Functional and Cognitive Occupational Therapy (FaCoT) Improves Self-Efficacy and Behavioral–Emotional Status of Individuals with Mild Stroke; Analysis of Secondary Outcomes

Background: Mild stroke is characterized by subtle impairments, such as low self-efficacy and emotional and behavioral symptoms, which restrict daily living. Functional and Cognitive Occupational Therapy (FaCoT) is a novel intervention, developed for individuals with mild stroke. Objectives: To examine the effectiveness of FaCoT compared to a control group to improve self-efficacy, behavior, and emotional status (secondary outcome measures). Material and Methods: Community-dwelling individuals with mild stroke participated in a single-blind randomized controlled trial with assessments at pre, post, and 3-month follow-up. FaCoT included 10 weekly individual sessions practicing cognitive and behavioral strategies. The control group received standard care. The New General Self-Efficacy Scale assessed self-efficacy; the Geriatric Depression Scale assessed depressive symptoms; the Dysexecutive Questionnaire assessed behavior and emotional status; and the ‘perception of self’ subscale from the Reintegration to Normal Living Index assessed participation. Results: Sixty-six participants were randomized to FaCoT (n = 33, mean (SD) age 64.6 (8.2)) and to the control (n = 33, age 64.4 (10.8)). Self-efficacy, depression, behavior, and emotional status improved significantly over time in the FaCoT group compared with the control, with small to large effect size values. Conclusion: The efficacy of FaCoT was established. FaCoT should be considered for community-dwelling individuals with mild stroke.


Introduction
Mild stroke is often overlooked, since individuals are independent in mobility and self-care and experience minimal neurological deficits [1]. However, individuals with mild stroke often experience difficulties in returning to their premorbid instrumental activities of daily living (IADL, such cooking or shopping), leisure activities, and work [1,2]. In addition, they typically experience mood disorders (such as depression and anxiety) as well as personality and behavioral changes [3,4], which might prevent them from returning to their life before the stroke [5]. These changes may include emotional instability, hypersensitivity, difficulty in expressing emotions, aggression, irritability, or apathy [6]. Individuals with mild stroke have also reported feelings of 'loss of control' and 'chaos', which may lead to changes in their perception of 'self' [7]. These perceptions, which are often not apparent to others, may explain their restricted participation and low self-reported quality of life [8,9].
Additionally, individuals with mild stroke may experience a gap between their actual and perceived ability to perform previous or new meaningful occupations [6], attributed to insecurity and low self-efficacy. Self-efficacy, defined as the individual's belief in their ability to perform a skill or task as well as belief in their behavior [10], is one of the core concepts of Bandura's Social Cognitive Theory. Self-efficacy influences how people feel, think, motivate themselves, and behave in relation to their health [11]. Self-efficacy is also sample size was calculated in G-Power analyses for F-test ANOVA repeated measures with 80% power and a significance level of 0.05 based on the primary outcome measure, the Canadian Occupational Performance Measure (COPM) [34]; 33 participants were recruited per group after accounting for a 15% dropout.

Randomization
Potential participants were invited to the assessment session (T1). Since this intervention is a functional-cognitive intervention, which might be impacted by the participant's cognitive status, participants found eligible were stratified by cognitive status (by a Montreal Cognitive Assessment (MoCA) [35] score ≤22 points or ≥23 points) and then randomly assigned to either the FaC o T or the control group (ratio 1:1).

