Long‐Term Effect of Intensive Education in Patients With First‐Ever Ischemic Stroke

Abstract

Background

This study evaluated the long‐term effects of intensive education on functional recovery and quality of life in patients with first‐ever mild ischemic stroke.

Methods

This propensity score–matched cohort study was conducted within the KOSCO (Korean Stroke Cohort for Functioning and Rehabilitation). Four of 9 institutions participated in the educational intervention substudy, recruiting patients between November 2016 and January 2020. Eligible participants were adults aged 19 to 74 years hospitalized within 7 days of a first‐ever ischemic stroke, with mild neurological deficits (Korean version of National Institutes of Health Stroke Scale score 1–5), who consented to participate in the study. The intervention consisted of 3 structured education sessions delivered over 3 months. Functional and quality‐of‐life outcomes were assessed at baseline and at multiple intervals up to 48 months. A matched control group was selected from the primary KOSCO cohort.

Results

After matching, 138 participants were included in each group. Baseline characteristics were well balanced. Over the 48‐month follow‐up period, the intervention group demonstrated greater improvements in the EuroQol‐5 Dimension (β=−0.005 [95% CI, −0.009 to −0.001]), Geriatric Depression Scale–Short Form (β=0.147 [95% CI, 0.015–0.279]), and modified Rankin Scale (β=11.48 [95% CI, 0.05–22.92]), compared with controls. No significant group‐by‐time interactions were found for other functional measures, including the Functional Independence Measure, Korean version of Modified Barthel Index, Fugl–Meyer Assessment, and Korean Mini‐Mental State Examination.

Conclusions

Structured, intensive, multisession education for patients with first‐ever mild ischemic stroke produced favorable long‐term effects on quality of life, psychological well‐being, and disability, highlighting the value of comprehensive education as part of stroke rehabilitation and secondary prevention.

REGISTRATION

URL: http://cris.nih.go.kr; Unique identifier: KCT0003277.

Nonstandard Abbreviations and Acronyms

EQ‐5D

EuroQol‐5 Dimension

GDS‐SF

The Geriatric Depression Scale–Short Form

K‐NIHSS

Korean version of the National Institutes of Health Stroke Scale

KOSCO

Korean Stroke Cohort for Functioning and Rehabilitation

mRS

modified Rankin Scale

Clinical Perspective.

What Is New?

• This is the first large‐scale, propensity score–matched cohort study to demonstrate that a structured, intensive, 3‐session educational intervention significantly improves long‐term quality of life and psychological well‐being in patients with first‐ever mild ischemic stroke.

• The study shows that intensive, structured education can yield sustained benefits over a 48‐month period.

What Are the Clinical Implications?

• Intensive, structured education should be considered an essential component of comprehensive stroke rehabilitation and secondary prevention, even in patients with mild deficits.

Stroke is the second leading cause of death globally. The prevalence has continued to increase with longer life expectancy and declining mortality rate. ¹ , ² There are 104.2 million patients with stroke worldwide, with more patients with cerebral infarction than those with cerebral hemorrhage. Stroke often leads to serious disabilities; hence, stroke is the third most common cause of disability‐adjusted life years. ³ , ⁴ Therefore, effective management of stroke and its risk factors is essential to reduce long‐term functional impairment and the associated socioeconomic burden among patients and their families.

Patients with stroke experience a variety of neurological symptoms, including motor paralysis, cognitive impairment, aphasia, dysphagia, and balance dysfunction. In addition, poststroke complications such as depression may occur during the recovery phase. These impairments significantly reduce patients' quality of life and lead to limitations in social participation. Furthermore, a decline in quality of life adversely affects not only the patients themselves but also their families.

