The Effect of PERMA model-Based Psychological Intervention on Subjective Well-Being and Post-Traumatic Growth levels in young and middle-aged Stroke Patients During Rehabilitation

The Effect of PERMA model-Based Psychological Intervention on Subjective Well-Being and Post-Traumatic Growth levels in young and middle-aged Stroke Patients During Rehabilitation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The Effect of PERMA model-Based Psychological Intervention on Subjective Well-Being and Post-Traumatic Growth levels in young and middle-aged Stroke Patients During Rehabilitation Xin Yin, Ruixia Zhang, Jing Kang, Hongxia Lv, Yunxiao Zhao, Cong Yu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8074453/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Young and middle-aged stroke patients face unique rehabilitation-related psychological distress—such as frustration from slow motor function recovery, anxiety about losing family/social roles, and low motivation for long-term rehabilitation—all of which directly hinder physical recovery and post-stroke adaptation. This study developed a rehabilitation-aligned PERMA intervention and evaluated its efficacy in improving subjective well-being (SWB) and post-traumatic growth (PTG) in young and middle-aged stroke patients. Methods A total of 120 eligible patients (18–64 years old) were randomized into two groups. The control group received conventional rehabilitation. The intervention group supplemented with 8 structured PERMA-based sessions over 4 weeks—each session designed to address stroke-specific needs. SWB and PTG were assessed at baseline, post-intervention, 1-month, and 3-month follow-ups. Results SWB scores were significantly higher in the post intervention, 1-month post-intervention, and 3-month post-intervention groups than in the control group ( t = 0.011, 0.000, 0.000; P < 0.05); PTG scores were also significantly higher at these time points ( t = 0.007, 0.000, 0.000; P < 0.01). Repeated-measures ANOVAs confirmed statistically significant time-dependent increases in both outcomes for the intervention group ( P < 0.01), with no such significant trend in the control group. Conclusions The rehabilitation-aligned PERMA intervention effectively enhances SWB and PTG in young and middle-aged stroke patients during recovery. By integrating positive psychology with functional rehabilitation goals, it addresses the unique psychological needs of this population and provides a feasible, clinically applicable support strategy that complements physical rehabilitation. Trial Registration Registration number of China Clinical Trials Registration Center: ChiCTR2200060103, First Posted date: 18/05/2022 Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Health sciences/Neurology Biological sciences/Neuroscience Biological sciences/Psychology Social science/Psychology Stroke PERMA model Psychological intervention young and middle-aged Subjective well-being (SWB) Post traumatic growth (PTG) Figures Figure 1 Figure 2 Figure 3 Introduction Stroke is the leading cause of disability among young and middle-aged adults [ 1 ] , with its incidence showing a global younger trend [ 2 , 3 ] . Beyond motor dysfunction and functional impairments, these patients often face rehabilitation-specific psychological distress—such as anxiety from slow functional recovery, despair over disrupted career/family roles, and low self-efficacy due to dependence [ 4 ] . Unlike general psychological problems, their emotional barriers are closely tied to rehabilitation progress, making it critical to integrate psychological support into physical rehabilitation. Positive emotions have been shown to enhance rehabilitation compliance, accelerate motor function recovery, and reduce post-stroke depression, highlighting the necessity of targeted psychological interventions [ 4 ] . Subjective well-being (SWB), a core construct in positive psychology, refers to an individual’s positive evaluation of life quality based on personal criteria—for young and middle-aged stroke patients, this is specifically linked to functional recovery, independent daily living, and reintegration into family/social roles [ 5 ] . Studies show 76.58% of stroke patients have moderate-to-low SWB, primarily driven by frustration with rehabilitation setbacks and fear of long-term disability [ 6 , 7 ] . Guiding these patients to recognize their residual strengths and leveraging positive emotions to address rehabilitation-related distress is key to improving SWB, which in turn promotes adherence to rehabilitation exercises and social participation [ 8 ] . In 1995, Tedeschi et al. [ 9 ] introduced the term "post traumatic growth (PTG)" and defined it as positive psychological changes experienced after struggling with traumatic events. A growing body of research has found that individuals experience positive psychological changes in addition to negative psychological changes after a stressful event, i.e., positive psychological changes [ 10 , 11 ] . A longitudinal qualitative study has confirmed that stroke patients can undergo PTG [ 12 ] , but young and middle-aged patients often show lower PTG levels due to unmet psychological needs during rehabilitation [ 13 ] . Previous studies have shown that positive psychological changes not only complement physical recovery but also modify health behaviors [ 14 ] and facilitate the transition from hospital to home life [ 15 ] . However, there is a paucity of interventional research focusing on the rehabilitation-specific psychological needs of young and middle-aged stroke patients. Most existing psychological interventions for stroke patients are deficit-focused (e.g., addressing depression/anxiety), while neglecting the cultivation of positive traits conducive to long-term recovery. The PERMA model [ 16 ] , originating from positive psychology, This study envisions integrating the model with core issues during the rehabilitation phase of young and middle-aged stroke patients, achieving precision in rehabilitation support through targeted adaptation of five key elements: Positive emotions (P) tied to rehabilitation milestones (e.g., joy from independent walking), Engagement (E) in functional recovery activities (e.g., "flow" during hand function training), Relationships (R) with family/recovered peers (e.g., mutual support in rehabilitation), Meaning (M) in post-stroke life (e.g., redefining self-worth beyond pre-stroke roles), and Achievement (A) in functional gains (e.g., mastering self-care skills). Unlike its application in neurodevelopmental or educational settings, the PERMA model in this study is tailored to address stroke-specific challenges—such as adapting communication for dysarthria patients and aligning "Achievement" with rehabilitation goals. While the PERMA model has demonstrated efficacy in cancer patients [ 17 ] , healthcare workers [ 18 , 19 ] , college students [ 20 ] , and psychiatric patients [ 21 ] ,its adaptation and application in the acute rehabilitation phase of young and middle-aged stroke patients remain understudied. This study fills this gap by developing a stroke-adapted PERMA intervention program, which aims to tap into patients’ positive emotions, stimulate intrinsic motivation for recovery, and ultimately improve their SWB and PTG. The goal is to help young and middle-aged stroke patients achieve physical-psychological adaptation, enhance rehabilitation motivation, and facilitate their return to family and society. Research Subjects and Methods 1.1 Research Subjects This study employed a randomized controlled trial design, enrolling young and middle-aged stroke patients hospitalized in the Department of Rehabilitation Medicine at a Grade III Class A hospital in Shenzhen, Guangdong Province, between December 1, 2022, and June 30, 2023. Inclusion criteria : patients who also met the following conditions: (1) age ≥ 18 years and < 65 years [ 22 ] (2) meeting the 2019 Chinese major cerebrovascular disease diagnosis points [ 23 ] . (3) stable disease; (4) modified Rankin Scale (mRS) score ≥ 3 [ 24 ] ; (5) normal cognition; (6) informed consent to participate in this study. Exclusion criteria : Patients with one of the following conditions (1) patients with other major concomitant diseases, such as heart failure, respiratory failure, malignancy, severe trauma, and other critical illnesses; (2) patients who are participating in other studies. Withdrawal criteria : patients with one of the following conditions: (1) patients who were unable to participate in the subject study due to disease regression; (2) patients who voluntarily requested to withdraw from the study due to personal reasons; (3) patients who were lost to follow-up. This clinical trial was registered at the Chinese Clinical Trial Registry (ChiCTR2200060103, First Posted date: 18/05/2022). Grouping was performed using a computer-generated random number table method: a statistician not involved in the study implementation generated a random sequence. Patients were sequentially assigned to either the control group or the intervention group based on their admission order. Allocation was concealed using sealed envelopes, ensuring that neither the researchers, patients, nor evaluators were aware of the group assignments. 1.2 Research Methodology 1.2.1 Establishment of the subject group All members of the group received uniform training and a division of responsibilities. There is one researcher mentor (a nursing expert in the field of chronic diseases), one national level 2 psychological counselor, two rehabilitation specialist nurses (intermediate level or above), one rehabilitation physician (intermediate level or above), one rehabilitation therapist, and two graduate students in the program. The supervisor is responsible for the overall design of the program and quality control; the counselor is involved in the program design and training of the guiding language; the rehabilitation physician is responsible for the assessment of the disease; the rehabilitation therapist is responsible for the rehabilitation guidance; the rehabilitation specialist nurse is responsible for the routine care; and the two postgraduate students are responsible for the implementation of the program, including sending and receiving questionnaires, data statistical analysis, and thesis writing with the assistance of other members of the subject group. 1.2.2 Sample size calculation By reviewing the literature, the subjective well-being score was 36.20 ± 2.84 in the intervention group and 33.41 ± 2.74 in the control group based on the results of an experimental study in the stroke patient category [ 25 ] , the degree of certainty (Power = 1-β) = 90%, and the significance level of two-sided = 0.05 were set, and the total sample size was calculated using G*Power 3.1 software. It was 110 cases, and at a 20% shedding rate, 132 cases should be included, 66 cases each in the intervention and control groups. 1.2.3 Constructing an intervention program The preliminary draft of the intervention program was formed through the results of the preliminary status survey combined with the literature review and the study of the PERMA model theory. To ensure the scientificity and feasibility of the intervention protocol, seven experts were invited to consult through face-to-face meetings, and the entries and contents of the protocol were improved and modified according to the experts' suggestions. In order to ensure the practicality and effectiveness of the program, 10 young and middle-aged stroke patients who met the inclusion and exclusion criteria were selected for pretesting, and the problems that occurred in the pretest were analyzed and revised to form the final draft of the PERMA model psychological intervention program. 1.2.4 Implementation method 1.2.4.1 Control group The control group received conventional rehabilitation treatment and care, including stroke disease knowledge education, prevention of common post-stroke complications, placement of an anti-spasticity position, rehabilitation exercise, medication instruction, rehabilitation compliance education, dietary instruction, psychological care, and discharge instruction. 1.2.4.2 Intervention group The intervention group was based on the PERMA model of psychological intervention for young stroke patients in the control group, with two graduate students and other members of the group assisting in a one-on-one approach. The order of the topics and the length of the intervention were flexibly adjusted according to the patient's needs and mastery, and the interval between the two interviews was 2–4 days. The specific intervention plan is shown in Table 1 . Table 1 Psychological intervention program for young stroke patients in the PERMA model Time Subject Intervention content Suggested Guidance Language 1st Understanding Stroke 1. Self-introduction of the subject group; introduction of the department staff and environment. 