s caregiver and at the same time verify if he or she met the selection criteria. If the caregiver met these criteria, the informed consent process was carried out in person at the hospital facilities or at the home of the patient and/or caregiver.

The intervention was performed after one day to three days after hospital discharge, in the caregiver’s and/or patient’s home. Videos were shown on a seven-inch tablet. Before starting the intervention, the caregiver was shown a video explaining mainly which side of the patient was affected in the videos (video 0). The maximum viewing time for each of the 8 videos was 30 minutes. Three videos were viewed on the first day, the next three on the second day, and the last two on the third day. The researcher, who was a medical technologist in physical therapy and rehabilitation, was present during the entire intervention to help the caregiver in case of problems with the handling of the tablet and/or any adverse event.

For the practical skills assessments of the eight videos, the caregiver was asked to perform each activity with the patient three times. Each activity item was scored as 1 if it was performed as indicated in at least two of the three repetitions, and 0 otherwise. For the knowledge assessment, each correct response was scored as 1 and 0 otherwise.

First, practical skills and knowledge were assessed for activity 1 (video 1). Second, caregivers watched video 1 (~30 min). Third, practical skills and knowledge were reassessed for that activity. This sequence was repeated for videos 2 through 8. Finally, after all eight videos, caregivers answered questions related to their satisfaction.

Sample size and statistical analysis

The sample size calculation was carried out based on a quantitative change in the practical skills and knowledge score, so the sample size was only 10 participants. We considered a minimum mean difference for the practical skill level of 20 points and a maximum standard deviation of 20 points ¹³13. Mulhall AM, Zafar MA, Record S, Channell H, Panos RJ. A Tablet-Based Multimedia Education Tool Improves Provider and Subject Knowledge of Inhaler Use Techniques. Respir Care. 2017;62(2):163-71. doi:10.4187/respcare.05008.
https://doi.org/10.4187/respcare.05008... , potence at 80% and a confidence level of 95%.

The Shapiro-Wilk test was used to verify the normal distribution of the post- and pre-differences for practical skills and knowledge, so the Student’s t-test for paired samples was used for both cases. An alpha error of 5% was established for all hypothesis tests. All analyses were performed in the statistical program Stata SE version 15 (StataCorp LLC).

Ethical aspects

The Ethics Committee of the Universidad Peruana Cayetano Heredia (Constancia 124-04-18) and of the Hospital Cayetano Heredia (Oficio No. 1129-2018) approved the study and the informed consent. The caregiver and patient received a copy of the signed informed consent.

RESULTS

From August to December 2018, stroke patients and their caregivers were contacted. Of 30 patients with ischemic stroke, 13 were excluded, eight because they presented cognitive, neurological, or psychiatric conditions that did not allow them to collaborate in mobilizations and transfers; and five because they presented other neurological, orthopedic, or traumatological disorders that affected their mobility. The caregivers of the 17 patients were eligible, and seven refused to participate. The 10 patients and their caregivers were assigned to the educational videos, completed the intervention, and were finally analyzed (Figure 1). The characteristics of the caregivers and patients are presented in Table 1. There were 10 caregiver-patient pairs. All caregivers were female and 9 of 10 of the patients were male. The mean age of the patients was older than the mean age of the caregivers (44.6 ± 12.5 vs. 67.9 ± 11.4). 6 of 10 of the caregivers were caring for their parents and 6 of 10 of the patients were right-sided affected.

The pre- and post-intervention practical skills and knowledge are shown in Table 2. The post-pre- difference for practical skills was 34.5 points (p<0.001), representing a 50.7% increase in score, while for knowledge it was 10 points (p<0.001), an increase of 37%.

In relation to the satisfaction variable (Table 3). 7 out of 10 of the caregivers were very satisfied with the videos, 7 out of 10 considered that the words used were “easy” and another 7 considered it easy to put the indications into practice. Nine caregivers would definitely recommend the videos and all considered them useful. In addition, 2 of the caregivers had no favorite video, while others preferred video 2 - alignment in the position lying on the affected side, video 3 - alignment lying on the healthy side and video 7 how to transfer the patient from a bed to a chair. Some comments for video 2 were: “the patient rests better” and “I find it perfect for resting”; for video 3, “my dad feels more comfortable” and “it is more comfortable”; for video 7, “it was easier to do it” and “it is the most difficult position to move the patient”. On the other hand, only one indicated that she had a non-favorite video (video 6 - how to sit the patient on the edge of the bed from the lying position). One observation for the video was: “the patient is very heavy for me”.

On the other hand, Supplementary Material 4 details the change in practical ability for each item, while Supplementary Material 5 details the change in knowledge for each question. “No-No” means that, on the pre- and post-assessment, the item/answer was incorrect. “No-Yes” (what is expected to be found with the intervention) indicates that on the pre-assessment the item/response was incorrect, but on the post-assessment it was correct. “Yes-No” means that on the pre-assessment the item/response was correct, but on the post-assessment it was incorrect. “Yes-Yes” indicates that in the pre-assessment and post-assessment the item/response was correct.