To minimize disability in the early stages of stroke, critical pathways, clinical practice guidelines, and acute treatment methods, such as pharmacological therapy and interventional procedures, have been developed. Furthermore, evidence‐based clinical guidelines for stroke rehabilitation have been established to promote recovery and facilitate reintegration into the community. ⁵

These guidelines recommend education for patients, families, and caregivers as part of secondary prevention. ⁶ Education should not only deliver information but also provide a 2‐way learning process tailored to patients' and families' needs, covering self‐management of exercise, risk factor control, secondary prevention, nutrition, sleep, medication adherence, emotional adjustment, cognition, communication, and overall health. ⁵ , ⁷

In the KOSCO (Korean Stroke Cohort for Functioning and Rehabilitation) study, the EuroQol‐5 Dimension (EQ‐5D) scores of patients with stroke ranged from 0.4929 to 0.8634 up to 24 months from stroke onset. These values were lower than the average score of 0.9600 observed in healthy individuals aged >40 years and patients with other chronic diseases. The Geriatric Depression Scale–Short Form (GDS‐SF) score was also significantly high in this population. ⁸ These findings indicate that reduced quality of life and elevated depressive symptoms are common after stroke and therefore may influence patients' motivation, engagement, and ability to participate in educational interventions aimed at self‐management and secondary prevention.

The caregivers or family members also experience physical discomfort, psychological distress, hopelessness, and guilt from long‐term care of the patients with stroke with impaired physical and cognitive functions. This leads to decreased quality of life, loss of function, and deterioration of health among family members, which negatively affects patients' rehabilitation outcomes. ⁹ The KOSCO study also demonstrated that the caregivers had a low quality of life and experienced tremendous psychosocial stress. Given this close interrelationship between patient outcomes and caregiver well‐being, it is essential that educational interventions address not only disease‐related knowledge but also psychosocial adaptation, with potential benefits extending beyond patients themselves.

Patients with cerebrovascular disease and their caregivers require substantial education about stroke treatment, secondary prevention, and functional recovery. ¹⁰ , ¹¹ Such education not only addresses their information needs but also yields measurable clinical benefits. For example, public education about stroke improves symptom recognition and accelerates tissue plasminogen activator delivery. ¹² In addition, social support and health education have been shown to reduce depression in patients with chronic stroke. ¹³ Various educational approaches including both face‐to‐face sessions with professionals and non–face‐to‐face programs using videos have been reported to enhance stroke knowledge, self‐efficacy in symptom recognition, and patient satisfaction. ¹⁴ A meta‐analysis of 17 studies involving 1773 patients and 1058 caregivers found that education improved patient and caregiver knowledge, reduced depression and anxiety, and increased satisfaction, especially when patients and caregivers actively participated in the program. ¹⁵

Despite these benefits, patients with stroke still receive limited, fragmented information about their disease and their role in treatment. As a result, public and patient awareness of stroke symptoms, risk factors, and the importance of early treatment remain low. ¹⁶ , ¹⁷ Structured and comprehensive educational programs could address these gaps by improving knowledge, enhancing quality of life, reducing caregiver burden, and strengthening family functioning. However, the lack of such programs continues to leave many patients dissatisfied with the quantity and quality of information they receive. ¹⁵ , ¹⁸ , ¹⁹

To address this gap, our study developed and evaluated a structured, intensive educational intervention specifically for patients with first‐ever mild ischemic stroke. Although the intervention was not explicitly designed on the basis of a formal adult learning theory, it incorporated principles consistent with adult learning methods, including relevance to daily life, repetition, and interactive reinforcement. By systematically implementing and assessing this program, we sought to provide evidence that such an approach can improve both quality of life and long‐term functional recovery in this patient group.

Methods

Ethics Approval and Consent to Participate

This study was approved by the Institutional Review Board of Chungnam National University Hospital (No. 2016‐05‐037) as well as the institutional review boards of the other participating institutions. Written informed consent was obtained from all participants before enrollment.

Data Availability

The data used in this study were derived from a multicenter cohort database managed by the coordinating institution. Due to data ownership and ethical restrictions, the raw data are not publicly available. The analytic data sets used for the current study are available from the corresponding author upon reasonable request, subject to approval by the data‐holding institution.

Study Design

This was a propensity score–matched cohort study. Participants in the intervention group were recruited between November 2016 and January 2020 from 4 institutions (Chungnam National University Hospital, Kyungpook National University Hospital, Wonkwang University Hospital, and Jeju National University Hospital) of KOSCO. A control group was selected from the primary KOSCO cohort using propensity score matching.