2. Explain the knowledge about stroke and rehabilitation to enhance the patient's confidence in the rehabilitation treatment of the disease. 3. Collect information about the patient, including the patient's basic information, disease information, psychological status, the degree of harmony with family members, and the degree of support from family members for the patient. 4. Establish a trusting relationship with the patient and leave contact information, such as a telephone number and WeChat, with each other. (e.g., patients with language dysfunction can communicate with each other through gestures, writing, or typing.) 1. Do you know about stroke? 2. You can tell me what questions you have about stroke rehabilitation. 3. I will be happy to help you if you are confused about the psychological aspects. 2nd Discovering positive psychological qualities (P) 1. Use the intake talk technique to understand the psycho-emotional state of the patient. 2. Analyze the psychological problems caused by the stroke for the patient and tap into the positive aspects of things. 3. Use non-verbal communication such as eye contact and touch to empathize with the patient and give encouragement and emotional support. 4. Encourage patients to share positive and happy things about themselves to tap into their positive psychological qualities. 5. For patients aged 18–44 years old with a higher monthly income before the disease, increase the communication time or frequency appropriately according to the talks. 1. You can think of me as your friend (a patient of similar age) or your junior (an older patient) and share your happy things with me. 2. It is reasonable for you to have such thoughts, and I can understand your feelings. 3. I can see that you are in a good state, for example, you just mentioned..., which is very positive. 3rd Cultivate positive emotions (P) 1. Start the interview around the concept and role of positive emotion and talk about the benefits of positive emotion and optimism for the disease. 2. Cultivate positive thinking and a positive attitude towards stroke events. Recommend watching movies with positive themes, such as "How Steel is Made" and "When Happiness Comes Knocking," so that patients can cooperate with treatment and rehabilitation with positive emotions and increase the initiative of participation. 3. Provide patients with the opportunity to watch the stroke promotional film "Time = Brain" and stroke rehabilitation case videos. 4. Give recognition and praise to patients for their positive emotions. 5. For patients with dysarthria, practice pronunciation and mobilize positive emotions through vocalization. 1. If you are willing to share, I would love to hear some positive and happy things about yourself. 2. Think back to a time when you had a difficult event in your life, and let's try to analyze it from the positive side. 3. According to the stroke propaganda film, people can recover well with active treatment and rehabilitation exercises. 4th Gratitude Exercise (P) 1. Talk about the positive effects of learning to be grateful for improving emotional states and enhancing the sense of well-being in life. 2. Focus on the events in life and during hospitalization for which one needs to be grateful as an entry point, and guide the patient to recall them together. 3. Encourage patients to pay attention to the good and happy things in their lives and record three good things that happen every day before going to bed in the form of a diary or a circle of friends, preferably for 21 days, or the patient can dictate them and the family can record them for them. 1. You think of things and people that have touched you in the past or during your hospital stay, and please tell us if it is convenient to share. 2. You can write a letter of appreciation, edit a WeChat message, or record a voicemail and send it to the person you appreciate. 3. You can keep a diary, send a WeChat friend circle, or any other form of record the happy and beautiful things that happen to you every day. 5th Engagement Exercise (E) 1. Explain the definition and positive effects of the "flow" state. 2. According to the rehabilitation needs of the patient, the rehabilitation therapist will assess the patient's condition and then perform rehabilitation activities together under the guidance of the rehabilitation therapist. Let the patient engage in positive emotions and experience a sense of well-being. For example, practice rehabilitation exercises for hand functions such as "picking up beans, screwing nuts, and buttoning". 3. Discuss with patients their hobbies and interests. Combine the patient's condition and hobbies to develop activities. For example, playing chess, reading books, listening to music, etc. After the patient enters the state of "flow", the patient's attention is distracted from the disease and the body and mind are relaxed, which is conducive to positive psychological changes. 1. We can communicate about what hobbies or things you are more interested in.2. How do you feel when we develop rehabilitation activities and do rehabilitation exercises together? You can communicate with me anytime if you have any ideas or suggestions.3. Now imagine that you are at home, sitting in your study reading your favorite book and listening to your favorite song. 6th Foster Positive Interpersonal Relationships (R) 1. Talk about positive communication skills and how good communication promotes interpersonal relationships. 2. Communicate around interpersonal relationships, give examples of the physical and psychological benefits of good interpersonal relationships, and guide patients to realize the importance of interpersonal relationships. 3. Conduct role plays so that patients can appreciate positive communication and experience the joy of interaction. 4. Play small games with family members, patients, and friends, such as "finger catching," if the rehabilitation physician's assessment of their condition permits. 5. Invite stroke patients who have recovered well to communicate with each other. 1.Tell about someone you like or something tough or happy you experienced together. 2. I just heard you discussing with a patient lower-limb exercises; it's good to communicate and learn more. 3. XXX is in bed, he is cheerful, optimistic, and engaged in positive rehabilitation exercises; his recovery is good; you can communicate more freely. 7th Perception Meaning (M) 1. Discuss with patients the meaning of life, the meaning of living, the meaning of loved ones, and the meaning of health, and guide them to establish a correct view of meaning. A positive view of meaning will enable patients to develop a sense of mission and direction. 2. Discuss the importance of each person's role in the family and the meaning of that role to loved ones, friends, and society. 3. Stimulate the patient's sense of responsibility to loved ones and society. 4. Instruct patients to deal with the ups and downs of life with optimism. As in the case of stroke events, learning to grow in adversity is also the meaning of life. 5. Guide patients to self-evaluate and talk about their interpretation of meaning. 1. Talk about something meaningful in your life or work. 2. I see that your family members are very patient with you; they need you very much, and you have a very important meaning to them. 3. In fact, everyone's life will encounter some unsatisfactory things, so believe that the rainbow will appear after the storm. 8th Experience the achievement (A) 1. Conduct an interview with the patient about achievement and explain the positive psychological effects of achievement. 2. Develop a "rehabilitation prescription" with the patient and, under the guidance of the rehabilitation therapist, help the patient achieve a sense of accomplishment through functional rehabilitation exercises. 3. Set achievable goals and encourage the patient to use their strengths under the guidance of the rehabilitation therapist to gain a sense of accomplishment. For example, dressing and undressing by themselves, eating by themselves, going to the bathroom, etc. within the limits of their ability. 4. Promptly acknowledge the patient's achievements and give recognition and praise even for the accomplishment of small goals. 1. I saw you exercising on your own in bed; that's great! 2. The rehabilitation physician even complimented you on your progress. You are doing great; keep up the good work! 3. Rehabilitation is very crucial in the early stages, and as long as you stick to it every day, a virtuous cycle will be formed. 4. What do you have in mind for the future? Now is the time for you to plan. 1.3 Data collection Assessments were made by scale before the intervention, immediately after the intervention, 1 month after the intervention, and 3 months after the intervention. Inpatients were assessed in the rehabilitation medicine ward or health education room, and discharged patients were assessed by telephone or face-to-face (face-to-face assessments were conducted at the stroke follow-up clinic). 1.4 Evaluation tools (1)General information questionnaire The investigator's own design included two sections: demographic and sociological information (gender, age, marital status, education, occupation, place of residence, monthly income, type of health insurance, smoking, alcohol consumption, primary caregiver) and disease-related information (comorbid chronic diseases, number of strokes, family genetic history). (2)Subjective well-being༈SWB༉ Campbell created it in 1976, and scholar Xiaodong Fan translated it into Chinese [ 26 ] . It consists of two parts: the overall affective index scale (8 items) and the overall life satisfaction questionnaire (1 item). The scale is based on a 7-point Likert scale. The mean score of the overall affective index scale and the score of the life satisfaction questionnaire (with a weight of 1.1) were added to the total score. 2.1-6 scores were considered low happiness, 6.1–10 scores were moderate happiness, and 10.1–14.7 scores were high happiness, and the Cronbach's coefficient of the scale was 0.90. (3)Post-Traumatic Growth༈PTG༉ The scale was designed and developed by the American scholar Tedeschi et al. [ 9 ] , and Chinese scholars Wang Ji et al. [ 27 ] Chineseized it. It has 5 dimensions and 20 items, which are used to assess the level of post-traumatic growth of individuals, including relationships with others (7 items), new possibilities (5 items), personal strength (4 items), spiritual change (1 item), and appreciation of life (3 items), with each item rated 0–5, and the total score ranging from 0 to 100. Higher scores indicate higher levels of post-traumatic growth. Cronbach's coefficient of consistency reliability ranged from 0.611 to 0.874 for each dimension and total scale. 1.5 Statistical methods All data in this study were statistically analyzed using SPSS 25.0 software at the level of significance ( α = 0.05). (1) Count data were statistically described by the number of cases, and measurement data were statistically described by the mean ± standard deviation. (2) The chi-square test was used to compare the general information of the two groups, and the rank sum test was used to compare the rank information. (3) The data followed a normal distribution, the variance was unity, and an independent sample t-test was used to compare two groups at the same point in time. (4) Repeated measures ANOVA was used to compare changes at different time points and to observe the interaction effects between groups over time. Results 2.1 participation Study population A convenience sampling method was used to select 132 middle-aged and young stroke patients who were admitted to the rehabilitation medicine department of a tertiary care general hospital in Shenzhen, Guangdong Province, China, and met the inclusion and exclusion criteria. 66 patients from 02–05, 2022 were used as the control group, and 66 patients from 04–07, 2022, were used as the intervention group. Figure 1 shows the flow of participants through the trial, and the final valid sample was 120 cases with an effective rate of 90.91% (see Fig. 1 ). 