State Self-Esteem Following Stroke
Anne M. Chang, MEdSt, RN; Ann E. Mackenzie, PhD, RN
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Background and Purpose—Physical rehabilitation after stroke is often highlighted in the absence of consideration of
psychosocial factors. This study sought to determine the relationship between state self-esteem and functional
independence in patients recovering from stroke.
Methods—In a longitudinal study, data were collected from 152 stroke patients within 48 hours of admission to a
rehabilitation hospital and at 2 weeks and 3 months after admission. The Modified Barthel Index was used to assess
functional ability. Patients’ current feelings of self-worth were assessed with use of the State Self-Esteem Scale.
Additional variables included perceived social support, trait self-esteem, age, previous stroke, side of stroke,
comorbidity, marital status, and gender.
Results—State self-esteem was significantly correlated to functional independence. The results of linear stepwise
regression analysis indicated that functional ability and state self-esteem at 2 weeks, as well as the presence of heart
disease, were significant predictors (55%) of functional ability at 3 months. For those with a functional ability score of
$81 on admission to the rehabilitation unit, state self-esteem and functional ability at 2 weeks as well as previous stroke
explained 53% of the variance in functional ability at 3 months. When functional ability was #80, baseline and 2-week
functional ability, state self-esteem at 2 weeks, and age predicted 53% of the variance in functional ability at 3 months.
Conclusions—Functional ability at 2 weeks was a stronger predictor than baseline functional ability in this study. The level
of state self-esteem was also a consistent factor in the prediction of functional outcome of patients after stroke. (Stroke.
1998;29:2325-2328.)
Key Words: psychology n rehabilitation n stroke outcome
M
any of the factors included in studies predicting functional recovery following stroke have focused on the
neurological features of stroke, time from onset to admission
to acute care and rehabilitation settings, comorbidity, age, and
occurrence of a previous stroke.1–3 Increasingly, the psychosocial handicap resulting from stroke and other chronic
diseases is recognized to be as overwhelming as the physical
disability.4 – 8
Such disabilities can lead to enduring problems for both the
stroke patient and the family, as well as for the community
and health services. Levenson9 found that medical patients
who had high psychosocial symptoms and no major differences in severity of illness had greater hospital costs and
longer length of stay. Browne et al10 reported that those
discharged home with poorer psychosocial adaptation had
greater use and thus greater costs of health services.
Self-esteem can be influential in a person’s response to
illness.11–13 Although a number of studies have examined
depression in those recovering from stroke,6,14 –16 little has
been reported on the level of self-esteem in those with stroke.
Self-esteem is viewed both as a symptom of depression17,18
and a causal factor in reactive depression.19 –21 Muhlenkamp
and Sayles22 found that self-esteem and social support jointly
influence the practice of self-care behavior in patients with
stroke.
Trait self-esteem is the more enduring aspect of a person’s
feelings of self-worth and is relatively unchanging. As
Crouch and Straub23 have proposed, a person’s trait, or basic,
self-esteem is established and unchanged by adulthood. State
self-esteem, however, refers to the aspect of a person’s
feeling of self-worth that is more subject to change, depending on the particular state or situation. Butler et al24 use the
term “self-esteem lability” to refer the reactivity of state
self-esteem to contextual and situational factors. This state or
functional self-esteem thus refers to the changeable type of
self-esteem that can alter in situations of acute or chronic
stress, such as disease or unemployment.23 The normally
close relationship between state and trait self-esteem is
reduced when a threat to ego is experienced,25 as in patients
who have a stroke and associated disability. Thus, the
purpose of our study was to examine the relationship between
stroke patients’ state self-esteem and their functional ability
during their rehabilitation. The inclusion of self-esteem in the
prediction of functional outcome may contribute to a more
comprehensive understanding of the factors that influence
stroke rehabilitation.
Received May 27, 1998; final revision received August 3, 1998; accepted August 3, 1998.
From the Department of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong.