Study Population

Control Group, KOSCO

The KOSCO study is a multicenter prospective cohort study of patients with first‐ever stroke who were admitted to hospitals and underwent longitudinal follow‐up for 10 years. Patients with first‐ever stroke were enrolled from August 2012 to May 2015 and are currently being followed up. Residual disabilities, activity limitations, and quality of life were assessed. Informed written consent was obtained from all participants within the first 7 days of stroke onset.

The participant selection criteria were as follows:

1. First‐ever acute stroke (ischemic stroke or intracerebral hemorrhage) with corresponding lesion with or without evidence of acute arterial occlusion on computed tomography with angiography or magnetic resonance imaging with angiography scan

2. Age ≥19 years at the onset of stroke

3. Onset of symptoms within 7 days before inclusion

The following were the participant exclusion criteria: (1) transient ischemic attack, (2) history of stroke, (3) traumatic intracerebral hemorrhage, and (4) non‐Korean nationality. After the baseline evaluation, participants were assessed face to face at 3, 6, 12, 18, 24, 30, and 36 months after stroke. Thereafter, annual follow‐up assessments were conducted. During hospitalization, the collected medical data included demographic information, cerebrovascular risk factors, comorbidities, initial stroke severity, and premorbid functional status. Additionally, information was gathered on clinical signs, symptoms, physical examination, blood tests, medications administered during hospitalization, treatment methods, side effects, stroke progression and worsening, hospital visit process, inpatient rehabilitation treatment, transfer to the department of rehabilitation medicine, and discharge destination. The detailed rationale and protocol of the KOSCO study have been described previously. ²⁰ For the present study, control participants were selected from the KOSCO cohort by applying the same eligibility criteria used for the intervention group before propensity score matching, thereby restricting the analysis to patients with first‐ever ischemic stroke.

Educational Intervention Group

Among the 9 institutions participating in the KOSCO study, 4 recruited patients with first‐ever ischemic stroke between November 2016 and January 2020. All participants met the original KOSCO inclusion and exclusion criteria, with the following additional criteria applied for the intervention group. Additional inclusion criteria required an initial score of 1 to 5 on the Korean version of the National Institutes of Health Stroke Scale (K‐NIHSS) and agreement to participate, while additional exclusion criteria included age >75 years, a premorbid modified Rankin Scale (mRS) score ≥2, a Korean Mini‐Mental State Examination score ≤20, progressive or unstable stroke, serious neurogenic or psychiatric disorders, severe organ disease, or serious medical conditions with a life expectancy of <1 year.

Eligible patients who provided written informed consent were enrolled in the study. The participants underwent face‐to‐face evaluations at baseline, 3, 6, 12, 18, 24, 30, and 36 months after stroke onset and annually thereafter. In this study, data up to 48 months after stroke were analyzed.

Outcome Measurement

Clinical Assessments

Clinical assessments were conducted at the designated assessment time points. Stroke severity, cognitive function, motor function, ambulatory ability, swallowing function, language function, and level of disability were assessed using K‐NIHSS, Fugl–Meyer Assessment, Functional Ambulatory Category, Korean version of the Frenchay Aphasia Screening Test, Korean Mini‐Mental State Examination, American Speech–Language–Hearing Association National Outcome Measurement System, and mRS, respectively. To assess activities of daily living, Functional Independence Measure and Korean version of Modified Barthel Index were also assessed.

Structured Self‐Administered Questionnaires for Patients

All participants completed structured self‐administered questionnaires at each assessment time point. The GDS‐SF and EQ‐5D were used to assess depressive symptoms and quality of life, respectively. These questionnaires were also administered at each follow‐up. Additionally, data on demographics, marital status, occupation, living conditions, stroke recurrence, lifestyle habits, and health care use were collected.

Educational Intervention

Educational interventions were delivered by an experienced stroke coordinator in three 1‐hour sessions: the first before discharge or transfer to rehabilitation and the second and third at monthly intervals. The sessions consisted of structured lectures on the basis of a standardized handbook, supplemented by interactive question‐and‐answer discussions. Caregivers or family members were not intentionally excluded and were able to attend the sessions when present, particularly during hospitalization, although the intervention primarily targeted patients.