Intervention
FaC o T includes 10 weekly 1 h individualized sessions, led by an experienced occupational therapist (OT). It entails task analysis of the participant's personal functional goals, defined as a goal to achieve a specific activity (such as preparing dinner or participating in social activities) that was identified using the COPM. Then, cognitive strategies of 'initiation', 'inhibition', 'planning', and 'decision making' were taught and practiced in the first half of the session in different everyday scenarios. Then, behavioral strategies, i.e., 'selfperception', 'situation interpretation', and 'future prediction', were taught and practiced using two personas-a positive persona (with high self-efficacy) and a negative persona (with low self-efficacy) in different everyday scenarios. Between the weekly sessions, participants were encouraged to perform daily activities and report back (success logs).
In line with the previous article, we will now demonstrate how all four of Bandura's [36] sources were incorporated into FaC o T sessions in order to enhance self-efficacy: 'Mastery Experience', 'Vicarious Experience', 'Verbal Persuasion', and 'Physiological Feedback'. 'Mastery Experiences', which is considered the most important factor, was attained by providing the participants with a sense of success using strategies to overcome a specific difficulty in daily living (based on the task analysis). The experience of success was also highlighted in the intervention by success logs, which helped raise the participants' awareness, even when occupational goals were only partially achieved (for example, the participant initiated 'small talk' with one of his employees, as part of his goal to improve his interpersonal communication). Modeling and 'Vicarious Experience' were achieved using everyday scenarios of 'case studies' who had a stroke and, similar to the participant, experienced difficulties in daily living. By utilizing cognitive and behavioral strategies, participants with the OT analyzed the case studies to help them deal with different situations by utilizing strategies, which can be then used in their own life. 'Verbal Persuasion' was achieved using positive therapeutic language and positive feedback throughout FaC o T. In addition, the participants' personal abilities, efforts, and progress were emphasized, which facilitated hope and increased the participants' self-efficacy. 'Physiological Feedback' was integrated by psycho-education and uncovering hidden symptoms and linking them to their function post stroke. In addition, physiological and emotional symptoms such as fatigue, cognitive impairments, and low self-efficacy were brought to the participants' awareness, and the impact of these on their daily living was highlighted. In addition, by analyzing the behavior and thoughts of two personas, the implications of the different points of view were easily understood. As the sessions progressed, the participants gradually transferred these strategies to their own feelings and emotions, and they became more aware of their consequences for their daily activity and wellbeing.
Following each session, the OT filled in a fidelity checklist and kept a log of the participants' comments and reactions. (See Figure 1 for a description of the FaC o T session process and the incorporation of strategies).
Following each session, the OT filled in a fidelity checklist and kept a log of the participants' comments and reactions. (See Figure 1 for a description of the FaCoT session process and the incorporation of strategies).
The control group did not receive rehabilitation services at the time of the study, which is considered standard care for most cases following mild stroke. They did undergo a full cognitive, behavioral, and emotional assessment (the same as the FaCoT group). Figure 1. The process of FaCoT treatment sessions and the incorporation of the cognitive strategies (light gray rectangles) and behavioral strategies (black triangles). A task analysis of specific activities revealed the specific difficulty of the daily activities. Executive function deficits and low self-efficacy that explain this difficulty were analyzed, and then cognitive and behavioral strategies were used to overcome the difficulty. Participants practiced the use of strategies and were encouraged to perform daily activities at home. During the next session, participants shared their experiences, feelings, and emotions from the previous week.

Instruments
The New General Self-Efficacy Scale (NGSE) [37] assessed self-efficacy. This self-report questionnaire comprises eight items that are rated using a 5-point Likert scale, from 1 (strongly disagree) to 5 (strongly agree), for example, "I will be able to achieve most of the goals that I have set for myself", or "I am confident that I can perform effectively on different tasks". The total score ranges from 8 to 40 points; a higher score indicates higher self-efficacy. The Geriatric Depression Scale (GDS) [38] was used to assess depressive symptoms. This 15-item self-report questionnaire ranges from 0 to 15 points; a score of 6 or higher indicates having depressive symptoms after stroke [39]. The Dysexecutive Questionnaire (DEX) [40] was used to assess the behavioral, emotional, and cognitive aspects related to the dysexecutive syndrome. It includes 20 questions rated on a 5-point Likert scale and produces three subscale scores [41]; the behavioral (0-32 points) and emotional (0-12 points) scores are reported here. The Reintegration to Normal Living Index (RNLI) [42] was used to assess participation by 11 statements regarding reintegration to productive, social, and leisure activities, rated from 0 (disagree) to 10 (strongly agree). In addition to the RNLI total score (0-100 points), two subscales can be calculated: 'Daily Living' (0-80 points) and 'Perception of Self' (0-30 points) [42], which evaluate how individuals perceive their ability to generally deal with situations. The RNLI 'Perception of Self' score was used as an additional measure of self-efficacy; higher scores indicate high self-perception.
In addition, we collected demographic (age, gender, education, and premorbid function), stroke (date, side, and type of lesion as well as the stroke severity measured by Figure 1. The process of FaC o T treatment sessions and the incorporation of the cognitive strategies (light gray rectangles) and behavioral strategies (black triangles). A task analysis of specific activities revealed the specific difficulty of the daily activities. Executive function deficits and low self-efficacy that explain this difficulty were analyzed, and then cognitive and behavioral strategies were used to overcome the difficulty. Participants practiced the use of strategies and were encouraged to perform daily activities at home. During the next session, participants shared their experiences, feelings, and emotions from the previous week.
The control group did not receive rehabilitation services at the time of the study, which is considered standard care for most cases following mild stroke. They did undergo a full cognitive, behavioral, and emotional assessment (the same as the FaC o T group).