2.2 Comparison of general information between the two groups of patients The differences between the general data of the two groups of patients were not statistically significant ( P > 0.05) and were comparable, as shown in Table 2 . Table 2 Comparison of general information between the two groups of patients (N = 120) Projects Classification Control group (60) Intervention group(60) Test- value P-value Gender Male 42 46 0.682 a 0.409 Female 18 14 Age(years) 18–44 9 10 0.063 a 0.803 45–64 51 50 Marital Status Married 58 59 0.342 a 0.599 Unmarried 2 1 Education Primary 7 6 -0.372 b 0.710 middle school 15 18 High School 23 16 University 15 20 Occupation Employee 38 42 4.969 a 0.174 Businessmen 7 11 Farmer 10 3 Unemployed 5 4 Place of residence Shenzhen 47 43 0.711 a 0.399 Non-Shenzhen 13 17 Monthly Income (¥) 10000 12 15 Insurance Type Urban Insurance 45 52 5.768 a 0.056 Rural Insurance 14 5 Self-funded 1 3 Smoking No smoking 32 27 0.834 a 0.361 Smoking 28 33 Drinking No drinking 37 30 1.656 a 0.198 Drinking 23 30 Comorbid chronic diseases No 15 16 0.043 a 0.835 Yes 45 44 Number of strokes Primary 42 50 -1.655 b 0.098 Secondary 16 8 Tertiary 2 2 Primary Caregiver Spouse 47 45 0.710 a 0.701 Relatives 2 4 Caregiver 11 11 Genetic history No 28 23 0.853 a 0.356 Yes 32 37 Note: a represents the X2 value and b represents the z value. 2.2 Comparison of baseline data scores between the two groups of patients before the intervention The baseline data scores were not significantly different between the two groups before the intervention ( P > 0.05) and were comparable, as detailed in Table 3 . Table 3 Comparison of baseline data scores between the two groups of patients before the intervention (points, X ± s) Projects Group Average value t-value P -value Subjective well-being(SWB) Control group (60) 7.53 ± 2.885 -0.459 0.647 Intervention group (60) 7.78 ± 2.978 Post-Traumatic Growth Inventory(PTGI) Control group (60) 43.81 ± 15.977 -0.419 0.676 Intervention group (60) 45.34 ± 22.944 2.3 Comparison of subjective well-being scores between the two groups after the intervention The comparison of well-being scores at each time point after the intervention was statistically higher in the intervention group than in the control group ( P < 0.05). A repeated measures ANOVA was performed on the well-being scores of the two groups at different times, and the time effect ( F = 616.854, P < 0.05), the between-group effect ( F = 12.452, P < 0.05) and the interaction effect between the two groups ( F = 47.246, P < 0.05) were all statistically significant, as shown in Table 4 . The subjective well-being scores of the patients in both groups changed over time and showed an increasing trend, but the increase in the intervention group was more obvious than that in the control group, as shown in Fig. 2 . Table 4 Comparison of subjective well-being scores between the two groups after the intervention Group Pre-intervention Post-intervention Post-intervention 1 month Post-intervention 3 months F a Fb Fc Control group (n = 60) 7.53 ± 2.885 7.82 ± 2.864 8.00 ± 2.838 8.18 ± 2.876 1309.157 13.354 635.436 Intervention group (n = 60) 7.78 ± 2.978 9.19 ± 2.952 10.83 ± 2.720 11.24 ± 2.603 t -value -0.459 -2.584 -5.572 -6.099 P -value 0.647 0.011 0.000 0.000 0.000 0.000 0.000 Note: Fa represents the time effect; Fb represents the between-group effect; Fc represents the interaction effect 2.4 Comparison of post-traumatic growth scores of survivors in the two groups after the intervention The post-traumatic growth scores were higher in the intervention group compared to the control group at each time point after the intervention, and the difference was statistically significant (P < 0.05). The post-traumatic growth scores of the two groups at different times were analyzed by repeated measures ANOVA, and the time effect (F = 885.384, P < 0.05), between-group effect (F = 10.337, P < 0.05) and interaction effect (F = 221.684, P < 0.05) were all statistically different, as shown in Table 5 . The post-traumatic growth levels of patients in both groups showed an increasing trend, but the increase was more pronounced in the intervention group than in the control group, as shown in Fig. 3 . Table 5 Comparison of post-traumatic growth scores between the two groups after the intervention (points, X ± s) Group Pre-intervention Post-intervention Post-intervention 1 month Post-intervention 3 months Fa Fb Fc Control group (n = 60) 43.81 ± 15.977 46.68 ± 15.873 48.75 ± 15.274 51.92 ± 15.397 885.384 10.337 221.684 Intervention group (n = 60) 45.34 ± 22.944 56.55 ± 22.808 62.28 ± 21.719 69.23 ± 20.086 t-value -0.419 -2.75 -3.948 -5.300 P-value 0.676 0.007 0.000 0.000 0.000 0.002 0.000 Note: Fa represents the time effect; Fb represents the between-group effect; Fc represents the interaction effect Discussion Young and middle-aged individuals stand at a pivotal juncture of life, where they juggle multiple core roles—serving as vital driving forces behind social progress and economic prosperity. This stage is marked by their pursuit of career milestones, the realization of personal aspirations, and the accumulation of life achievements, making it a period of immense potential for self-fulfillment and value creation. However, the abrupt onset of stroke shatters this stable life trajectory: beyond the physical impairments such as motor dysfunction or speech disorders, it brings a heavy psychological toll. Patients often grapple with the loss of self-efficacy, anxiety about unfulfilled family and social obligations, and despair over disrupted life plans—emotional struggles that can erode their willingness to engage in rehabilitation and dampen their enthusiasm for daily activities. In this context, targeted interventions aimed at nurturing their subjective well-being and fostering post-traumatic growth are not merely timely but indispensable. By addressing the psychological void left by the disease, these interventions can help patients rebuild resilience, rediscover a sense of purpose amid adversity, and rekindle their intrinsic drive to persist in rehabilitation training and actively participate in daily life. In turn, this not only accelerates their physical recovery but also supports their successful reintegration into family life and society, allowing them to reclaim their roles as contributors to their loved ones and communities. This study confirms that the stroke-adapted PERMA intervention can effectively improve the subjective well-being (SWB) of young and middle-aged stroke patients, which is consistent with the findings of Zhang Ying et al. [ 28 ] on the subjective well-being of 80 stroke patients through self-determination theory.The PERMA model is a positive psychological model that promotes individual flourishing and is more relevant for subjective well-being interventions [ 29 ] . The results of this study showed that the PERMA-based psychological intervention program increased the subjective well-being score of the intervention group from 7.78 ± 2.978 to 11.24 ± 2.603, i.e., from moderate to high levels of well-being, 3 months after the intervention, while the score of the control group was 8.18 ± 2.876, still moderate well-being, with no significant change. The PERMA model in this study achieves SWB improvement by deeply integrating with stroke rehabilitation needs—specifically through three scenario-adapted mechanisms: Positive emotions (P) linked to rehabilitation progress: Instead of generic positive thinking guidance, we anchored emotional reinforcement to tangible functional gains (e.g., praising patients for independently buttoning clothes or walking 50 meters unassisted). This targeted recognition directly alleviated patients’ anxiety about dependence and reinforced the link between “emotional positivity” and “rehabilitation progress,” driving sustained engagement; Engagement (E) in function-focused “flow” activities: We designed immersive rehabilitation tasks (e.g., screwing nuts to improve hand dexterity, chess-playing to enhance cognitive-motor coordination) that align with patients’ hobbies and rehabilitation goals. When patients entered the “flow” state during these activities, their attention shifted from pain and frustration to skill mastery, reducing psychological distress while promoting functional recovery; Relationships (R) reinforced by family-involved rehabilitation: We organized small-scale family rehabilitation games (e.g., “finger catching” with spouses) and peer sharing sessions with recovered stroke patients. These interactions provided patients with practical rehabilitation role models and emotional support from loved ones, addressing the “social isolation” common in stroke recovery and enhancing their sense of belonging. This study concluded that psychological interventions based on the PERMA model can improve post-traumatic growth (PTG) levels in young and middle-aged stroke patients, which is consistent with the findings of Wang Juan et al. [ 30 ] on post-traumatic growth levels in 100 stroke patients through a focal resolution model. Post-traumatic growth (PTG) is a positive emotional change experienced by individuals in the face of a traumatic life event that helps to improve mental health and promote healthy behaviors. In this study, by tapping into the positive qualities of the patients and better enhancing their positive emotions, the patients' post-traumatic growth scores improved from 45.34 ± 22.944 before the intervention to 69.23 ± 20.086 at 3 months after the intervention, while the control group scored 51.92 ± 15.397 at 3 months after the intervention, which was not a significant change. This outcome differs from the PTG promotion in non-rehabilitation populations [ 21 ] in that our intervention ties growth to stroke-specific recovery needs: Meaning (M) reconstructed around post-stroke roles: Discussions focused on “redefining self-worth in family and society post-stroke” (e.g., “being a parent who can help with children’s homework” or “returning to part-time work”) rather than abstract “life meaning.” This concrete role reconstruction resonated with patients’ urgent need to reaffirm their value, stimulating their sense of responsibility and resilience. Achievement (A) through incremental rehabilitation goals: We co-designed “stepwise rehabilitation prescriptions” with patients and therapists (e.g., “independent toileting within 2 weeks,” “dressing without assistance in 1 month”). Each small goal’s achievement provided patients with a tangible sense of progress, counteracting the frustration of slow recovery and fostering a “growth mindset” toward post-stroke challenges. Adaptations for stroke-related impairments: For patients with dysarthria, we integrated vocalization training with positive feedback (e.g., “your pronunciation is clearer than last week”) to link speech rehabilitation with emotional enhancement, ensuring PTG promotion was not hindered by physical limitations. Notably, this study differs from positive psychology interventions for other populations in two key ways: first, the intervention duration (4 weeks) was aligned with the acute rehabilitation phase of stroke (golden period for functional recovery), rather than long-term support; second, all activities were co-designed with rehabilitation therapists to ensure they complemented physical training (e.g., hand function exercises during “Engagement” sessions). These adaptations explain why the intervention’s effects persisted at 3-month follow-up—unlike general psychological interventions that may fade over time. This study has limitations: First, convenience sampling from a single hospital may limit generalizability; future multi-center studies with larger samples are needed to validate the model’s adaptability across different regions and healthcare settings. Second, elderly stroke patients were not included, and the intervention’s effectiveness for this population (with distinct psychological needs such as fear of mortality) requires further exploration. Third, we did not assess the independent contributions of each PERMA element, which could be addressed in future factorial design studies. Conclusion The stroke-adapted PERMA intervention—grounded in positive psychology and tailored to rehabilitation needs—effectively improves SWB and PTG in young and middle-aged stroke patients. By linking psychological enhancement to functional recovery, it addresses the unique psychological distress of this population and boosts rehabilitation motivation. Future research could refine the intervention’s duration and intensity for different stroke severities, and explore its application in community-based rehabilitation settings to benefit more patients. Declarations Conflicts of Interest The authors declare that they have no conflicts of interest. Ethics approval and consent to participate Firstly, in this study, all methods used by the researcher throughout the questionnaire survey of the study participants were carried out in accordance with the relevant guidelines and regulations. Secondly, this study was approved by the Clinical Research Ethics Committee of the Shenzhen Second People's Hospital (approval number: 2022038004-FS01) and all experimental protocols were approved by the Clinical Research Ethics Committee of the Shenzhen Second People's Hospital. The clinical trial was registered with the Chinese Clinical Trials Registry (ChiCTR2200060103, First Posted date: 18/05/2022) and certified that the study was conducted in accordance with the ethical standards set out in the 1964 Declaration of Helsinki. Finally, all participants in this study were young and middle-aged and had normal consciousness and cognitive ability, and all subjects gave their informed consent and signed a written informed consent form. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Funding This work was supported by Metallurgical Safety and Health Branch of the Chinese Society for Metals ID (jkws202537). A Study on Early Identification and Intervention Pathways for Frailty in Elderly Stroke Patients Based on Comprehensive Geriatric Assessment Technology Author’s contributions XY contributed to the drafting of the manuscript; JK, YZ, HL, and RZ contributed to the data collection and intervention; CY, RZ, HL, and JK contributed to the analysis and interpretation of the data; XY and ZZ contributed to the conception and critical revision of the manuscript; ZZ approved the final version of the submitted manuscript. Acknowledgements The research team extends its gratitude to all patients for their cooperation. References Boot E, Ekker M S, Putaala J, et al. 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The relationship between music references and positive emotions, subjective well-being and life satisfaction among medical students[J]. Chinese Journal of Medical Education and Exploration, 2018, 17(01): 65-71. Wang J, Chen Y, Wang YB, et al. Revision and reliability analysis of the Posttraumatic Growth Assessment Scale[J]. Journal of Nursing, 2011, 26(14): 26-28. Zhang Y, Zhang GF, Zhang YL, et al. Effects of self-determination theory of rehabilitation intervention on self-care ability and subjective well-being of stroke patients[J]. Chinese Journal of Health Psychology, 2022, 30(06): 872-876. Slavin S J, Schindler D, Chibnall J T, et al. PERMA: a model for institutional leadership and culture change[J]. Academic Medicine: Journal of the Association of American Medical Colleges, 2012, 87(11): 1481. Wang J, Wang Y, Zhang HJ, et al. Effect of psychological interventions of focal resolution model on disability acceptance in ischemic stroke patients[J]. Chinese Journal of Modern Nursing, 2022, 28(31): 4399-4403. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 16 Dec, 2025 Reviews received at journal 16 Dec, 2025 Reviews received at journal 15 Dec, 2025 Reviewers agreed at journal 26 Nov, 2025 Reviewers agreed at journal 25 Nov, 2025 Reviewers invited by journal 25 Nov, 2025 Editor invited by journal 24 Nov, 2025 Editor assigned by journal 24 Nov, 2025 Submission checks completed at journal 22 Nov, 2025 First submitted to journal 22 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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2","display":"","copyAsset":false,"role":"figure","size":54189,"visible":true,"origin":"","legend":"\u003cp\u003eGraph of SWB scores over time\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8074453/v1/a9c8f5310c63957d1c832f6c.png"},{"id":97128019,"identity":"709d7d71-f048-42a5-93d1-8c38ed4374ed","added_by":"auto","created_at":"2025-12-01 08:33:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":74920,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8074453/v1/d9e0a948978f0e5a93452b88.png"},{"id":97248983,"identity":"2b5af1ef-fc3e-4025-88e2-884d6cafd4d9","added_by":"auto","created_at":"2025-12-02 13:09:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1752410,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8074453/v1/9e49297f-04b8-42b4-ab3f-5baa0bbc9c9b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effect of PERMA model-Based Psychological Intervention on Subjective Well-Being and Post-Traumatic Growth levels in young and middle-aged Stroke Patients During Rehabilitation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStroke is the leading cause of disability among young and middle-aged adults \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e, with its incidence showing a global younger trend \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Beyond motor dysfunction and functional impairments, these patients often face rehabilitation-specific psychological distress\u0026mdash;such as anxiety from slow functional recovery, despair over disrupted career/family roles, and low self-efficacy due to dependence \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Unlike general psychological problems, their emotional barriers are closely tied to rehabilitation progress, making it critical to integrate psychological support into physical rehabilitation. Positive emotions have been shown to enhance rehabilitation compliance, accelerate motor function recovery, and reduce post-stroke depression, highlighting the necessity of targeted psychological interventions \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSubjective well-being (SWB), a core construct in positive psychology, refers to an individual\u0026rsquo;s positive evaluation of life quality based on personal criteria\u0026mdash;for young and middle-aged stroke patients, this is specifically linked to functional recovery, independent daily living, and reintegration into family/social roles \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Studies show 76.58% of stroke patients have moderate-to-low SWB, primarily driven by frustration with rehabilitation setbacks and fear of long-term disability \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Guiding these patients to recognize their residual strengths and leveraging positive emotions to address rehabilitation-related distress is key to improving SWB, which in turn promotes adherence to rehabilitation exercises and social participation \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn 1995, Tedeschi et al. \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e introduced the term \"post traumatic growth (PTG)\" and defined it as positive psychological changes experienced after struggling with traumatic events. A growing body of research has found that individuals experience positive psychological changes in addition to negative psychological changes after a stressful event, i.e., positive psychological changes\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. A longitudinal qualitative study has confirmed that stroke patients can undergo PTG \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e, but young and middle-aged patients often show lower PTG levels due to unmet psychological needs during rehabilitation \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Previous studies have shown that positive psychological changes not only complement physical recovery but also modify health behaviors \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e and facilitate the transition from hospital to home life \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHowever, there is a paucity of interventional research focusing on the rehabilitation-specific psychological needs of young and middle-aged stroke patients. Most existing psychological interventions for stroke patients are deficit-focused (e.g., addressing depression/anxiety), while neglecting the cultivation of positive traits conducive to long-term recovery. The PERMA model \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e, originating from positive psychology, This study envisions integrating the model with core issues during the rehabilitation phase of young and middle-aged stroke patients, achieving precision in rehabilitation support through targeted adaptation of five key elements: Positive emotions (P) tied to rehabilitation milestones (e.g., joy from independent walking), Engagement (E) in functional recovery activities (e.g., \"flow\" during hand function training), Relationships (R) with family/recovered peers (e.g., mutual support in rehabilitation), Meaning (M) in post-stroke life (e.g., redefining self-worth beyond pre-stroke roles), and Achievement (A) in functional gains (e.g., mastering self-care skills). Unlike its application in neurodevelopmental or educational settings, the PERMA model in this study is tailored to address stroke-specific challenges\u0026mdash;such as adapting communication for dysarthria patients and aligning \"Achievement\" with rehabilitation goals.\u003c/p\u003e\u003cp\u003eWhile the PERMA model has demonstrated efficacy in cancer patients\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, healthcare workers \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e, college students\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e, and psychiatric patients\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e,its adaptation and application in the acute rehabilitation phase of young and middle-aged stroke patients remain understudied. This study fills this gap by developing a stroke-adapted PERMA intervention program, which aims to tap into patients\u0026rsquo; positive emotions, stimulate intrinsic motivation for recovery, and ultimately improve their SWB and PTG. The goal is to help young and middle-aged stroke patients achieve physical-psychological adaptation, enhance rehabilitation motivation, and facilitate their return to family and society.\u003c/p\u003e"},{"header":"Research Subjects and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e1.1 Research Subjects\u003c/h2\u003e\u003cp\u003eThis study employed a randomized controlled trial design, enrolling young and middle-aged stroke patients hospitalized in the Department of Rehabilitation Medicine at a Grade III Class A hospital in Shenzhen, Guangdong Province, between December 1, 2022, and June 30, 2023.\u003cb\u003eInclusion criteria\u003c/b\u003e: patients who also met the following conditions: (1) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years and \u0026lt;\u0026thinsp;65 years\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e (2) meeting the 2019 Chinese major cerebrovascular disease diagnosis points\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. (3) stable disease; (4) modified Rankin Scale (mRS) score\u0026thinsp;\u0026ge;\u0026thinsp;3\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e ; (5) normal cognition; (6) informed consent to participate in this study. \u003cb\u003eExclusion criteria\u003c/b\u003e: Patients with one of the following conditions (1) patients with other major concomitant diseases, such as heart failure, respiratory failure, malignancy, severe trauma, and other critical illnesses; (2) patients who are participating in other studies. \u003cb\u003eWithdrawal criteria\u003c/b\u003e: patients with one of the following conditions: (1) patients who were unable to participate in the subject study due to disease regression; (2) patients who voluntarily requested to withdraw from the study due to personal reasons; (3) patients who were lost to follow-up.\u003c/p\u003e\u003cp\u003eThis clinical trial was registered at the Chinese Clinical Trial Registry (ChiCTR2200060103, First Posted date: 18/05/2022).\u003c/p\u003e\u003cp\u003eGrouping was performed using a computer-generated random number table method: a statistician not involved in the study implementation generated a random sequence. Patients were sequentially assigned to either the control group or the intervention group based on their admission order. Allocation was concealed using sealed envelopes, ensuring that neither the researchers, patients, nor evaluators were aware of the group assignments.