The educational content covered core stroke‐related topics, including disease knowledge (definition, types, symptoms), modifiable and nonmodifiable risk factors with emphasis on secondary prevention, medication management, diet and nutrition, exercise, and fall prevention. Patients received practical guidance on medication use and side effects, individualized dietary recommendations for common comorbidities, and instruction on appropriate physical activity, self‐rehabilitation exercises, and strategies to reduce fall risk (Table 1).

Table 1.

Contents of the Educational Interventions

Educator	Content
In‐hospital coordinator Researcher Physician	Definition of stroke Risk factors of stroke Symptoms of stroke Diagnosis process of stroke The importance of early stroke treatment The treatment process of cerebral infarction Stroke progress Sequelae of stroke Rehabilitation treatment for stroke Recurrence and prevention of stroke Emphasis on the importance of early stroke rehabilitation
	Risk factor management and goal setting for each patient Lifestyle modification and exercise training Medication education for each patient Nutrition and diet Changes in psychological status and depression
	Evaluation sheet and handbooks for each patient Risk factor evaluation result sheet Types and administration methods of medications

Propensity Score Matching and Control Group Extraction

The selection criteria for the intervention group were applied to participants from the KOSCO cohort to extract a comparable control group using propensity score matching. A total of 10 636 patients were assessed for eligibility and 7858 agreed to participate in the KOSCO study (Figure 1). Among those, 6067 participants were excluded according to the intervention group exclusion criteria, while 1791 participants were eligible for propensity score matching.

Figure 1. Study flowchart.

K‐MMSE indicates Korean Mini‐Mental State Examination; and KOSCO, Korean Stroke Cohort for Functioning and Rehabilitation.

In the intervention group, 284 participants were screened. A total of 196 were enrolled and selected for propensity score matching (Figure 1).

Propensity score matching was performed to correct the differences in the baseline clinical characteristics between the control and intervention groups. The propensity score was estimated using a logistic regression model. The criteria variables for matching were age, the Combined Condition and Age‐Related Score, the K‐NIHSS, and the Korean Mini‐Mental State Examination, which were part of intervention group selection criteria. The education level was also included in the criteria variable because it was expected to affect patients' educational understanding. The nearest‐neighbor method, with a caliper of 0.1, was used for propensity score matching. The R version 4.0.3 (R Foundation for Statistical Computing, Vienna, Austria) and the R Studio version 1.3.1093 (R studio, PBC, Boston, MA) were used.

Sample Size Estimation

The sample size was calculated using a target test power (1‐β) of 80%, significance level (α) of 5%, and the primary variable was defined as EQ‐5D value at 6 months after stroke onset. A difference of 0.0266 was considered clinically significant. The expected SD (σ) and follow‐up rates were 0.088 and 70%, respectively. These were based on the data of the KOSCO study in August 2015. G*power version 3.1 was used to estimate the required sample size.

Statistical Analysis

Statistical analyses were performed using IBM SPSS Statistics for Windows version 26.0 (IBM Corp., Armonk, NY). The normality of continuous variables was assessed with the Shapiro–Wilk test. Continuous variables are presented as mean±SD and categorical variables as frequencies and percentages. Between‐group differences in baseline characteristics were analyzed using the independent t test or χ² test, as appropriate. Group‐by‐time interactions for clinical outcomes were examined using generalized estimating equations, which can accommodate missing data without imputation. To control for potential confounding, propensity score matching was applied before analysis. Participants lost to follow‐up were excluded from the longitudinal analyses.

Results

Study Population

After propensity score matching, 138 patients were included in both the control and intervention groups (Figure 1).

Demographics and Baseline Functional Characteristics

The demographics and baseline functional characteristics before and after propensity score matching are shown in Table 2. Following propensity score matching, demographic and baseline functional characteristics were well balanced between the 2 groups, except for the Korean version of the Frenchay Aphasia Screening Test score.

Table 2.