Instruments
The New General Self-Efficacy Scale (NGSE) [37] assessed self-efficacy. This selfreport questionnaire comprises eight items that are rated using a 5-point Likert scale, from 1 (strongly disagree) to 5 (strongly agree), for example, "I will be able to achieve most of the goals that I have set for myself", or "I am confident that I can perform effectively on different tasks". The total score ranges from 8 to 40 points; a higher score indicates higher selfefficacy. The Geriatric Depression Scale (GDS) [38] was used to assess depressive symptoms. This 15-item self-report questionnaire ranges from 0 to 15 points; a score of 6 or higher indicates having depressive symptoms after stroke [39]. The Dysexecutive Questionnaire (DEX) [40] was used to assess the behavioral, emotional, and cognitive aspects related to the dysexecutive syndrome. It includes 20 questions rated on a 5-point Likert scale and produces three subscale scores [41]; the behavioral (0-32 points) and emotional (0-12 points) scores are reported here. The Reintegration to Normal Living Index (RNLI) [42] was used to assess participation by 11 statements regarding reintegration to productive, social, and leisure activities, rated from 0 (disagree) to 10 (strongly agree). In addition to the RNLI total score (0-100 points), two subscales can be calculated: 'Daily Living' (0-80 points) and 'Perception of Self' (0-30 points) [42], which evaluate how individuals perceive their ability to generally deal with situations. The RNLI 'Perception of Self' score was used as an additional measure of self-efficacy; higher scores indicate high self-perception.
In addition, we collected demographic (age, gender, education, and premorbid function), stroke (date, side, and type of lesion as well as the stroke severity measured by NIHSS [33]), and independence in daily living information (total score of the Functional Independence Measure (FIM) [43]).

Data Analysis
All data were analyzed using SPSS version 26. Descriptive statistics (t-tests for independent samples or the chi-square test) were used to describe the groups and the dependent variables at T1, T2, and T3. Normality testing of the data was performed using the Shapiro-Wilk test (p > 0.05). Differences between groups pre-intervention were analyzed using t-tests for independent samples (continuous measures) or chi-square tests (for dichotomous measures). A repeated measures 2(groups)X 3(time) analysis of variance ANOVA was used to compare within-and between-group scores, as well as for the interaction effect. To correct for the degrees of freedom, Mauchly's test of sphericity was used, and the Greenhouse-Geisser procedure was conducted. Partial eta squared (ï P 2 ) was used to calculate the magnitude of the difference; 0.01, 0.06, and 0.14 values were considered small, medium, and large effect sizes, respectively [44]. To better understand the main effect of time, post-hoc pairwise comparisons with Bonferroni correction were performed. Group effects were interpreted by t-test for independent samples with Cohen's d. Intention-to-treat analysis was used with the last observation carried over [45].

Results
Individuals with mild stroke were recruited from lists from a community-based healthcare service between March 2017 and February 2020 and were randomly allocated to the FaC o T group ((n = 33, 33.3% women, mean (SD) age-64.6 (8.2)) or the control group ((n = 33, 45.4% women, mean (SD) age-64.4 (10.8)). See Figure 2 for the recruitment, allocation, and flow of participants. As shown in Table 1, most participants from both groups had a first ischemic subcortical mild stroke, and per inclusion criteria, they were independent in BADL. Participants from both groups identified four personal functional goals and reported low performance (FaC o T group mean (SD) 3.1 (1.3); control 3.7 (1.3) out of a maximum 10 points) and low satisfaction from their performance (FaC o T group 2.4 (1.3); control 3.1 (2.1) out of a maximum 10 points). In addition, their self-efficacy was somewhat low (FaC o T group 29.1 (7.7); control group 25.5 (9.5) out of a maximum 40 points), and 48.5% of the FaC o T group and 45.5% of the control group reported depressive symptoms. Groups were similar pre intervention (see Table 1). NIHSS [33]), and independence in daily living information (total score of the Functional Independence Measure (FIM) [43]).