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003e1.2 Research Methodology\u003c/b\u003e\u003c/h2\u003e\u003cdiv id=\"Sec5\" class=\"Section3\"\u003e\u003ch2\u003e\u003cb\u003e1.2.1 Establishment of the subject group\u003c/b\u003e\u003c/h2\u003e\u003cp\u003eAll members of the group received uniform training and a division of responsibilities. There is one researcher mentor (a nursing expert in the field of chronic diseases), one national level 2 psychological counselor, two rehabilitation specialist nurses (intermediate level or above), one rehabilitation physician\u003c/p\u003e\u003cp\u003e(intermediate level or above), one rehabilitation therapist, and two graduate students in the program. The supervisor is responsible for the overall design of the program and quality control; the counselor is involved in the program design and training of the guiding language; the rehabilitation physician is responsible for the assessment of the disease; the rehabilitation therapist is responsible for the rehabilitation guidance; the rehabilitation specialist nurse is responsible for the routine care; and the two postgraduate students are responsible for the implementation of the program, including sending and receiving questionnaires, data statistical analysis, and thesis writing with the assistance of other members of the subject group.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003ch2\u003e1.2.2 Sample size calculation\u003c/h2\u003e\u003cp\u003eBy reviewing the literature, the subjective well-being score was 36.20\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;2.84 in the intervention group and 33.41\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;2.74 in the control group based on the results of an experimental study in the stroke patient category\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e, the degree of certainty (Power\u0026thinsp;=\u0026thinsp;1-β)\u0026thinsp;=\u0026thinsp;90%, and the significance level of two-sided\u0026thinsp;=\u0026thinsp;0.05 were set, and the total sample size was calculated using G*Power 3.1 software. It was 110 cases, and at a 20% shedding rate, 132 cases should be included, 66 cases each in the intervention and control groups.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e1.2.3 Constructing an intervention program\u003c/h2\u003e\u003cp\u003e The preliminary draft of the intervention program was formed through the results of the preliminary status survey combined with the literature review and the study of the PERMA model theory. To ensure the scientificity and feasibility of the intervention protocol, seven experts were invited to consult through face-to-face meetings, and the entries and contents of the protocol were improved and modified according to the experts' suggestions. In order to ensure the practicality and effectiveness of the program, 10 young and middle-aged stroke patients who met the inclusion and exclusion criteria were selected for pretesting, and the problems that occurred in the pretest were analyzed and revised to form the final draft of the PERMA model psychological intervention program.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e1.2.4 Implementation method\u003c/h2\u003e\u003cdiv id=\"Sec9\" class=\"Section4\"\u003e\u003ch2\u003e1.2.4.1 Control group\u003c/h2\u003e\u003cp\u003eThe control group received conventional rehabilitation treatment and care, including stroke disease knowledge education, prevention of common post-stroke complications, placement of an anti-spasticity position, rehabilitation exercise, medication instruction, rehabilitation compliance education, dietary instruction, psychological care, and discharge instruction.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section4\"\u003e\u003ch2\u003e1.2.4.2 Intervention group\u003c/h2\u003e\u003cp\u003eThe intervention group was based on the PERMA model of psychological intervention for young stroke patients in the control group, with two graduate students and other members of the group assisting in a one-on-one approach. The order of the topics and the length of the intervention were flexibly adjusted according to the patient's needs and mastery, and the interval between the two interviews was 2\u0026ndash;4 days. The specific intervention plan is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePsychological intervention program for young stroke patients in the PERMA model\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubject\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIntervention content\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSuggested Guidance Language\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1st\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnderstanding Stroke\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. Self-introduction of the subject group; introduction of the department staff and environment.\u003c/p\u003e\u003cp\u003e2. Explain the knowledge about stroke and rehabilitation to enhance the patient's confidence in the rehabilitation treatment of the disease.\u003c/p\u003e\u003cp\u003e3. Collect information about the patient, including the patient's basic information, disease information, psychological status, the degree of harmony with family members, and the degree of support from family members for the patient.\u003c/p\u003e\u003cp\u003e4. Establish a trusting relationship with the patient and leave contact information, such as a telephone number and WeChat, with each other. (e.g., patients with language dysfunction can communicate with each other through gestures, writing, or typing.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1. Do you know about stroke?\u003c/p\u003e\u003cp\u003e2. You can tell me what questions you have about stroke rehabilitation.\u003c/p\u003e\u003cp\u003e3. I will be happy to help you if you are confused about the psychological aspects.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2nd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiscovering positive psychological qualities\u003c/p\u003e\u003cp\u003e(P)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. Use the intake talk technique to understand the psycho-emotional state of the patient.\u003c/p\u003e\u003cp\u003e2. Analyze the psychological problems caused by the stroke for the patient and tap into the positive aspects of things.\u003c/p\u003e\u003cp\u003e3. Use non-verbal communication such as eye contact and touch to empathize with the patient and give encouragement and emotional support.\u003c/p\u003e\u003cp\u003e4. Encourage patients to share positive and happy things about themselves to tap into their positive psychological qualities.\u003c/p\u003e\u003cp\u003e5. For patients aged 18\u0026ndash;44 years old with a higher monthly income before the disease, increase the communication time or frequency appropriately according to the talks.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1. You can think of me as your friend (a patient of similar age) or your junior (an older patient) and share your happy things with me.\u003c/p\u003e\u003cp\u003e2. It is reasonable for you to have such thoughts, and I can understand your feelings.\u003c/p\u003e\u003cp\u003e3. I can see that you are in a good state, for example, you just mentioned..., which is very positive.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3rd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCultivate\u003c/p\u003e\u003cp\u003epositive\u003c/p\u003e\u003cp\u003eemotions\u003c/p\u003e\u003cp\u003e (P)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. Start the interview around the concept and role of positive emotion and talk about the benefits of positive emotion and optimism for the disease.\u003c/p\u003e\u003cp\u003e2. Cultivate positive thinking and a positive attitude towards stroke events. Recommend watching movies with positive themes, such as \"How Steel is Made\" and \"When Happiness Comes Knocking,\" so that patients can cooperate with treatment and rehabilitation with positive emotions and increase the initiative of participation.\u003c/p\u003e\u003cp\u003e3. Provide patients with the opportunity to watch the stroke promotional film \"Time\u0026thinsp;=\u0026thinsp;Brain\" and stroke rehabilitation case videos.\u003c/p\u003e\u003cp\u003e4. Give recognition and praise to patients for their positive emotions.\u003c/p\u003e\u003cp\u003e5. For patients with dysarthria, practice pronunciation and mobilize positive emotions through vocalization.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1. If you are willing to share, I would love to hear some positive and happy things about yourself.\u003c/p\u003e\u003cp\u003e2. Think back to a time when you had a difficult event in your life, and let's try to analyze it from the positive side.\u003c/p\u003e\u003cp\u003e3. According to the stroke propaganda film, people can recover well with active treatment and rehabilitation exercises.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGratitude Exercise\u003c/p\u003e\u003cp\u003e (P)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. Talk about the positive effects of learning to be grateful for improving emotional states and enhancing the sense of well-being in life.\u003c/p\u003e\u003cp\u003e2. Focus on the events in life and during hospitalization for which one needs to be grateful as an entry point, and guide the patient to recall them together.\u003c/p\u003e\u003cp\u003e3. Encourage patients to pay attention to the good and happy things in their lives and record three good things that happen every day before going to bed in the form of a diary or a circle of friends, preferably for 21 days, or the patient can dictate them and the family can record them for them.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1. You think of things and people that have touched you in the past or during your hospital stay, and please tell us if it is convenient to share.\u003c/p\u003e\u003cp\u003e2. You can write a letter of appreciation, edit a WeChat message, or record a voicemail and send it to the person you appreciate.\u003c/p\u003e\u003cp\u003e3. You can keep a diary, send a WeChat friend circle, or any other form of record the happy and beautiful things that happen to you every day.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEngagement Exercise\u003c/p\u003e\u003cp\u003e(E)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. Explain the definition and positive effects of the \"flow\" state.\u003c/p\u003e\u003cp\u003e2. According to the rehabilitation needs of the patient, the rehabilitation therapist will assess the patient's condition and then perform rehabilitation activities together under the guidance of the rehabilitation therapist. Let the patient engage in positive emotions and experience a sense of well-being. For example, practice rehabilitation exercises for hand functions such as \"picking up beans, screwing nuts, and buttoning\".\u003c/p\u003e\u003cp\u003e3. Discuss with patients their hobbies and interests. Combine the patient's condition and hobbies to develop activities. For example, playing chess, reading books, listening to music, etc. After the patient enters the state of \"flow\", the patient's attention is distracted from the disease and the body and mind are relaxed, which is conducive to positive psychological changes.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1. We can communicate about what hobbies or things you are more interested in.2. How do you feel when we develop rehabilitation activities and do rehabilitation exercises together? You can communicate with me anytime if you have any ideas or suggestions.3. Now imagine that you are at home, sitting in your study reading your favorite book and listening to your favorite song.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFoster Positive Interpersonal Relationships\u003c/p\u003e\u003cp\u003e (R)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. Talk about positive communication skills and how good communication promotes interpersonal relationships.\u003c/p\u003e\u003cp\u003e2. Communicate around interpersonal relationships, give examples of the physical and psychological benefits of good interpersonal relationships, and guide patients to realize the importance of interpersonal relationships.\u003c/p\u003e\u003cp\u003e3. Conduct role plays so that patients can appreciate positive communication and experience the joy of interaction.\u003c/p\u003e\u003cp\u003e4. Play small games with family members, patients, and friends, such as \"finger catching,\"\u0026nbsp;if the rehabilitation physician's assessment of their condition permits.\u003c/p\u003e\u003cp\u003e5. Invite stroke patients who have recovered well to communicate with each other.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.Tell about someone you like or something tough or happy you experienced together.\u003c/p\u003e\u003cp\u003e2. I just heard you discussing with a patient lower-limb exercises; it's good to communicate and learn more.