eHealth Interventions of Health Literacy for Stroke Survivors: Systematic Review and Meta-Analysis.

BACKGROUND: eHealth literacy interventions have emerged as a new approach in management of stroke survivors. Its effect on knowledge and clinical outcomes presents an inconsistent result in literature. OBJECTIVES: We aim to evaluate the impact of eHealth interventions on health literacy, clinical metrics, adherence to healthy behaviors, stroke recurrence, mortality, and health-related quality of life in stroke survivors. METHODS: We systematically searched six databases (PubMed, Cochrane Library, CINAHL, EMBASE, Web of Science, ProQuest) up to February 21, 2024, selecting articles that meet these criteria: (i) patients with stroke; (ii) intervention with education content; (iii) eHealth interventions included telehealth, mobile phone, internet or computer; (iv) randomized controlled trials. The mean differences (MD) and standardized mean differences (SMD) between groups were measured. Risk of bias was evaluated using the Cochrane tool. RESULTS: From 16 studies involving 9646 participants, we observed that eHealth interventions significantly improved systolic blood pressure (MD = -2.78 mmHg, 95% confidence interval (CI) [-4.67 to -0.88], p = 0.004), medication adherence (SMD = 0.28, 95% CI [0.04 to 0.52], p = 0.023), and health-related quality of life (SMD = 0.21, 95% CI [0.04 to 0.37], p = 0.013). Meta-regression found that age modified the effect size of systolic blood pressure (p = 0.027). There was insufficient evidence to conclude effects on other outcomes. The quality of evidence was moderate. Outcome variation may be due to the diversity in eHealth intervention approaches. The limited number of studies precluded the subgroup analysis. More interactive interventions with longer follow-ups were more effective. CONCLUSIONS: eHealth interventions may benefit stroke survivors in terms of blood pressure, medication adherence, and health-related quality of life. IMPLICATIONS FOR NURSING POLICY: eHealth literacy interventions could be implemented to improve the management of stroke survivors, especially in the context of resource limitations. TRIAL REGISTRATION: PROSPERO registration number: CRD42024502470.

Quantifying Coloring Skills Among Preschoolers.

IMPORTANCE: Coloring is popular with preschool children and reveals their developmental state. However, interpreting coloring performances is challenging because descriptive and subjective evaluations are commonly used with large variations. OBJECTIVE: To develop a scoring method to objectively quantify children's coloring skills. DESIGN: Colored blank train templates were analyzed using four indicators (entropy, complexity, coloring outside the lines, and unexpected blank areas) to form a summed score. SETTING: Kindergarten in a urban city (Tainan, Taiwan). PARTICIPANTS: Two hundred thirty-nine typically developing children ages 3 to 6 yr. OUTCOME AND MEASURES: A newly developed method to assess coloring skill on the basis of a colored picture of a train. RESULTS: The summed score exhibited good internal consistency (Cronbach's α = .80), discriminative validity (p = .04), convergent validity (rs = .66 and .59 with age and visual-motor integration), and acceptable factorial validity (comparative fit index = .99, standardized root-mean-square residual = .04, and root-mean-square error of approximation = .13). Moreover, three coloring patterns (mature, transitional, and immature) were identified. CONCLUSIONS AND RELEVANCE: The new method provides objective, reliable, and valid scores representing coloring skills in typically developing children. In addition, the coloring patterns can be recognized. This method can be used to facilitate comparisons of children's coloring skills with peers and provide valuable insight into children's development. Plain-Language Summary: This study proposes a new method to objectively quantify children's coloring skills with sound reliability and validity in typically developing children. The method can be used to evaluate children's coloring skills and patterns to shed light on their developmental stages.

Development of a 13-item Short Form for Fugl-Meyer Assessment of Upper Extremity Scale Using a Machine Learning Approach.

