Research Article| Volume 32, ISSUE 3, 106993, March 2023

Download started.


Stroke survivors’ preferences for post-stroke self-management programs: A discrete choice experiment


      • At least half of patients in our sample, who were diagnosed with transient ischemic attack or stroke in the past three years and had Mini-Mental State Examination score ≥ 22, would be interested in self-management programs.
      • Survivors are especially interested in health education and risk management.
      • Program topic and schedule and financial incentive/burden are key to improving program uptake.


      Background and purpose

      Self-management programs enhance survival in stroke patients. However, they require patient-centered designs to be effective. The aim of this study was therefore to investigate the type of post-stroke self-management programs that appeal to stroke survivors, and to estimate their willingness to participate in such programs.


      A Discrete Choice Experiment was administered to patients who had either a transient ischemic attack (TIA) or stroke within the past 3 years and were cognitively intact (i.e., stroke survivors). Stroke survivors were presented with eight choice tasks and asked to choose between ‘No Program’ and two hypothetical post-stroke management programs that varied by six attributes: Topics covered by the program; schedule of the program; frequency and duration of the sessions; number of participants; out-of-pocket registration fee for the whole program; and rewards for completing the program.


      The analysis involved 146 stroke survivors. Based on the mixed logit model, the predicted willingness to participate ranged from 53% to 76%. The most popular characteristics in a program were topics on health education and risk management, being scheduled during weekends as four sessions that are each 2 hours long and involve four participants, a registration fee of SGD50 (∼USD36), and SGD500 (∼USD359) reward for program completion.


      Interest in post-stroke self-management programs was high, with at least half of the sample showing interest in participating in these programs. Program features such as focusing on health education and risk management, charging a low registration fee, and offering incentives helped to increase the demand.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Venketasubramanian N
        • Chen C.
        Burden of stroke in Singapore.
        Int J Stroke. 2008; 3: 51-54
      1. Ramani NV AA, Hoon AY, Chan B, Meng CH, He KK, Young S, Foo TK. Singapore Stroke Registry Annual Report 2015. 2015. National Registry of Disease Office.

        • Easton JD
        • Saver JL
        • Albers GW
        • et al.
        Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease: the American Academy of Neurology affirms the value of this statement as an educational tool for neurologists.
        Stroke. 2009; 40: 2276-2293
        • Amarenco P
        • Lavallée PC
        • Labreuche J
        • et al.
        One-year risk of stroke after transient ischemic attack or minor stroke.
        N Engl J Med. 2016; 374: 1533-1542
        • Cheiloudaki E
        • EC Alexopoulos
        Adherence to treatment in stroke patients.
        Int J Environ Res Public Health. 2019; 16: 196
        • Diener H-C
        • Hankey GJ.
        Primary and secondary prevention of ischemic stroke and cerebral hemorrhage: JACC focus seminar.
        J Am Coll Cardiol. 2020; 75: 1804-1818
        • Pandian JD
        • Gall SL
        • Kate MP
        • et al.
        Prevention of stroke: a global perspective.
        Lancet North Am Ed. 2018; 392: 1269-1278
        • Lim W
        • Chuang DF
        • Chue KM
        • et al.
        Stroke literacy in Singapore: data from a survey of public housing estate residents.
        Ann Acad Med Singapore. 2014; 43: 454-463
        • Ward AB
        • Chen C
        • Norrving B
        • et al.
        Evaluation of the post stroke checklist: a pilot study in the United Kingdom and Singapore.
        Int J Stroke. 2014; 9: 76-84
        • Mackey LM
        • Doody C
        • Werner EL
        • et al.
        Self-management skills in chronic disease management: what role does health literacy have?.
        Med Decis Making. 2016; 36: 741-759
        • Greenway A
        • Gustafsson L
        • Bower K
        • et al.
        Exploring self-management within hospital-based stroke care: current and future opportunities.
        Disabil Rehabil. 2022; 44: 2340-2346
        • Bayliss EA
        • Bosworth H
        • Noel P
        • et al.
        Supporting self-management for patients with complex medical needs: recommendations of a working group.
        Chronic Illness. 2007; 3: 167-175
        • Parke HL
        • Epiphaniou E
        • Pearce G
        • et al.
        Self-management support interventions for stroke survivors: a systematic meta-review.
        PLoS One. 2015; 10e0131448
        • Barlow J
        • Sturt J
        • Hearnshaw H.
        Self-management interventions for people with chronic conditions in primary care: examples from arthritis, asthma and diabetes.
        Health Educ J. 2002; 61: 365-378
        • Kendall E
        • Catalano T
        • Kuipers P
        • et al.
        Recovery following stroke: the role of self-management education.
        Soc Sci Med. 2007; 64: 735-746
        • Hafsteinsdóttir TB
        • Vergunst M
        • Lindeman E
        • et al.
        Educational needs of patients with a stroke and their caregivers: a systematic review of the literature.
        Patient Educ Couns. 2011; 85: 14-25
        • Duncan Millar J
        • Mason H
        • Kidd L
        What is important in supporting self-management in community stroke rehabilitation? AQ methodology study.
        Disabil Rehabil. 2022; : 1-9
        • Kitchens R
        • Armstead A
        • Deer R
        • et al.
        Clinicians' Perspectives on the Barriers and Facilitators to Implementation of An Evidence-Based Stroke Self-Management Program.
        Arch Phys Med Rehabil. 2022; 103: e23-e24
        • Dineen-Griffin S
        • Garcia-Cardenas V
        • Williams K
        • et al.
        Helping patients help themselves: a systematic review of self-management support strategies in primary health care practice.
        PLoS One. 2019; 14e0220116
        • Opmeer BC
        • De Borgie CA
        • Mol BW
        • et al.
        Assessing Preferences Regarding Healthcare Interventions that Involve Non-Health Outcomes.
        Patient Patient-Center Outcom Res. 2010; 3: 1-10
        • van Beest W
        • Boon WP
        • Andriessen D
        • et al.
        Successful implementation of self-management health innovations.
        J Public Health. 2020; : 1-15
        • Gbiri CA
        • Olawale OA
        • Isaac SO.
        Stroke management: Informal caregivers’ burdens and strians of caring for stroke survivors.
        Ann Phys Rehab Med. 2015; 58: 98-103
        • Ryan M
        • Scott DA
        • Reeves C
        • et al.
        Eliciting public preferences for healthcare: a systematic review of techniques.
        Health Technol Assess. 2001; 5: 1-186
        • Feng L
        • Chong MS
        • Lim WS
        • et al.
        The Modified Mini-Mental State Examination test: normative data for Singapore Chinese older adults and its performance in detecting early cognitive impairment.
        Singapore Med J. 2012; 53: 458-462
        • Phillips EA
        • Himmler SF
        • Schreyögg J.
        Preferences for e-mental health interventions in Germany: a discrete choice experiment.
        Value in Health. 2021; 24: 421-430
        • Ozdemir S
        • Baid D
        • Verghese NR
        • et al.
        Patient preferences for medications in managing type 2 diabetes mellitus: a discrete choice experiment.
        Value in Health. 2020; 23: 842-850
        • Whitty JA
        • Walker R
        • Golenko X
        • et al.
        A think aloud study comparing the validity and acceptability of discrete choice and best worst scaling methods.
        PLoS One. 2014; 9: e90635
      2. Johnson FR, Kanninen B, Bingham M, et al. Experimental design for stated-choice studies. Valuing environmental amenities using stated choice studies. Springer, 2006, pp.159-202.