\u003c/p\u003e\u003cp\u003e3. XXX is in bed, he is cheerful, optimistic, and engaged in positive rehabilitation exercises; his recovery is good; you can communicate more freely.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePerception Meaning\u003c/p\u003e\u003cp\u003e(M)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. Discuss with patients the meaning of life, the meaning of living, the meaning of loved ones, and the meaning of health, and guide them to establish a correct view of meaning. A positive view of meaning will enable patients to develop a sense of mission and direction.\u003c/p\u003e\u003cp\u003e2. Discuss the importance of each person's role in the family and the meaning of that role to loved ones, friends, and society.\u003c/p\u003e\u003cp\u003e3. Stimulate the patient's sense of responsibility to loved ones and society.\u003c/p\u003e\u003cp\u003e4. Instruct patients to deal with the ups and downs of life with optimism. As in the case of stroke events, learning to grow in adversity is also the meaning of life.\u003c/p\u003e\u003cp\u003e5. Guide patients to self-evaluate and talk about their interpretation of meaning.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1. Talk about something meaningful in your life or work.\u003c/p\u003e\u003cp\u003e2. I see that your family members are very patient with you; they need you very much, and you have a very important meaning to them.\u003c/p\u003e\u003cp\u003e3. In fact, everyone's life will encounter some unsatisfactory things, so believe that the rainbow will appear after the storm.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExperience the achievement\u003c/p\u003e\u003cp\u003e (A)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. Conduct an interview with the patient about achievement and explain the positive psychological effects of achievement.\u003c/p\u003e\u003cp\u003e2. Develop a \"rehabilitation prescription\" with the patient and, under the guidance of the rehabilitation therapist, help the patient achieve a sense of accomplishment through functional rehabilitation exercises.\u003c/p\u003e\u003cp\u003e3. Set achievable goals and encourage the patient to use their strengths under the guidance of the rehabilitation therapist to gain a sense of accomplishment. For example, dressing and undressing by themselves, eating by themselves, going to the bathroom, etc. within the limits of their ability.\u003c/p\u003e\u003cp\u003e4. Promptly acknowledge the patient's achievements and give recognition and praise even for the accomplishment of small goals.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1. I saw you exercising on your own in bed; that's great!\u003c/p\u003e\u003cp\u003e2. The rehabilitation physician even complimented you on your progress. You are doing great; keep up the good work!\u003c/p\u003e\u003cp\u003e3. Rehabilitation is very crucial in the early stages, and as long as you stick to it every day, a virtuous cycle will be formed.\u003c/p\u003e\u003cp\u003e4. What do you have in mind for the future? Now is the time for you to plan.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e1.3 Data collection\u003c/h2\u003e\u003cp\u003eAssessments were made by scale before the intervention, immediately after the intervention, 1 month after the intervention, and 3 months after the intervention. Inpatients were assessed in the rehabilitation medicine ward or health education room, and discharged patients were assessed by telephone or face-to-face (face-to-face assessments were conducted at the stroke follow-up clinic).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003e1.4 Evaluation tools\u003c/b\u003e\u003c/h2\u003e\u003cp\u003e(1)General information questionnaire\u003c/p\u003e\u003cp\u003e The investigator's own design included two sections: demographic and sociological information (gender, age, marital status, education, occupation, place of residence, monthly income, type of health insurance, smoking, alcohol consumption, primary caregiver) and disease-related information (comorbid chronic diseases, number of strokes, family genetic history).\u003c/p\u003e\u003cp\u003e(2)Subjective well-being༈SWB༉\u003c/p\u003e\u003cp\u003eCampbell created it in 1976, and scholar Xiaodong Fan translated it into Chinese \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. It consists of two parts: the overall affective index scale (8 items) and the overall life satisfaction questionnaire (1 item). The scale is based on a 7-point Likert scale. The mean score of the overall affective index scale and the score of the life satisfaction questionnaire (with a weight of 1.1) were added to the total score. 2.1-6 scores were considered low happiness, 6.1\u0026ndash;10 scores were moderate happiness, and 10.1\u0026ndash;14.7 scores were high happiness, and the Cronbach's coefficient of the scale was 0.90.\u003c/p\u003e\u003cp\u003e(3)Post-Traumatic Growth༈PTG༉\u003c/p\u003e\u003cp\u003eThe scale was designed and developed by the American scholar Tedeschi et al. \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, and Chinese scholars Wang Ji et al. \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e Chineseized it. It has 5 dimensions and 20 items, which are used to assess the level of post-traumatic growth of individuals, including relationships with others (7 items), new possibilities (5 items), personal strength (4 items), spiritual change (1 item), and appreciation of life (3 items), with each item rated 0\u0026ndash;5, and the total score ranging from 0 to 100. Higher scores indicate higher levels of post-traumatic growth. Cronbach's coefficient of consistency reliability ranged from 0.611 to 0.874 for each dimension and total scale.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003e1.5 Statistical methods\u003c/b\u003e\u003c/h2\u003e\u003cp\u003eAll data in this study were statistically analyzed using \u003cem\u003eSPSS\u003c/em\u003e 25.0 software at the level of significance (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e(1) Count data were statistically described by the number of cases, and measurement data were statistically described by the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/p\u003e\u003cp\u003e(2) The chi-square test was used to compare the general information of the two groups, and the rank sum test was used to compare the rank information.\u003c/p\u003e\u003cp\u003e(3) The data followed a normal distribution, the variance was unity, and an independent sample t-test was used to compare two groups at the same point in time.\u003c/p\u003e\u003cp\u003e(4) Repeated measures ANOVA was used to compare changes at different time points and to observe the interaction effects between groups over time.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e2.1 participation Study population\u003c/h2\u003e\u003cp\u003eA convenience sampling method was used to select 132 middle-aged and young stroke patients who were admitted to the rehabilitation medicine department of a tertiary care general hospital in Shenzhen, Guangdong Province, China, and met the inclusion and exclusion criteria. 66 patients from 02\u0026ndash;05, 2022 were used as the control group, and 66 patients from 04\u0026ndash;07, 2022, were used as the intervention group. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the flow of participants through the trial, and the final valid sample was 120 cases with an effective rate of 90.91% (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003e2.2 Comparison of general information between the two groups of patients\u003c/b\u003e\u003c/h2\u003e\u003cp\u003eThe differences between the general data of the two groups of patients were not statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) and were comparable, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of general information between the two groups of patients (N\u0026thinsp;=\u0026thinsp;120)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProjects\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClassification\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl group\u003c/p\u003e\u003cp\u003e(60)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntervention group(60)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTest-\u003c/p\u003e\u003cp\u003evalue\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.682\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.409\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge(years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u0026ndash;44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.063\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.803\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45\u0026ndash;64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMarital\u003c/p\u003e\u003cp\u003eStatus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.342 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.599\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnmarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.372\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.710\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUniversity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOccupation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.969 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.174\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBusinessmen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFarmer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePlace of residence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eShenzhen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.711\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.399\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-Shenzhen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eMonthly\u003c/p\u003e\u003cp\u003eIncome\u003c/p\u003e\u003cp\u003e(\u0026yen;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;1000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-1.278\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.201\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1000\u0026ndash;2999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3000\u0026ndash;4999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5000\u0026ndash;10000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;10000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eInsurance Type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban Insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.768\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.056\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural Insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-funded\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSmoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo smoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.834\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.361\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSmoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDrinking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo drinking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.656\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.198\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDrinking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eComorbid chronic diseases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.043 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.835\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eNumber of strokes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-1.655\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.098\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003ePrimary Caregiver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSpouse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.710 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.701\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRelatives\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCaregiver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGenetic history\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.853 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.356\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: a represents the \u003cem\u003eX2 value\u003c/em\u003e and b represents the \u003cem\u003ez\u003c/em\u003e value.