OBJECTIVE: To develop and validate a short form of the Fugl-Meyer Assessment of Upper Extremity Scale (FMA-UE) using a machine learning approach (FMA-UE-ML). In addition, scores of items not included in the FMA-UE-ML were predicted. DESIGN: Secondary data from a previous study, which assessed individuals post-stroke using the FMA-UE at 4 time points: 5-30 days post-stroke screen, 2-month post-stroke baseline assessment, 6-month post-stroke assessment, and 12-month post-stroke assessment. SETTING: Rehabilitation units in hospitals. PARTICIPANTS: A total of 408 individuals post-stroke (N=408). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The 30-item FMA-UE. RESULTS: We established 29 candidate versions of the FMA-UE-ML with different numbers of items, from 1 to 29, and examined their concurrent validity and responsiveness. We found that the responsiveness of the candidate versions obviously declined when the number of items was less than 13. Thus, the 13-item version was selected as the FMA-UE-ML. The concurrent validity was good (intra-class correlation coefficients ≥0.99). The standardized response means of the FMA-UE-ML and FMA-UE were 0.54-0.88 and 0.52-0.91, respectively. The Pearson's rs between the change scores of the FMA-UE-ML and those of the FMA-UE were 0.96-0.98. The predicted item scores had acceptable to good accuracy (Kappa=0.50-0.92). CONCLUSIONS: The FMA-UE-ML seems a promising short form to improve administrative efficiency while retaining good concurrent validity and responsiveness. In addition, the FAM-UE-ML can provide all item scores of the FMA-UE for users.

Using Artificial Intelligence to Identify the Associations of Children's Performance of Coloring, Origami, and Copying Activities With Visual-Motor Integration.

IMPORTANCE: Performance of coloring, origami, and copying activities reflects children's visual-motor integration (VMI), but the levels of association remain unclear. OBJECTIVE: To use artificial intelligence (AI) to investigate associations of performance of coloring, origami, and copying activities with VMI. DESIGN: Cross-sectional study. SETTING: Kindergartens. PARTICIPANTS: A sample of 370 children (182 boys and 188 girls) in the second and third years of kindergarten. OUTCOMES AND MEASURES: Beery-Buktenica Developmental Test of Visual-Motor Integration, 6th Edition (VMI-6). RESULTS: Data for preschool children from an ongoing project were retrieved. AI models were trained to use photographs of activity products to predict total score on the VMI-6. R2 values were used to identify the variance in VMI-6 standardized scores explained by predicted scores from the activities. That is, R2 values reflected associations between activity performance and VMI. The R2 values for the combination of origami and copying were the largest (.390-.577). These R2 values were larger than those for each individual activity (.340-.473) and similar to those for the combination of all three activities (.400-.550). CONCLUSIONS AND RELEVANCE: Because moderate R2 values were found between performance of the three activity products and VMI, the three activities have high potential for use in identifying children's level of VMI or as teaching materials to facilitate the development of children's VMI. Furthermore, combining origami and copying activities is recommended for teachers and clinicians who need to address VMI. What This Article Adds: A combination of origami and copying activities had the strongest associations with children's VMI. Teachers and clinicians can use these two activities when addressing VMI development among preschool children.

Using Machine Learning to Develop a Short-Form Measure Assessing 5 Functions in Patients With Stroke.

OBJECTIVE: This study aimed to develop and validate a machine learning-based short measure to assess 5 functions (the ML-5F) (activities of daily living [ADL], balance, upper extremity [UE] and lower extremity [LE] motor function, and mobility) in patients with stroke. DESIGN: Secondary data from a previous study. A follow-up study assessed patients with stroke using the Barthel Index (BI), Postural Assessment Scale for Stroke (PASS), and Stroke Rehabilitation Assessment of Movement (STREAM) at hospital admission and discharge. SETTING: A rehabilitation unit in a medical center. PARTICIPANTS: Patients (N=307) with stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The BI, PASS, and STREAM. RESULTS: A machine learning algorithm, Extreme Gradient Boosting, was used to select 15 items from the BI, PASS, and STREAM, and transformed the raw scores of the selected items into the scores of the ML-5F. The ML-5F demonstrated good concurrent validity (Pearson's r, 0.88-0.98) and responsiveness (standardized response mean, 0.28-1.01). CONCLUSIONS: The ML-5F comprises only 15 items but demonstrates sufficient concurrent validity and responsiveness to assess ADL, balance, UE and LE functions, and mobility in patients with stroke. The ML-5F shows great potential as an efficient outcome measure in clinical settings.