Demographics and Clinical Characteristics

Characteristic	Before propensity score matching		After propensity score matching
	Control group (n=1789)	Intervention group (n=196)	Control group (n=138)	Intervention group (n=138)
Age, y, mean ± SD	58.94±10.40	60.14±9.66	58.22±9.81	59.64±10.42
Sex, male, %	69.70	68.37	67.39	68.12
Body mass index, mean±SD	24.36±3.18	24.44±2.96	24.28±3.20	24.36±3.17
Educational level (A/B/C), n	360/945/479	33/109/49	21/76/41	27/78/33
Stroke risk factor, %
Hypertension	53.1	48.9	53.6	42.0
Diabetes	27.8	24.0	23.1	26.8
Atrial fibrillation	5.9	5.7	5.0	3.6
Hyperlipidemia	17.2	18.4	15.2	14.5
CCAS, mean±SD	5.01±1.55	4.19±1.66	4.64±1.62	4.77±1.56
Prestroke functional level (mRS), mean±SD	0.18±0.38	0.05±0.22	0.14±0.35	0.07±0.26
Baseline clinical parameters, mean±SD
K‐NIHSS	1.38±1.77	1.76±1.26	1.76±2.39	1.65±1.19
Fugl–Meyer Assessment	92.80±16.71	93.10±12.37	92.00±19.63	94.23±9.05
Functional Ambulatory Category	4.01±1.30	3.92±1.23	3.91±1.38	3.93±1.15
K‐FAST	25.34±5.27	27.02±4.30	25.08±5.80	26.67±4.52
K‐MMSE	27.22±2.52	27.18 ± 2.73	27.05 ± 2.63	27.12 ± 2.48
ASHA‐NOMS	6.73±0.86	6.56±0.92	6.71±0.86	6.50±1.03
mRS	1.63±1.17	1.78±1.30	1.65±1.27	1.85±0.98
Functional Independence Measure	111.41±17.20	111.89±15.43	110.53±18.04	111.92±15.10
Korean version of  Modified Barthel Index	86.53±17.72	86.10±16.00	85.46±18.91	85.33±15.49
EQ‐5D	0.8160±0.1887	0.7966±0.1616	0.8274±0.1820	0.8054±0.1446
Geriatric Depression Scale‐Short Form	5.39±3.85	5.25±3.72	5.80±4.13	5.00±3.68

A indicates elementary school graduate; B, middle and high school graduate; C, university graduate or higher; CCAS, Combined Condition and Age‐Related Score; mRS, modified Rankin scale; ASHA‐NOMS, American Speech–Language–Hearing Association National Outcome Measurement; EQ‐5D, EuroQol ‐5 Dimension; K‐FAST, Korean version of Frenchay Aphasia Screening Test; K‐MMSE, Korean Mini‐Mental State Examination; and K‐NIHSS, Korean version of the National Institutes of Health Stroke Scale.

Effect of Educational Intervention on Functional Outcomes

Over the 48‐month follow‐up period, most functional outcome measures, including K‐NIHSS, Fugl–Meyer Assessment, Functional Ambulatory Category, Korean version of the Frenchay Aphasia Screening Test, Korean Mini‐Mental State Examination, American Speech–Language–Hearing Association National Outcome Measurement System, Functional Independence Measure, and Korean version of Modified Barthel Index, showed no significant group × time interactions between the intervention and control groups, indicating that changes in these outcomes over time were comparable between groups (Figures S1–S3).

In contrast, significant group × time interactions were observed for the mRS (β=11.48 [95% CI, 0.05–22.92]), EQ‐5D (β=−0.005 [95% CI, −0.009 to −0.001]), and GDS‐SF (β=0.147 [95% CI, 0.015–0.279]), demonstrating greater improvement in disability, quality of life, and depressive symptoms in the intervention group compared with the control group (Figure 2).

Figure 2. Temporal changes in outcomes showing significant group × time interactions over the 48‐month follow‐up period.

A, mRS. B, EQ‐5D. C, GDS‐SF. Data are presented as means with error bars representing SDs.

EQ‐5D indicates EuroQol‐5 Dimension; GDS‐SF, Geriatric Depression Scale–Short Form; and mRS, modified Rankin Scale.

