A cross-sectional study was employed from April 8 to April 30, 2020, in the general public hospital of Liaoning, China. A total of 258 stroke inpatients who were receiving pharmacotherapy, rehabilitation and met the inclusion criteria were consecutive selected in this study and these participants were interviewed face-to-face by the trained investigators using a mobile phone questionnaire via the WeChat platform. The inclusion criteria of stroke patients were the following: age more than 20 years old; fluent in oral or written Chinese, and able to consent to join the study. The exclusion criteria were having a history of serious mental illness or a serious chronic illness including schizophrenia, bipolar disorder, Alzheimer's disease, hysteria, cancer, dementia, or severe hearing or vision impairment. The participant was informed of the research aims and that the questionnaire was anonymous prior to informed consent. The questionnaire took approximately 25 min to complete. The questionnaire had been preset for submission only after all the questions were answered within the range of the selected choices. Answers were not available if the questions were not completed. Therefore, the collected questionnaire had been filtered with data cleaning, checking the consistency and logicality of the answers, adjusting invalid and missing values.

The information collected on stroke patient's demographic and clinical characteristics included age, gender, marital status, education level, residence, monthly income, duration of stroke, stroke type, and activities of daily living (ADL). “Marital status” was grouped as “married” or “other.” “Residence” was classified as “urban” or “rural.” “Education level” was defined as “junior high school and below” or “senior high school and above.” “Monthly income (RMB)” was categorized as: “ ≤ 3,000 yuan,” “3,001~6,000 yuan” and “>6,000 yuan.” “Duration of stroke” was grouped as “ ≤ 2 weeks” or “more than 2 weeks.” “Stroke type” was classified as “hemorrhagic stroke” or “ischemic stroke.” “ADL scores” were categorized as “mild disability (ADL scores ≤ 26)” or “high disability (ADL scores > 26).”

The responses to the COVID-19 pandemic in stroke patients were measured by 4 questions: (1) Community shut-down measures (yes/no), (2) Daily life impact due to the pandemic (yes/no), (3) Perception about the risks of SARS-CoV-2 infection (yes/no), (4) Anxiety about the pandemic (yes/no).

The Family Adaptation, Partnership, Growth, Affection, and Resolve (FAPGAR) Scale was employed to assess the perception of family functioning (30). This scale included five items that were answered on a 3-point Likert scale, ranging from 0 (never) to 2 (always) (30 28). The Cronbach's alpha coefficient for this scale was 0.936.

Optimism was evaluated by the 6-item Revised Life Orientation Test (LOT-R) that assessed the generalized expectations for positive or negative outcomes. The LOT-R was rated on a 5-point Likert scale from 0 (strongly disagree) to 4 (strongly agree) and the total scores were summed after reverse coding three items (31). The total scores ranged from 0 to 24, with higher scores indicating a greater degree of optimism. The Cronbach's alpha coefficient for this scale was 0.810.

Life satisfaction was assessed by the Satisfaction with Life Scale (SWLS) which was developed by Diener and is widely applied as a valid and reliable measure of life satisfaction for a variety of populations (32). It comprised of 5 items, to which the participants gave their responses of agreement on a 7-point Likert scale from 1 (“strongly disagree”) to 7 (“strongly agree”) (33). The Cronbach's alpha for this scale was 0.972.

The statistical analyses were performed using SPSS 22.0 version statistical software for Windows. The radar chart was used to describe significant association factors of life satisfaction for stroke patients during the COVID-19 epidemic. T-tests and one-way ANOVA were conducted to compare differences in life satisfaction among the categorical groups. The Spearman correlation was employed to test the correlations between family functioning, optimism, and life satisfaction. Hierarchical multiple regression (HMR) analysis was performed to predict factors associated with life satisfaction, in which, life satisfaction was used as the dependent variable. And the independent variables were entered in four steps: Step 1: stroke patient's demographic and clinical variables; Step 2: epidemic responses; Step 3: family functioning; and Step 4: optimism. A two-tailed probability value of <0.05 was considered statistically significant.

Of the 258 stroke patients, 207 took part in this study and provided valid answers to the questionnaire, resulting in a valid response rate of 80.23%. The demographic and clinical characteristics, and epidemic responses of the stroke patients and the associations with life satisfaction are provided in Table 1. The mean age of patients was 64.7 years old (ranging from 33 to 93), and 63.3% of the patients were men. Approximately, 89.4% of the patients were currently married, and 93.7% had a monthly income of <6,000 yuan. Of the participants, 23.7% had a stroke duration of more than 2 weeks and 79.7% were diagnosed with a hemorrhagic stroke. Among the stroke patients, 79.2% experienced community shut-down measures during the research study. Patients whose duration of stroke was ≤ 2 weeks reported higher levels of life satisfaction than those whose stroke duration was more than 2 weeks (P < 0.05). Patients who lived in urban areas reported higher life satisfaction than those lived in rural areas (P < 0.05). Ischemic stroke patients exerted a lower level of life satisfaction than hemorrhagic stroke patients (P < 0.05). The stroke patients who lived in communities that were shut-down by the Chinese government had lower life satisfaction than their comparative group (P < 0.05). The radar chart of life satisfaction is shown in Figure 1.