        • Özdemir S
        • Mohamed AF
        • Johnson FR
        • et al.
        Who pays attention in stated-choice surveys?.
        Health Econ. 2010; 19: 111-118
      3. Johnson R and Orme B. Getting the most from CBC. Sawtooth Software Research Paper Series. Sequim, WA: Sawtooth Software 2003.

      4. Train KE. Discrete choice methods with simulation. Cambridge university press, 2009.

        • Gonzalez JM.
        A guide to measuring and interpreting attribute importance.
        Patient-Patient-Center Outcom Res. 2019; 12: 287-295
        • Doshi K
        • Henderson S
        • Sugumar L
        • et al.
        A pilot study investigating the impact of mindfulness based interventions on the psychosocial well-being of stroke survivors.
        J Neurol Sci. 2017; 381: 410-411
        • Stein LA
        • Goldmann E
        • Zamzam A
        • et al.
        Association between anxiety, depression, and post-traumatic stress disorder and outcomes after ischemic stroke.
        Front Neurol. 2018; 9: 890
        • Strilciuc S
        • Grad DA
        • Radu C
        • et al.
        The economic burden of stroke: a systematic review of cost of illness studies.
        J Med Life. 2021; 14: 606
        • Vlaev I
        • King D
        • Darzi A
        • et al.
        Changing health behaviors using financial incentives: a review from behavioral economics.
        BMC Public Health. 2019; 19: 1-9
        • Lo SHS
        • Chau JPC.
        Exploring community-dwelling stroke survivors’ experiences of receiving a nurse-led theory-based stroke self-management programme: A qualitative study.
        Medicine (Baltimore). 2021; 100
        • Bakas T
        • Clark PC
        • Kelly-Hayes M
        • et al.
        Evidence for stroke family caregiver and dyad interventions: a statement for healthcare professionals from the American Heart Association and American Stroke Association.
        Stroke. 2014; 45: 2836-2852
        • Dehghan Nayeri N
        • Mohammadi S
        • Pedram Razi S
        • et al.
        Investigating the effects of a family-centered care program on stroke patients’ adherence to their therapeutic regimens.
        Contemp Nurse. 2014; 47: 88-96
        • Brouns B
        • Meesters JJ
        • Wentink MM
        • et al.
        Why the uptake of eRehabilitation programs in stroke care is so difficult—a focus group study in the Netherlands.
        Implement Sci. 2018; 13: 1-11
        • Barr V
        • Robinson S
        • Marin-Link B
        • et al.
        The expanded chronic care model.
        Hosp Q. 2003; 7: 73-82