High levels of screen time were associated with increased probabilities of lagged development in 3-year-old children.

AIM: This study determined whether higher screen time was associated with the development of 3-year-old children in Taiwan. It also examined whether differences would be found between television and other screen-based media in the probability of lagged development. METHODS: We examined 2139 children aged 3 years and their parents. The association between daily screen time was assessed using multiple logistic regression analysis. All the odds ratios (ORs) were calculated using the rates of lagged developmental achievement, with the group who used screens for less than 1 h a day as the reference category. Screen time comprised television and other screen-based media, such as smartphones, touch screens, computers and laptops. RESULTS: Children who used screens for more than 3 h per day had the lowest developmental scores and highest probabilities of lagged development. The children who used other screen-based media for more than 1 h per day had greater probabilities of lagged developmental achievements (ORs 1.85-4.98, all p < 0.05) than those who watched television for the same amount of time (OR 1.41-2.77, all p < 0.05). CONCLUSION: Increased screen time was associated with higher probabilities of lagged developmental achievement in multiple development domains in 3-year-old children, particularly other screen-based media.

Development of a Short-Form Stroke Impact Scale Using a Machine Learning Algorithm for Patients at the Subacute Stage.

IMPORTANCE: Several short forms of the Stroke Impact Scale Version 3.0 (SIS 3.0) have been proposed in order to decrease its administration time of about 20 min. However, none of the short-form scores are comparable to those of the original measure. OBJECTIVE: To develop a short-form SIS 3.0 using a machine learning algorithm (ML-SIS). DESIGN: We developed the ML-SIS in three stages. First, we calculated the frequencies of items having the highest contribution to predicting the original domain scores across 50 deep neural networks. Second, we iteratively selected the items showing the highest frequency until the coefficient of determination (R2) of each domain was ≥.90. Third, we examined the comparability and concurrent and convergent validity of the ML-SIS. SETTING: Hospitals. PARTICIPANTS: We extracted complete data for 1,010 patients from an existing data set. RESULTS: Twenty-eight items were selected for the ML-SIS. High average R2s (.90-.96) and small average residuals (mean absolute errors and root-mean-square errors = 0.49-2.84) indicate good comparability. High correlations (rs = .95-.98) between the eight domain scores of the ML-SIS and the SIS 3.0 indicate sufficient concurrent validity. Similar interdomain correlations between the two measures indicate satisfactory convergent validity. CONCLUSIONS AND RELEVANCE: The ML-SIS uses about half of the items in the SIS 3.0, has an estimated administration time of 10 min, and provides valid scores comparable to those of the original measure. Thus, the ML-SIS may be an efficient alternative to the SIS 3.0. What This Article Adds: The ML-SIS, a short form of the SIS 3.0 developed using a machine learning algorithm, shows good potential to be an efficient and informative measure for clinical settings, providing scores that are valid and comparable to those of the original measure.

Development of the CAT-FER: A Computerized Adaptive Test of Facial Emotion Recognition for Adults With Schizophrenia.

IMPORTANCE: The most frequently used measures of facial emotion recognition (FER) are insufficiently comprehensive, reliable, valid, and efficient; moreover, the impact of gender on scoring has not been controlled. OBJECTIVE: To develop a computerized adaptive test of FER for adults with schizophrenia. DESIGN: First, we selected photographs from a published database. Second, items that fitted well to a Rasch model were used to form the item bank. Third and last, we determined the best administration mode for prospective users to achieve both high reliability and efficiency. SETTING: Psychiatric hospitals and the community. PARTICIPANTS: Adults living with schizophrenia (n = 351) and adults without diagnosed mental illness (n = 101). RESULTS: After removal of misfit items (infit or outfit ≥1.4), the remaining 165 items were selected to form an item bank. Among them, 39 showed severe gender bias, so the item difficulties were adjusted accordingly. On the basis of the item bank, two administration modes were recommended for prospective users. The reliable mode required approximately 128 items (nearly 20 min) to achieve reliability (.72-.81), similar to that of the entire item bank. The efficient mode required approximately 73 items (approximate 11 min) to provide acceptable reliability (.69-.73) for the seven domain scores. CONCLUSIONS AND RELEVANCE: Our newly developed measure provides comprehensive, valid, and unbiased (to examinees' gender) assessments of FER in adults living with schizophrenia. In addition, the administration modes can be flexibly changed to optimize the reliability or efficiency for prospective users. WHAT THIS ARTICLE ADDS: This newly developed FER measure can help occupational therapists identify deficits in recognizing specific basic emotions and plan corresponding interventions to manage the impact on their clients' social functions.