Correspondence to Anne Chang, Department of Nursing, Sino Building, The Chinese University of Hong Kong, Shatin, NT, Hong Kong. E-mail
[email protected]
© 1998 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org
2325
2326
State Self-Esteem and Stroke
TABLE 1. Correlations Between Functional Ability, State
Self-Esteem, Social Support, Age, and Length of Stay (n5115)
Pearson Correlation
With 3-Mo MBI
Variable
r
P
Mean
SD
3 mo
91.48
15.20
2 wk
80.48
21.58
zzz
0.70
zzz
,0.001
Baseline (rehabilitation admission)
67.23
21.08
0.56
,0.001
Functional ability (MBI)
State self-esteem
2 wk
75.16
11.08
0.40
,0.001
Baseline
71.86
11.10
0.33
,0.001
2 wk
29.16
6.12
0.22
,0.05
Baseline
NS
Social support satisfaction
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29.17
5.60
0.15
Age, y
69.44
9.33
20.17
NS
Length of stay, d
21.80
13.66
20.56
,0.001
Subjects and Methods
A longitudinal design was used to collect data from stroke patients
within 48 hours of admission to a rehabilitation hospital and at 2
weeks and 3 months after admission. Because the patients remaining
in the study at 3 months had been discharged from the rehabilitation
hospital, data were collected from the patients at their home or
nursing home. Patients were transferred to the rehabilitation hospital
from the acute-care hospital when assessed by medical staff as
having a stable condition and rehabilitation potential. One hundred
fifty-two patients in the rehabilitation hospital met the inclusion
criteria of speaking Cantonese and being able to communicate,
having no severe hearing impairment, having a score of $4 on the
Abbreviated Mental Test,26 and agreeing to participate in the initial
data collection. Those excluded from the study were those who had
a second stroke within the 3-month study period and would not
remain in Hong Kong upon discharge.
The response rate for data collected at 2 weeks was 143 (94%) and
at 3 months was 115 (76%). The mean baseline and 2-week Modified
Barthel Index (MBI) scores for the 37 patients (24%) who did not
remain in the study at 3 months were 64.11 (SD, 19.27) and 75.54
(SD, 23.77), respectively. Comparison with the mean values for the
115 patients who remained in the study (see Table 1) indicates the
similarity between mean levels of MBI. The time from onset of
stroke to admission to the rehabilitation hospital ranged from 1 to 17
days, with the mean being 5.02 (SD, 2.62) days. The length of time
spent in the rehabilitation hospital ranged from 3 to 67 days (mean,
21.18; SD, 13.66 days). Ethics approval was gained by the Institutional Review Panel. Informed consent was obtained before collection of data from the patients.
The MBI was used to assess total functional independence and the
2 subscores of self-care and mobility. Granger et al27 modified the
original 10-item Barthel Index to improve clinical sensitivity, extending the number of items to 15. This index comprises 9 items
relating to independence in self-care and 6 items focusing on
mobility.
Patients’ feelings of current self-worth were assessed with use of
the 20-item State Self-Esteem Scale developed by Heatherton and
Polivy25 to detect changes in self-esteem that measures of trait
self-esteem often fail to detect. Trait self-esteem was measured using
the 10-item Rosenberg Self-Esteem Scale.28
Social support satisfaction and number of support persons were
measured using the Social Support Questionnaire short form.29 This
short form was developed from the original 27-item Social Support
Questionnaire following recognition of the need for rapid assessment
in clinical settings.
Additional variables included age, marital status, religion, educational level, comorbidity, and length of stay. Multiple regression
analysis was used to identify factors predicting functional independence at 3 months.
Results
The mean6SD age of patients was 69.4469.33 years (range,
24 to 93 years). The majority of patients (91) were married,
with 61 being either single, widowed, separated, or divorced.
There were 67 female patients (44%) and 85 male patients
(66%). One hundred thirteen patients (74%) had no previous
stroke, 31 (20%) had 1 previous stroke, 7 (5%) had 2 previous
strokes, and 1 patient had 4 previous strokes. The majority of
patients (70; 46%) had right-sided CVA; 51 patients (34%)
had left-sided, 3 had brain stem, and 1 had cerebellar stroke;
20 (13%) were unclassified. Most patients (124; 82%) had an
ischemic type of stroke; 18 (12%) had a hemorrhagic stroke.
The number of days between stroke occurrence and baseline
data collection ranged from 2 to 20 (mean6SD, 6.562.75
days). The number of days spent in the rehabilitation hospital
ranged from 3 to 67 (mean6SD, 21.18613.66). The majority
of patients had no cardiac disease (90%), while 32% had
diabetes and 64% had hypertension.