DISCUSSION

This research shows that educational videos improve the practical skills and knowledge of caregivers of subacute stroke patients, specifically on positioning, mobilizations and transfers. On the other hand, caregivers had a positive perception of the videos and no adverse events were reported during the intervention.

The improvement in practical skills was similar to what was found in a research that used educational videos to enhance three inhaler use techniques in COPD patients (22.7%, 22.9%, and 12.8%) ¹³13. Mulhall AM, Zafar MA, Record S, Channell H, Panos RJ. A Tablet-Based Multimedia Education Tool Improves Provider and Subject Knowledge of Inhaler Use Techniques. Respir Care. 2017;62(2):163-71. doi:10.4187/respcare.05008.
https://doi.org/10.4187/respcare.05008... , as well as in another research about improving face-to-face training for caregivers of patients with stroke on medication, food intake, correct posture, ulcer prevention, among others (16.7%) ²⁰20. Choi JS, Seo YM, Kwon IS. Effects of education on knowledge and practice of caregivers of the stroke patient. J Korean Acad Nurs. 2006;36(7):1175-1182. doi:10.4040/jkan.2006.36.7.1175.
https://doi.org/10.4040/jkan.2006.36.7.1... . Although the improvement in practical skills in our study was greater, this could be due to the fact that COPD patients were on average 20 years older than the population in this investigation (67.7 versus 44.6 years), which would imply a different learning curve. Also, because the evaluation of caregivers of stroke patients trained in person was through self-reporting, while in this study it was through the researcher’s evaluation with a checklist.

Regarding knowledge, both classroom training of stroke patients ²⁰20. Choi JS, Seo YM, Kwon IS. Effects of education on knowledge and practice of caregivers of the stroke patient. J Korean Acad Nurs. 2006;36(7):1175-1182. doi:10.4040/jkan.2006.36.7.1175.
https://doi.org/10.4040/jkan.2006.36.7.1... and videos of caregivers of patients with asthma ¹⁵15. Riera A, Ocasio A, Tiyyagura G, Thomas A, Goncalves P, Krumeich L, et al. A web-based educational video to improve asthma knowledge for limited English proficiency Latino caregivers. J Asthma. 2017;54(6):624-31. doi:10.1080/02770903.2016.1251597.
https://doi.org/10.1080/02770903.2016.12... , children with epilepsy ¹⁶16. Saengow VE, Chancharoenchai P, Saartying W, Pimpa W, Chotichanon N, Lewsirirat T, et al. Epilepsy video animation: Impact on knowledge and drug adherence in pediatric epilepsy patients and caregivers. Clin Neurol Neurosurg. 2018;172:59-61. doi:10.1016/j.clineuro.2018.06.031.
https://doi.org/10.1016/j.clineuro.2018.... , and patients in intensive care ¹⁷17. Krewulak KD, Bull MJ, Wesley Ely E, Davidson JE, Stelfox HT, Fiest KM. Effectiveness of an intensive care unit family education intervention on delirium knowledge: a pre-test post-test quasi-experimental study. Can J Anesth. 2020;67(12):1761-74. doi:10.1007/s12630-020-01810-5.
https://doi.org/10.1007/s12630-020-01810... , have increased knowledge of the pathology, health condition, or management, despite the fact that adaptations of validated questionnaires, validated questionnaires, or questionnaires developed for research without a formal validation process have been used to assess knowledge. Some studies have not considered the educational level of the caregivers, and in others, as in this one, it has been found that most caregivers had at least a high school level of education. Therefore, this type of intervention could have different effects on the knowledge of the participants according to their level of education.

It is important to assess caregivers’ satisfaction to know their experience regarding the videos. Positive results were found in other single-group investigations with pretest and posttest ¹⁴14. Denny MC, Vahidy F, Vu KYT, Sharrief AZ, Savitz SI. Video-based educational intervention associated with improved stroke literacy, selfefficacy, and patient satisfaction. PLoS One. 2017;12(3):e0171952. doi:10.1371/journal.pone.0171952.
https://doi.org/10.1371/journal.pone.017... ^,2323. Vogler CN, Sattovia S, Salazar LY, Leung TI, Botchway A. Assessing outcomes of educational videos in group visits for patients with chronic pain at an academic primary care clinic. Postgrad Med. 2017;129(5):524-30. doi:10.1080/00325481.2017.1324228.
https://doi.org/10.1080/00325481.2017.13... ; however, in quasi-experimental studies with a non-equivalent control group, videos have not demonstrated superiority over other methods, for example, adding videos to a comprehensive educational approach does not change the level of satisfaction ²⁴24. Meighan MM. Stroke Education Video Does Not Affect Patient Satisfaction Scores: A System Analysis. J Neurosci Nurs. 2018;50(4):233-7. doi:10.1097/JNN.0000000000000383.
https://doi.org/10.1097/JNN.000000000000... , nor do caregivers notice differences between the usefulness of videos or paper instructions ²⁵25. Wood EB, Harrison G, Trickey A, Friesen MA, Stinson S, Rovelli E, et al. Evidence-Based Practice: Video-Discharge Instructions in the Pediatric Emergency Department. J Emerg Nurs. 2017;43(4):316-21. doi:10.1016/j.jen.2016.11.003.
https://doi.org/10.1016/j.jen.2016.11.00... .