Cross-Validation of the Factorial Validity of the Stroke Impact Scale 3.0 in Patients With Stroke.

IMPORTANCE: The Stroke Impact Scale 3.0 appears to be a promising outcome measure of health-related quality of life (HRQOL) for clients with stroke. However, because the factorial validity of the Stroke Impact Scale 3.0 remains unclear, its validity is limited. OBJECTIVE: To examine the underlying structure of the Stroke Impact Scale 3.0 by comparing the currently available eight- and four-domain structures simultaneously. DESIGN: Secondary data analysis of responses to the Stroke Impact Scale 3.0 from a previous psychometric validation study. SETTING: Five general hospitals in northern and southern Taiwan. PARTICIPANTS: Two hundred sixty-three patients with stroke from rehabilitation wards (inpatients) and neurology and rehabilitation clinics (outpatients). OUTCOMES AND MEASURES: Confirmatory factor analysis was used to examine the eight- and four-domain structures of the Stroke Impact Scale 3.0. Four fit indices were considered simultaneously to examine the model fits of both structures. RESULTS: The eight- and four-domain structures of the Stroke Impact Scale 3.0 were not supported by all four indices (χ²/df = 2.7 and 5.0, comparative fit index = .79 and .86, root mean square error of approximation = .08 and .12, standardized root mean square residual = .08 and .08, respectively). The unidimensionality of each domain in the two structures was not supported. CONCLUSIONS AND RELEVANCE: Neither the eight- nor the four-domain structure of the Stroke Impact Scale 3.0 was supported, suggesting that scores may not provide valid assessments of HRQOL in clients with stroke. Further modification and validation of the Stroke Impact Scale 3.0 are warranted. WHAT THIS ARTICLE ADDS: Our findings suggest that the eight- and four-domain scores of the Stroke Impact Scale 3.0 may not be valid. Therefore, until more supporting evidence is developed, these scores should be interpreted cautiously in regard to clients' HRQOL; alternatively, other measures could be used.

Development of a Computerized Adaptive Testing System for Assessing 5 Functions in Patients with Stroke: A Simulation and Validation Study.

OBJECTIVE: The authors aimed to develop and validate the Computerized Adaptive Testing System for Assessing 5 Functions in Patients with Stroke (CAT-5F) based on the Barthel Index (BI), Postural Assessment Scale for Stroke patients (PASS), and Stroke Rehabilitation Assessment of Movement (STREAM) to improve the efficiency of assessment. The purposes of the CAT-5F assessment are to describe patients' levels of impairments or disabilities in the 5 functions and to serve as an outcome measure in patients with stroke. DESIGN: This is a data-mining study based on data from a previous study using simulation analysis to develop and validate the CAT-5F. SETTING: One rehabilitation unit in a medical center in Taiwan served as the setting for this study. PARTICIPANTS: Data were retrieved from totals of 540 (initial assessment) and 309 (discharge assessment) participants with stroke assessed in a previous study. The assessment data (N=540) were from the BI, PASS, and STREAM. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The outcome measures for this study were from BI, PASS, and STREAM. RESULTS: The CAT-5F using the optimal stopping rule (limited reliability increased <0.010) had good Rasch reliability across the 5 functions (0.86-0.96) and needed 12.7 items, on average, for the whole administration. The concurrent validity (Pearson product-moment correlation coefficient, r=0.91-0.96) and responsiveness (standardized response mean=0.33-0.91) of the CAT-5F were sufficient in the patients. CONCLUSION: The CAT-5F has sufficient administrative efficiency, reliability, concurrent validity, and responsiveness to simultaneously assess basic activities of daily living, postural control, upper extremity/lower extremity motor functions, and mobility in patients with stroke.