*Indicates a statistically significant group × time interaction identified using generalized estimating equations.

At baseline, the proportion of subjects reporting “no problem” in the anxiety/depression dimension of the EQ‐5D was comparable between the control and intervention groups (65.1% versus 66.4%). However, from 3 months onward, a significant between‐group difference was observed in the proportion of participants reporting “no problem,” favoring the intervention group, and this difference was sustained through 6‐month follow‐up (Table 3). No statistically significant differences between the control and intervention groups were observed in the mobility, self‐care, usual activity, and pain/discomfort dimensions at 3 and 6 months.

Table 3.

EQ‐5D Subitem Analysis at Each Time Point, Anxiety/Depression Dimension

	Baseline, n (%)		OR (95% CI)
	No problems	Some or extreme problems
Control group (n=129)	84 (65.1)	45 (34.9)
Intervention group (n=107)	71 (66.4)	36 (33.6)	0.95 (0.55–1.62)

	3 mo
Control group (n=101)	73 (72.3)	28 (27.7)
Intervention group (n=84)	72 (85.7)	12 (14.3)	0.44 (0.21–0.92)

	6 mo
Control group (n=99)	70 (70.7)	29 (29.3)
Intervention group (n=87)	74 (85.1)	13 (14.9)	0.42 (0.20–0.88)

ORs with 95% CIs were calculated for the intervention group relative to the control group.

EQ‐5D indicates EuroQol‐5 Dimension; and OR, odds ratio.

At 3 months after stroke, a significantly greater proportion of participants in the intervention group had returned to work compared with those in the control group (65.7% versus 45.5%). However, by 6 months, the return‐to‐work rates were comparable between the 2 groups (Table 4).

Table 4.

Return to Work

	3 mo, n (%)		OR (95% CI)
	Yes	No
Control group (n=66)	30 (45.5)	36 (54.5)
Intervention group (n=67)	44 (65.7)	23 (34.3)	2.29 (1.18–4.43)

	6 mo
Control group (n=70)	35 (50.0)	35 (50.0)
Intervention group (n=68)	42 (61.8)	26 (38.2)	1.62 (0.84–3.12)

ORs with 95% CIs were calculated for the intervention group relative to the control group. OR indicates odds ratio.

Discussion

This is the first study to evaluate the effects of a structured and intensive 3‐session educational intervention on quality of life and functional recovery in a large cohort of patients with first‐ever ischemic stroke. Compared with the control group, the intervention group showed significant improvements in EQ‐5D, GDS‐SF, and mRS scores over 48 months. These findings are consistent with previous studies reporting benefits of stroke‐related education on health‐related quality of life. ²¹ , ²² , ²³ Education provides patients with information on self‐management and treatment, enabling person‐centered care and improving quality of life, even in chronic conditions such as chronic obstructive pulmonary disease and cancer. ²⁴ , ²⁵

Sub‐item analyses of the EQ‐5D revealed that the intervention particularly improved the anxiety/depression dimension at 3 and 6 months after stroke. The educational program addressed psychological changes after stroke and stress management, which may have contributed to these improvements, consistent with earlier reports of reduced anxiety and depression following educational interventions. ¹³ , ²⁶

Although the effect of education on quality of life in patients with stroke has been inconsistent, ¹⁹ , ²⁷ , ²⁸ such variability may stem from the unique characteristics of stroke. In contrast with conditions like diabetes or asthma, where correct use of medication can rapidly improve symptoms, stroke often results in irreversible deficits that limit the impact of information alone. ²⁹ Many previous studies also did not adequately stratify patients by disability level, which may have contributed to inconsistent quality‐of‐life outcomes. By focusing on patients with mild stroke severity (K‐NIHSS score 1–5), our study suggests that this population may be more responsive to educational interventions.

Depression severity showed a statistically significant improvement in the intervention group compared with the control group over the 48‐month follow‐up period. In previous studies, educational interventions were reported to have a positive impact on depression in patients with stroke. ¹³ , ²⁶ A 2009 Cochrane review on information provision for patients with stroke also reported improvements in patient and caregiver knowledge and patient satisfaction following educational interventions, with a concurrent reduction in depression scores; however, the magnitude of the reduction was too small to be considered clinically meaningful. ²⁸ The sustained improvement observed here suggests that structured, ongoing education may yield clinically relevant benefits for emotional well‐being.