Our research did not evaluate clinical indicators, unlike some studies that have determined that videos before an intrathecal chemotherapy procedure decrease anxiety levels ²⁶26. Bany Hamdan A, Ballourah W, Elghazaly A, Javison S, Alshammary S, Erlandez R, et al. The Effect of Video-Assisted Education Prior Intrathecal Chemotherapy on Anxiety and Knowledge Enhancement. J Cancer Educ. 2020;28(1):e12113. doi:10.1007/s13187-020-01787-1.
https://doi.org/10.1007/s13187-020-01787... ⁾ or the number of complications in patients with sequelae of stroke ²⁷27. Kamal A, Khoja A, Usmani B, Magsi S, Malani A, Peera Z, et al. Effect of 5-minute movies shown via a mobile phone app on risk factors and mortality after stroke in a low- To middle-income country: Randomized controlled trial for the stroke caregiver dyad education intervention (MovIes4Stroke). JMIR mHealth uHealth. 2020;8(1). doi:10.2196/12113.
https://doi.org/10.2196/12113... . However, according to Kirkpatrick’s model, which evaluates training programs in 4 levels; satisfaction, knowledge and practical skills correspond to the first two levels (reaction level and learning level), which are necessary and important to impact on higher levels (behavioral level and outcome level) ²⁸28. Smidt A, Balandin S, Sigafoos J, Reed VA. The Kirkpatrick model: A useful tool for evaluating training outcomes. J Intellect Dev Disabil. 2009;34(3):266-74. doi:10.1080/13668250903093125.
https://doi.org/10.1080/1366825090309312... . On the other hand, several theories and principles were taken into account for the development of the videos in order to maximize the caregiver’s learning, among them, theories such as cognitive load and the cognitive theory of multimedia learning; and principles such as signaling, segmentation, weeding and matching modality ²⁹29. Brame CJ. Effective educational videos: Principles and guidelines for maximizing student learning from video content. CBE Life Sci Educ. 2016;15(4):es6. doi:10.1187/cbe.16-03-0125.
https://doi.org/10.1187/cbe.16-03-0125... .

This study has some limitations; therefore, the results should be interpreted with caution. First, observation bias, because the researcher was the one who performed the pre and post assessment, which could explain that the difference in practical skills was greater than that of knowledge. Second, the presence of the researcher could have a positive influence on the caregivers’ practical skills because they felt observed or more confident. However, the differences found in practical skills and knowledge were high; 50.7% and 37%, respectively. Third, there is no control group to identify the real effect of the intervention; however, it is unlikely that the dramatic improvement observed in both practice and knowledge in a short time can be explained by secular trends, or by the gradual acquisition of experience in managing these patients. Fourth, the sample size was small, since the estimate was made on the basis of an expected difference of 20 points; however, there is no evidence that this is a value accepted as relevant to see changes. Fifth, the instruments used were self-developed and had no formal validation, although they were developed based on specialized literature, expert judgment and a pilot. Sixth, there was no follow-up to assess the effect over time, although it is likely that knowledge tends to decrease ⁽³⁰30. Chan YF, Lavery R, Fox N, Kwon R, Zinzuwadia S, Massone R, et al. Effect of an Educational Video on Emergency Department Patient Stroke Knowledge. J Emerg Med. 2008;34(2):215-20. doi:10.1016/j.jemermed.2007.04.003.
https://doi.org/10.1016/j.jemermed.2007.... ⁾ and even practical skills. Seventh, the evaluation was conducted immediately after the intervention, which does not necessarily mean that caregivers put into practice what they learned; however, according to Kirkpatrick’s model, the evaluation conducted is necessary to subsequently assess behavioral change.

The educational videos that have been developed could be used to train caregivers on the management of stroke patients, and even be part of an ongoing comprehensive training program that also includes face-to-face training, practice on simulated patients, among other strategies. On the other hand, although the videos have been developed for stroke patients with certain clinical characteristics, these videos could be useful in other stroke conditions, as indicated by specialists; and even in other types of patients whose mobility is affected, for example, in geriatric patients, palliative care patients and hospitalized patients. The advantages of the videos are that they are practical, inexpensive tools once produced, people can learn at their own pace, and many people can access the videos at the same time without a healthcare professional necessarily being present.

The educational videos improve the practical skills and knowledge of informal caregivers of subacute stroke patients. In addition, the caregivers received the videos positively, were very satisfied, considered the words of the videos to be “easy” and put the indications into practice, would definitely recommend them and considered them useful. It is recommended that improved versions of the videos be developed based on the analysis that has been done for each of the items and questions for practical skills and knowledge, respectively. In addition, studies should be carried out to conduct long-term follow-up on the indicators evaluated and to assess the impact of the training, for example, on clinical indicators in patients and on mental health indicators in caregivers.

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