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003e2.2 Comparison of baseline data scores between the two groups of patients before the intervention\u003c/b\u003e\u003c/h2\u003e\u003cp\u003eThe baseline data scores were not significantly different between the two groups before the intervention (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) and were comparable, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of baseline data scores between the two groups of patients before the intervention (points, X\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProjects\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAverage value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et-value\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSubjective well-being(SWB)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl group (60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e7.53\u0026thinsp;\u0026plusmn;\u0026thinsp;2.885\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.459\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.647\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention group (60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e7.78\u0026thinsp;\u0026plusmn;\u0026thinsp;2.978\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePost-Traumatic Growth Inventory(PTGI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl group (60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e43.81\u0026thinsp;\u0026plusmn;\u0026thinsp;15.977\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.419\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.676\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention group (60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e45.34\u0026thinsp;\u0026plusmn;\u0026thinsp;22.944\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003e2.3 Comparison of subjective well-being scores between the two groups after the intervention\u003c/b\u003e\u003c/h2\u003e\u003cp\u003eThe comparison of well-being scores at each time point after the intervention was statistically higher in the intervention group than in the control group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). A repeated measures ANOVA was performed on the well-being scores of the two groups at different times, and the time effect (\u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;616.854, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), the between-group effect (\u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12.452, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and the interaction effect between the two groups (\u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;47.246, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were all statistically significant, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The subjective well-being scores of the patients in both groups changed over time and showed an increasing trend, but the increase in the intervention group was more obvious than that in the control group, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eComparison\u003c/b\u003e of subjective well-being scores between the two groups after the intervention\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost-intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePost-intervention 1 month\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePost-intervention 3 months\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003csub\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sub\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eFb\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003eFc\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003egroup\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.53\u0026thinsp;\u0026plusmn;\u0026thinsp;2.885\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.82\u0026thinsp;\u0026plusmn;\u0026thinsp;2.864\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.838\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.18\u0026thinsp;\u0026plusmn;\u0026thinsp;2.876\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1309.157\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e13.354\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e635.436\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntervention group (n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.78\u0026thinsp;\u0026plusmn;\u0026thinsp;2.978\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.19\u0026thinsp;\u0026plusmn;\u0026thinsp;2.952\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.83\u0026thinsp;\u0026plusmn;\u0026thinsp;2.720\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.24\u0026thinsp;\u0026plusmn;\u0026thinsp;2.603\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.459\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-2.584\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-5.572\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-6.099\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.647\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.011\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eNote: Fa represents the time effect; Fb represents the between-group effect;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eFc represents the interaction effect\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Comparison of post-traumatic growth scores of survivors in the two groups after the intervention\u003c/h2\u003e\u003cp\u003eThe post-traumatic growth scores were higher in the intervention group compared to the control group at each time point after the intervention, and the difference was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The post-traumatic growth scores of the two groups at different times were analyzed by repeated measures ANOVA, and the time effect (F\u0026thinsp;=\u0026thinsp;885.384, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), between-group effect (F\u0026thinsp;=\u0026thinsp;10.337, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and interaction effect (F\u0026thinsp;=\u0026thinsp;221.684, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were all statistically different, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. The post-traumatic growth levels of patients in both groups showed an increasing trend, but the increase was more pronounced in the intervention group than in the control group, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eComparison of post-traumatic growth scores between the two groups after the intervention (points, X\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost-intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePost-intervention\u003c/p\u003e\u003cp\u003e1 month\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePost-intervention\u003c/p\u003e\u003cp\u003e3 months\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eFa\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eFb\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003eFc\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003egroup\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43.81\u0026thinsp;\u0026plusmn;\u0026thinsp;15.977\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46.68\u0026thinsp;\u0026plusmn;\u0026thinsp;15.873\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48.75\u0026thinsp;\u0026plusmn;\u0026thinsp;15.274\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e51.92\u0026thinsp;\u0026plusmn;\u0026thinsp;15.397\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e885.384\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e10.337\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e221.684\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntervention group (n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45.34\u0026thinsp;\u0026plusmn;\u0026thinsp;22.944\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56.55\u0026thinsp;\u0026plusmn;\u0026thinsp;22.808\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62.28\u0026thinsp;\u0026plusmn;\u0026thinsp;21.719\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e69.23\u0026thinsp;\u0026plusmn;\u0026thinsp;20.086\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003et-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.419\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-2.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-3.948\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-5.300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.676\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eNote: Fa represents the time effect; Fb represents the between-group effect;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eFc represents the interaction effect\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eYoung and middle-aged individuals stand at a pivotal juncture of life, where they juggle multiple core roles\u0026mdash;serving as vital driving forces behind social progress and economic prosperity. This stage is marked by their pursuit of career milestones, the realization of personal aspirations, and the accumulation of life achievements, making it a period of immense potential for self-fulfillment and value creation. However, the abrupt onset of stroke shatters this stable life trajectory: beyond the physical impairments such as motor dysfunction or speech disorders, it brings a heavy psychological toll. Patients often grapple with the loss of self-efficacy, anxiety about unfulfilled family and social obligations, and despair over disrupted life plans\u0026mdash;emotional struggles that can erode their willingness to engage in rehabilitation and dampen their enthusiasm for daily activities. In this context, targeted interventions aimed at nurturing their subjective well-being and fostering post-traumatic growth are not merely timely but indispensable. By addressing the psychological void left by the disease, these interventions can help patients rebuild resilience, rediscover a sense of purpose amid adversity, and rekindle their intrinsic drive to persist in rehabilitation training and actively participate in daily life. In turn, this not only accelerates their physical recovery but also supports their successful reintegration into family life and society, allowing them to reclaim their roles as contributors to their loved ones and communities.\u003c/p\u003e\u003cp\u003eThis study confirms that the stroke-adapted PERMA intervention can effectively improve the subjective well-being (SWB) of young and middle-aged stroke patients, which is consistent with the findings of Zhang Ying et al. \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e on the subjective well-being of 80 stroke patients through self-determination theory.The PERMA model is a positive psychological model that promotes individual flourishing and is more relevant for subjective well-being interventions\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. The results of this study showed that the PERMA-based psychological intervention program increased the subjective well-being score of the intervention group from 7.78\u0026thinsp;\u0026plusmn;\u0026thinsp;2.978 to 11.24\u0026thinsp;\u0026plusmn;\u0026thinsp;2.603, i.e., from moderate to high levels of well-being, 3 months after the intervention, while the score of the control group was 8.18\u0026thinsp;\u0026plusmn;\u0026thinsp;2.876, still moderate well-being, with no significant change. The PERMA model in this study achieves SWB improvement by deeply integrating with stroke rehabilitation needs\u0026mdash;specifically through three scenario-adapted mechanisms:\u003c/p\u003e\u003cp\u003ePositive emotions (P) linked to rehabilitation progress: Instead of generic positive thinking guidance, we anchored emotional reinforcement to tangible functional gains (e.g., praising patients for independently buttoning clothes or walking 50 meters unassisted). This targeted recognition directly alleviated patients\u0026rsquo; anxiety about dependence and reinforced the link between \u0026ldquo;emotional positivity\u0026rdquo; and \u0026ldquo;rehabilitation progress,\u0026rdquo; driving sustained engagement;\u003c/p\u003e\u003cp\u003eEngagement (E) in function-focused \u0026ldquo;flow\u0026rdquo; activities: We designed immersive rehabilitation tasks (e.g., screwing nuts to improve hand dexterity, chess-playing to enhance cognitive-motor coordination) that align with patients\u0026rsquo; hobbies and rehabilitation goals. When patients entered the \u0026ldquo;flow\u0026rdquo; state during these activities, their attention shifted from pain and frustration to skill mastery, reducing psychological distress while promoting functional recovery;\u003c/p\u003e\u003cp\u003eRelationships (R) reinforced by family-involved rehabilitation: We organized small-scale family rehabilitation games (e.g., \u0026ldquo;finger catching\u0026rdquo; with spouses) and peer sharing sessions with recovered stroke patients. These interactions provided patients with practical rehabilitation role models and emotional support from loved ones, addressing the \u0026ldquo;social isolation\u0026rdquo; common in stroke recovery and enhancing their sense of belonging.