Few studies have used the mRS as an outcome measure to assess the effects of educational interventions. In the present study, the intervention group showed a more pronounced reduction in mRS scores than the control group, with a significant group‐by‐time interaction. Because the mRS reflects global disability and social participation, this improvement may relate to enhanced engagement in occupational, social, and leisure activities rather than direct physical recovery. Indeed, return‐to‐work rates at 3 months were higher in the intervention group. These effects are consistent with the program's emphasis on secondary prevention, self‐care, depression management, and social reintegration.

The positive effects of intensive education in this study can be understood through the framework of self‐management. By providing structured information about stroke and strategies for ongoing care, the intervention promoted self‐efficacy, which is the confidence to perform necessary health behaviors and adhere to treatment goals. ³⁰ , ³¹ This process empowered patients to take an active role in managing their condition, fostering a greater sense of responsibility and autonomy. As self‐management skills improved, patients likely experienced increased confidence in coping with their illness, which in turn contributed to enhanced psychological well‐being, including reductions in depression and improved quality of life. ³² , ³³ , ³⁴

Despite these positive findings, the intervention did not produce measurable gains in muscle strength or activities of daily living. Evidence supporting an effect of education on physical functional recovery remains limited, and the participants in our study primarily had mild cerebral infarction, which may have resulted in a ceiling effect, limiting the potential for further functional improvement.

Previous comprehensive programs have sometimes improved knowledge and access to services without enhancing health status and, in some cases, were associated with lower social functioning or only modest reductions in anxiety. ²⁷ , ³⁵ Such mixed results likely reflect methodological limitations, including small sample sizes, lack of stratification by stroke severity, generic content, and short follow‐up, which may underestimate the value of tailored, structured education.

This study has several limitations. First, it is not a randomized controlled trial, although propensity score matching was used to reduce bias. Second, the control group was drawn from 9 institutions while the intervention group came from only 4, with a 5‐year recruitment gap, introducing possible regional and temporal differences. Third, although multicenter prospective follow‐up can raise concerns about data consistency, evaluator training sessions were held twice annually. Fourth, participating institutions were mainly urban, which may limit generalizability to rural populations or other regions. Therefore, while the results suggest potential benefits of structured educational interventions, their applicability to populations in different health care settings, geographic areas, or with different baseline characteristics should be interpreted with caution. Fifth, because the study focused on patients with mild ischemic stroke, most participants already demonstrated high baseline independence in basic activities of daily living. As a result, measures such as the Korean version of Modified Barthel Index and Functional Independence Measure may have been affected by ceiling effects, limiting their ability to capture subtle changes. The higher‐level assessments such as instrumental activities of daily living might better detect subtle functional changes. Finally, the GDS‐SF was originally developed to assess depression in older adults. Because the present study included participants across a broad adult age range, the use of the GDS‐SF for depression assessment warrants cautious interpretation. Nevertheless, previous studies have demonstrated a strong correlation between the GDS‐SF and the Beck Depression Inventory in younger adult populations, and the GDS‐SF has been applied in studies assessing depression among younger patients. ³⁶ , ³⁷

Conclusions

This study demonstrated that early, structured, and intensive education for patients with mild, first‐ever ischemic stroke has positive effects on the patients' quality of life, social participation, and psychological well‐being. Educational interventions enhance patients' self‐management abilities and self‐efficacy, which help alleviate depression and anxiety and promote the resumption of prestroke social activities. These improvements collectively lead to an enhanced quality of life. Importantly, such benefits are not achieved through the simple provision of information, but through systematic, well‐organized, and intensive educational programs. These findings highlight the need for implementing more structured and comprehensive educational interventions in stroke rehabilitation.

Sources of Funding

This work was funded by the Korea National Institute of Health research project (No. 2025‐E0901‐00).

Disclosures

None.

Supporting information

Figures S1–S3