The Spearman correlation analyses of life satisfaction, family functioning, and optimism are presented in Table 2. Results revealed that family functioning (r = 0.305, P < 0.01) and optimism were both positively correlated with life satisfaction (r = 0.296, P < 0.01).

Table 3, Figure 2 illustrates the final results of the HMR models of stroke patients' life satisfaction. A total of 25.1% of the variance was explained by the final model. Results from the R² change indicated that the variance explained by each block of variables was 15.4, 3.0, 2.9, and 3.8% for demographic and clinical characteristics, pandemic responses, family functioning, and optimism, respectively. Living in the rural areas (β = −1.110, 95% CI−1.698-−0.522, P < 0.001) and ischemic stroke (β = −0.420, 95% CI−0.772-−0.069, P < 0.05) were observed to decrease life satisfaction, while more than 2 weeks duration of stroke (β =0.428, 95% CI 0.080–0.776, P < 0.05) and from an area without community shut-down measures (β = 0.452, 95% CI 0.077–0.827, P < 0.05) were observed to increase life satisfaction. Moreover, stroke patients who had better family functioning (β = 0.188, 95% CI 0.047–0.330, P < 0.01) and optimism (β = 0.202, 95% CI 0.073–0.331, P < 0.01) were observed to experience higher life satisfaction.

Although the COVID-19 pandemic in China was nearly quelled after 3 months, a paucity of research has been conducted on the extent to which the pandemic affected stroke patient's subjective wellbeing in hospitals. More importantly, this survey represents the first cross-sectional study on the association of family functioning and optimism with life satisfaction among the population of stroke patients during the COVID-19 pandemic. The present study showed that the levels of life satisfaction in Chinese stroke patients was higher than those in general public of other countries and university students in Poland during the first peak of COVID-19 pandemic (34, 35). The reason for this phenomenon might be that COVID-19 outbreak was under control with serene and spacious medical environment (36). Shenyang was less influenced by COVID-19 pandemic and was in a low risk are in China compared with others (37). Besides, during the COVID-19 pandemic, a series of hospitals have provided prevention and management protocols to offer quality and continuous care for stroke patients, such as providing green channels with personal protective equipment, implementing group management in the process of diagnosis and treatment to avoid cross-infection (38), stroke patients with non-infectious were provided in separate rooms with more meticulous, assured health and psychological care, which resulted in the enhancement of life satisfaction (39).

The results from this study indicate that demographic and clinical factors were critical to interpret life satisfaction among stroke patients, accounting for 15.4% of the observed variance in stroke patient's subjective wellbeing. Furthermore, individual's internal support or psychological resources like family functioning and optimism, played critical roles in promoting life satisfaction, which corroborates previous research illustrating that positive beliefs could affect the appraisal of the stress response, help individuals facilitate and adapt to the stressful settings and tackle difficulties, which could improve stroke patient's life satisfaction (40).

Residence, duration of stroke, stroke type, and epidemic responses with community shut-down measures were strong predictors of life satisfaction for stroke patients during the COVID-19 pandemic. Stroke patients living in cities experienced slightly higher levels of life satisfaction during the COVID-19 pandemic. The most likely reason is that, Chinese stroke patients living in urban areas tend to obtain quality medical care in tertiary hospitals, which would be conducive to current life quality, psychological health, and subjective wellbeing (41). A longer stroke duration was positively associated with life satisfaction, which is in accordance with a previous research suggesting that the patients have adapted to the disease control and management (42). Ischemic stroke was a risk factor for poor life satisfaction among stroke patients. This may be because patients with ischemic stroke are more prone to hemiplegia, slurred speech, crooked mouth and other clinical symptoms, leading to a poorer prognosis and thus may cause ischemic stroke patients to have a lower subjective wellbeing (43). In addition, stroke patients who did not experience community shut-down measures during the COVID-19 epidemic were more satisfied with their life, which has been also shown by Fan et al. (44).

This study found that family functioning was moderately and positively associated with life satisfaction, which confirmed that a higher familial sense of togetherness, familiarity, and satisfaction with family ties contributed to improved psychological wellbeing for stroke patients when they faced a public health emergency (21, 45). Most research has shown that people who have stronger familial cohesion and communication have more positive perceived family roles and responsibilities, and thus, higher life satisfaction (46, 47). Conversely, poor family relationships and negative caregiving experiences could decrease the sense of life satisfaction for stroke patients. Accordingly, sufficient family support and positive experiences of caregiving from both family caregivers and hospital workers were related to higher life satisfaction for stroke patients during the COVID-19 epidemic.

In this study, optimism was positively associated with life satisfaction, which was in agreement with studies showing that optimistic stroke patients were more likely to have higher subjective wellbeing during the COVID-19 pandemic (48). The greater family support that stroke patients received, the higher optimism levels they had, which made stroke patients believe that positive events would continuously and universally take place, thereby increasing their life satisfaction (49). Attribution theory states that individuals with optimism appraise difficult circumstances (e.g., the COVID-19 pandemic) in a positive way and have a more hopeful outlook regarding the future, which leads to improved life satisfaction (50). Conversely, patients with low levels of optimism might tackle the difficult events in a more negative way and have bleak expectations for their future, which could result in the reduction of life satisfaction among stroke patients (51). Therefore, investment in enhancing optimism and family functioning may be effective in reducing the negative effects of public health emergencies and improving perceived subjective wellbeing.