Significant positive correlations were found between functional ability and state self-esteem (Table 1). Social support
satisfaction at 2 weeks was positively correlated with state
self-esteem at all stages of data collection and with MBI at 2
weeks and at 3 months. The number of persons providing
social support was significantly correlated with social support
satisfaction but no other study variable. Those with higher
state self-esteem at 2 weeks also had a shorter length of stay
in the rehabilitation hospital (P,0.01). Age was significantly
and inversely correlated with functional ability at baseline
and 2 weeks. Biserial correlations for examining relationships
between continuous and dichotomous variables30 revealed
that there were no significant correlations between 3-month
functional ability and the dichotomous variables of heart
disease, hypertension, diabetes, previous stroke, gender, marital status, and left or right hemisphere stroke.
Linear, stepwise multiple regression was used to determine
the variables predicting functional ability at 3 months after
admission to a rehabilitation hospital. The variables entered
into the equation were baseline and 2-week functional ability,
state self-esteem, social support satisfaction, age, marital
status, length of stay, trait self-esteem, previous stroke, heart
disease, diabetes, hypertension, and left- or right-sided stroke.
Functional ability and state self-esteem at 2 weeks, age
,and the presence of heart disease accounted for 55% of the
variance in functional ability at 3 months (See Table 2).
Further analysis of the functional ability at 3 months was
performed to determine the factors predicting each of the 2
MBI subscores of self-care and mobility. The variables
accounting for 53% of the variance in self-care MBI at 3
months were self-care functional subscore at 2 weeks, presence of heart disease, and social support satisfaction on
admission to the rehabilitation hospital. The variables accounting for 48% of the variance in the mobility functional
ability subscore at 3 months were the self-care subscore, state
self-esteem, and mobility subscore at 2 weeks.
Chang and Mackenzie
TABLE 2. Predictors of Functional Ability, Self-Care, and
Mobility Subscores at 3 Months
b
df
P
R2
F
0.63
,0.001
,0.001
0.55
45.79*
0.20
0.53
41.38*
0.48
34.41*
MBI at 3 mo
2-wk MBI
3, 111
2-wk SSES
20.16
Heart disease
,0.01
Self-care MBI at 3 mo
2-wk self-care MBI
0.68
,0.001
0.13
,0.05
20.13
,0.05
3, 111
Baseline SSQ6
Heart disease
Mobility MBI at 3 mo
0.38
,0.001
2-wk SSES
0.23
,0.001
Baseline mobility MBI
0.24
,0.05
2-wk self-care MBI
3, 111
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b indicates standardized partial regression coefficient; SSES, State SelfEsteem Scale.
*P,0.001.
Multiple regression analysis was also performed to examine the factors influential when functional ability on admission to the rehabilitation unit was #80 (that is, more
dependent) and when it was .80 (less severe).31 In the
admission MBI of the #80 group, 2-week functional ability
and state self-esteem, age, and baseline functional ability
accounted for 56% of the variance in functional ability at 3
months (See Table 3). For those with an MBI score of $81 on
admission to the rehabilitation unit, 2-week MBI and state
self-esteem, as well as previous stroke, accounted for 53% of
the variance in functional ability at 3 months (See Table 3).
In this study, state self-esteem on admission to the rehabilitation hospital, satisfaction with social support at 2 weeks,
as well as the length of rehabilitation stay, site of lesion,
diabetes, hypertension, and marital status, were not significant factors in predicting functional ability at 3 months.
Discussion
The findings of this study indicate that the state self-esteem of
patients with a stroke contributed significantly to the total
TABLE 3. Predictors of Functional Ability at 3 Months
According to Rehabilitation Admission Functional Ability
df
b
P
R2
F
0.43
,0.001
,0.001
0.56
22.54*
0.26
0.53
13.01*
Admission MBI #80
2-wk MBI
4, 71
2-wk SSES
Age, y
Baseline MBI
20.19
,0.05
0.24
,0.05
Admission MBI $81
2-wk MBI
Previous stroke
2-wk SSES
3, 35
0.40
,0.01
20.35
,0.01
0.26
,0.05
b indicates standardized partial regression coefficient; SSES, State SelfEsteem Score.