\u003c/p\u003e\u003cp\u003eThis study concluded that psychological interventions based on the PERMA model can improve post-traumatic growth (PTG) levels in young and middle-aged stroke patients, which is consistent with the findings of Wang Juan et al.\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003eon post-traumatic growth levels in 100 stroke patients through a focal resolution model. Post-traumatic growth (PTG) is a positive emotional change experienced by individuals in the face of a traumatic life event that helps to improve mental health and promote healthy behaviors. In this study, by tapping into the positive qualities of the patients and better enhancing their positive emotions, the patients' post-traumatic growth scores improved from 45.34\u0026thinsp;\u0026plusmn;\u0026thinsp;22.944 before the intervention to 69.23\u0026thinsp;\u0026plusmn;\u0026thinsp;20.086 at 3 months after the intervention, while the control group scored 51.92\u0026thinsp;\u0026plusmn;\u0026thinsp;15.397 at 3 months after the intervention, which was not a significant change. This outcome differs from the PTG promotion in non-rehabilitation populations \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e in that our intervention ties growth to stroke-specific recovery needs:\u003c/p\u003e\u003cp\u003eMeaning (M) reconstructed around post-stroke roles: Discussions focused on \u0026ldquo;redefining self-worth in family and society post-stroke\u0026rdquo; (e.g., \u0026ldquo;being a parent who can help with children\u0026rsquo;s homework\u0026rdquo; or \u0026ldquo;returning to part-time work\u0026rdquo;) rather than abstract \u0026ldquo;life meaning.\u0026rdquo; This concrete role reconstruction resonated with patients\u0026rsquo; urgent need to reaffirm their value, stimulating their sense of responsibility and resilience.\u003c/p\u003e\u003cp\u003eAchievement (A) through incremental rehabilitation goals: We co-designed \u0026ldquo;stepwise rehabilitation prescriptions\u0026rdquo; with patients and therapists (e.g., \u0026ldquo;independent toileting within 2 weeks,\u0026rdquo; \u0026ldquo;dressing without assistance in 1 month\u0026rdquo;). Each small goal\u0026rsquo;s achievement provided patients with a tangible sense of progress, counteracting the frustration of slow recovery and fostering a \u0026ldquo;growth mindset\u0026rdquo; toward post-stroke challenges.\u003c/p\u003e\u003cp\u003eAdaptations for stroke-related impairments: For patients with dysarthria, we integrated vocalization training with positive feedback (e.g., \u0026ldquo;your pronunciation is clearer than last week\u0026rdquo;) to link speech rehabilitation with emotional enhancement, ensuring PTG promotion was not hindered by physical limitations.\u003c/p\u003e\u003cp\u003eNotably, this study differs from positive psychology interventions for other populations in two key ways: first, the intervention duration (4 weeks) was aligned with the acute rehabilitation phase of stroke (golden period for functional recovery), rather than long-term support; second, all activities were co-designed with rehabilitation therapists to ensure they complemented physical training (e.g., hand function exercises during \u0026ldquo;Engagement\u0026rdquo; sessions). These adaptations explain why the intervention\u0026rsquo;s effects persisted at 3-month follow-up\u0026mdash;unlike general psychological interventions that may fade over time.\u003c/p\u003e\u003cp\u003eThis study has limitations: First, convenience sampling from a single hospital may limit generalizability; future multi-center studies with larger samples are needed to validate the model\u0026rsquo;s adaptability across different regions and healthcare settings. Second, elderly stroke patients were not included, and the intervention\u0026rsquo;s effectiveness for this population (with distinct psychological needs such as fear of mortality) requires further exploration. Third, we did not assess the independent contributions of each PERMA element, which could be addressed in future factorial design studies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe stroke-adapted PERMA intervention\u0026mdash;grounded in positive psychology and tailored to rehabilitation needs\u0026mdash;effectively improves SWB and PTG in young and middle-aged stroke patients. By linking psychological enhancement to functional recovery, it addresses the unique psychological distress of this population and boosts rehabilitation motivation. Future research could refine the intervention\u0026rsquo;s duration and intensity for different stroke severities, and explore its application in community-based rehabilitation settings to benefit more patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirstly, in this study, all methods used by the researcher throughout the questionnaire survey of the study participants were carried out in accordance with the relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003eSecondly, this study was approved by the Clinical Research Ethics Committee of the Shenzhen Second People\u0026apos;s Hospital (approval number: 2022038004-FS01) and all experimental protocols were approved by the Clinical Research Ethics Committee of the Shenzhen Second People\u0026apos;s Hospital. The clinical trial was registered with the Chinese Clinical Trials Registry (ChiCTR2200060103, First Posted date: 18/05/2022) and certified that the study was conducted in accordance with the ethical standards set out in the 1964 Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eFinally, all participants in this study were young and middle-aged and had normal consciousness and cognitive ability, and all subjects gave their informed consent and signed a written informed consent form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Metallurgical Safety and Health Branch of the Chinese Society for Metals ID (jkws202537). A Study on Early Identification and Intervention Pathways for Frailty in Elderly Stroke Patients Based on Comprehensive Geriatric Assessment Technology\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXY contributed to the drafting of the manuscript; JK, YZ, HL, and RZ contributed to the data collection and intervention; CY, RZ, HL, and JK contributed to the analysis and interpretation of the data; XY and ZZ contributed to the conception and critical revision of the manuscript; ZZ approved the final version of the submitted manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team extends its gratitude to all patients for their cooperation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBoot E, Ekker M S, Putaala J, et al. Ischaemic stroke in young adults: a global perspective[J]. 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Chinese Journal of Medical Education and Exploration, 2018, 17(01): 65-71.\u003c/li\u003e\n\u003cli\u003eWang J, Chen Y, Wang YB, et al. Revision and reliability analysis of the Posttraumatic Growth Assessment Scale[J]. Journal of Nursing, 2011, 26(14): 26-28.\u003c/li\u003e\n\u003cli\u003eZhang Y, Zhang GF, Zhang YL, et al. Effects of self-determination theory of rehabilitation intervention on self-care ability and subjective well-being of stroke patients[J]. Chinese Journal of Health Psychology, 2022, 30(06): 872-876.\u003c/li\u003e\n\u003cli\u003eSlavin S J, Schindler D, Chibnall J T, et al. PERMA: a model for institutional leadership and culture change[J]. Academic Medicine: Journal of the Association of American Medical Colleges, 2012, 87(11): 1481.\u003c/li\u003e\n\u003cli\u003eWang J, Wang Y, Zhang HJ, et al. Effect of psychological interventions of focal resolution model on disability acceptance in ischemic stroke patients[J]. Chinese Journal of Modern Nursing, 2022, 28(31): 4399-4403.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Stroke, PERMA model, Psychological intervention, young and middle-aged, Subjective well-being (SWB), Post traumatic growth (PTG)","lastPublishedDoi":"10.21203/rs.3.rs-8074453/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8074453/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYoung and middle-aged stroke patients face unique rehabilitation-related psychological distress—such as frustration from slow motor function recovery, anxiety about losing family/social roles, and low motivation for long-term rehabilitation—all of which directly hinder physical recovery and post-stroke adaptation. This study developed a rehabilitation-aligned PERMA intervention and evaluated its efficacy in improving subjective well-being (SWB) and post-traumatic growth (PTG) in young and middle-aged stroke patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 120 eligible patients (18–64 years old) were randomized into two groups. The control group received conventional rehabilitation. The intervention group supplemented with 8 structured PERMA-based sessions over 4 weeks—each session designed to address stroke-specific needs. SWB and PTG were assessed at baseline, post-intervention, 1-month, and 3-month follow-ups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSWB scores were significantly higher in the post intervention, 1-month post-intervention, and 3-month post-intervention groups than in the control group (\u003cem\u003et\u003c/em\u003e = 0.011, 0.000, 0.000; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05); PTG scores were also significantly higher at these time points (\u003cem\u003et\u003c/em\u003e = 0.007, 0.000, 0.000; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01). Repeated-measures ANOVAs confirmed statistically significant time-dependent increases in both outcomes for the intervention group (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01), with no such significant trend in the control group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe rehabilitation-aligned PERMA intervention effectively enhances SWB and PTG in young and middle-aged stroke patients during recovery. By integrating positive psychology with functional rehabilitation goals, it addresses the unique psychological needs of this population and provides a feasible, clinically applicable support strategy that complements physical rehabilitation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration \u003c/strong\u003eRegistration number of China Clinical Trials Registration Center: ChiCTR2200060103, First Posted date: 18/05/2022\u003c/p\u003e","manuscriptTitle":"The Effect of PERMA model-Based Psychological Intervention on Subjective Well-Being and Post-Traumatic Growth levels in young and middle-aged Stroke Patients During Rehabilitation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-01 08:33:06","doi":"10.21203/rs.3.rs-8074453/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-16T17:02:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-16T09:07:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-16T02:40:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53422278012887278105366677441863060100","date":"2025-11-26T20:07:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"193965072154196964219910319367740782150","date":"2025-11-25T14:15:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-25T08:17:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-25T04:47:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-24T14:24:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-22T09:03:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-11-22T08:59:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"09df7837-e8b3-48f0-9cfc-cbc13ed445a3","owner":[],"postedDate":"December 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":58724406,"name":"Health sciences/Diseases"},{"id":58724407,"name":"Health sciences/Health care"},{"id":58724408,"name":"Health sciences/Medical research"},{"id":58724409,"name":"Health sciences/Neurology"},{"id":58724410,"name":"Biological sciences/Neuroscience"},{"id":58724411,"name":"Biological sciences/Psychology"},{"id":58724412,"name":"Social science/Psychology"}],"tags":[],"updatedAt":"2026-05-18T06:25:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-01 08:33:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8074453","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8074453","identity":"rs-8074453","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}