*P,0.001.
November 1998
2327
variance in a person’s functional ability at 3 months after the
stroke. State self-esteem contributed to the variance found in the
3-month functional ability for all patients when the admission
MBI was ,81 and from 81 to 100, as well as for the 3-month
mobility subscore, but not in the 3-month self-care subscore.
These findings indicate that state self-esteem may be important
in understanding some of the previously unaccounted-for variation in functional outcome in stroke patients. Trait self-esteem,
however, did not contribute to the variance found at 3 months for
any of the regression equations.
These results support previous findings of correlations
between low self-esteem and physical illness12 as well as
depressive symptoms and disability.8,32 Similarly, Strauss33
has reported that patients experience dehumanization following stroke. Thus, the importance of consideration of the self
has been found from both quantitative and qualitative methods. Many reports have also highlighted the prevalence of
depression in stroke patients16,34,35 and the negative relationship between self-esteem and depression.25,36,37
It may be that state self-esteem acts in a manner similar to the
effect of depression on the level of participation and gain from
rehabilitation patients.16 Thus, further study is needed to distinguish between patients with low state self-esteem and those with
depression, as it may be that the interventions for raising state
self-esteem will differ from those needed for depression. As can
be seen from this study, self-esteem can influence outcome,
although the way in which it affects outcome requires clarification. More study is needed to examine the use of psychosocial
interventions in ameliorating the threat to self from stroke and
the effect on functional outcome. Livneh38 proposes that intrapersonal psychosocial interventions can help the disabled adjust
and improve their self-esteem. Murphy16 and Berk and Schall39
have pointed out the lack of attention to the psychosocial
component of stroke rehabilitation, with a continuing focus on
the physical factors alone.
The 2-week MBI was consistently the main predictor of
functional outcome. That the 2-week MBI rather than baseline MBI was more frequently and consistently a significant
predictor differs from previous studies in which the best
predictor was baseline functional ability.1,2,30,40 However it
may be that the timing for collecting the baseline MBI
accounts for the finding that 2-week more often than baseline
contributed to predicting 3-month functional outcome.
Jongbloed1 reported that the time of collecting baseline
functional ability either has not been clearly stated or varies
across studies, thus rendering comparisons unreliable. In this
study the baseline measurement of MBI occurred within 48
hours of admission to the rehabilitation hospital, which was
on average 1 week after the stroke had occurred.
Age had a significant, negative correlation with functional
ability on admission to the rehabilitation hospital and 2 weeks
later, as has been found in previous studies.40 – 42 At 3 months
the correlation between age and functional ability in this
study was not significant. Nevertheless, age was a significant
predictor of 3-month functional ability for subjects with a
baseline MBI of ,81, with older subjects having a lower
3-month functional ability. However, it remains unclear
whether this negative correlation between age and functional
2328
State Self-Esteem and Stroke
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ability is due to age alone or to the association between age
and a greater incidence of chronic illness.1
The presence of heart disease, which was also a significant
predictor in this study, has been found in previous studies2,43 to
significantly influence functional ability after stroke. However,
in this study there were only 16 patients who had comorbid heart
disease. Although 39 patients had $1previous strokes, this was
found to be a significant predictor only for those with an
admission MBI of .80. Thirteen (28%) of those with a
functional ability of .80 had previous stroke, while 26 (24.5%)
of those with an admission functional ability of ,80 had a
previous stroke. Previous stroke has been reported in other
studies1 to adversely affect functional outcome.
Satisfaction with social support was a significant factor
contributing to the variance in self-care functional ability at 3
months, where higher levels of self-care MBI were related to
higher levels of social support satisfaction. This positive
relationship confirms previous findings that social support is
beneficial to stroke patients.3,44,45 However, social support did
not contribute to the explanation of variance in either the
overall functional ability at 3 months or the mobility MBI
subscore at 3 months. The absence of correlations between
the number of persons providing social support and functional ability further supports the proposal28,46 that satisfaction
with the support received is more important than the number.
Acknowledgments
Funding for this research was provided by the Health Services
Research Committee, Hong Kong.
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State Self-Esteem Following Stroke
Anne M. Chang and Ann E. Mackenzie
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Stroke. 1998;29:2325-2328
doi: 10.1161/01.STR.29.11.2325
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
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