Data Analysis
All data were analyzed using SPSS version 26. Descriptive statistics (t-tests for independent samples or the chi-square test) were used to describe the groups and the dependent variables at T1, T2, and T3. Normality testing of the data was performed using the Shapiro-Wilk test (p > 0.05). Differences between groups pre-intervention were analyzed using t-tests for independent samples (continuous measures) or chi-square tests (for dichotomous measures). A repeated measures 2(groups)X 3(time) analysis of variance ANOVA was used to compare within-and between-group scores, as well as for the interaction effect. To correct for the degrees of freedom, Mauchly's test of sphericity was used, and the Greenhouse-Geisser procedure was conducted. Partial eta squared (ɳP 2 ) was used to calculate the magnitude of the difference; 0.01, 0.06, and 0.14 values were considered small, medium, and large effect sizes, respectively [44]. To better understand the main effect of time, post-hoc pairwise comparisons with Bonferroni correction were performed. Group effects were interpreted by t-test for independent samples with Cohen's d. Intention-to-treat analysis was used with the last observation carried over [45].

Results
Individuals with mild stroke were recruited from lists from a community-based healthcare service between March 2017 and February 2020 and were randomly allocated to the FaCoT group ((n = 33, 33.3% women, mean (SD) age-64.6 (8.2)) or the control group ((n = 33, 45.4% women, mean (SD) age-64.4 (10.8)). See Figure 2 for the recruitment, allocation, and flow of participants. As shown in Table 1, most participants from both groups had a first ischemic subcortical mild stroke, and per inclusion criteria, they were independent in BADL. Participants from both groups identified four personal functional goals and reported low performance (FaCoT group mean (SD) 3.1 (1.3); control 3.7 (1.3) out of a maximum 10 points) and low satisfaction from their performance (FaCoT group 2.4 (1.3); control 3.1 (2.1) out of a maximum 10 points). In addition, their self-efficacy was somewhat low (FaCoT group 29.1 (7.7); control group 25.5 (9.5) out of a maximum 40 points), and 48.5% of the FaCoT group and 45.5% of the control group reported depressive symptoms. Groups were similar pre intervention (see Table 1).
No between-subject effects were found.
Significant within-subject effects were found for GDS for both groups (F(2, 128) = 4.6, p < 0.01, ï P 2 = 0.07), with medium effect size values. Post-hoc analysis with a Bonferroni adjustment revealed that GDS significantly decreased from T1 to T3 (0.76 (95% CI, 0.08 to 1.44), p < 0.02). In the FaC o T group, 48.5% of individuals at T1 reported depressive symptoms, and only 33.3% reported these symptoms at T3. In the control group, 45.5% reported depressive symptoms at T1, and 48.5% at T3.
No between-subject effects were found.
No within-subject main effect or TimeXGroup primary effect were found.

Discussion
This paper focused on evaluating the impact of FaC o T on self-efficacy, behavior, emotional status, and self-perception of individuals with mild stroke compared to a control group. Previously, we reported that participants who received FaC o T improved their performance and satisfaction in daily living [27]. Findings of this study also demonstrated improvement in self-efficacy, which is a person's belief in their own ability and our secondary outcome measure. We can carefully suggest that these two aspects are related and had a mutual effect, as improvement in self-efficacy could have led to the improved occupational performance and satisfaction, and vice versa [27]. This positive change was also apparent at the three-month follow-up. These encouraging findings were achieved possibly because all four sources of Bandura's theory [36] were incorporated into the FaC o T to increase self-efficacy, as suggested previously [46]. 'Mastery Experience', 'Vicarious Experience', 'Verbal Persuasion', and 'Physiological Feedback' were interpreted and adapted to promote self-efficacy and daily living and to achieve the participant's personal goals. Stroke self-management programs have used different strategies and have focused on several domains, such as social support, communication, knowledge, goal setting, and lifestyle [47]. However, self-efficacy strategies to improve daily activity have rarely been used [48]. Previous stroke self-management programs have included small samples that were heterogeneous in terms of stroke severity and stage of recovery [49].
Significant improvements at T2 and T3 with medium to large effect size values for FaC o T compared with the control group were observed: a decrease in depressive symptoms (GDS) and an increase in the behavior and emotional status (DEX) for the FaC o T group. Post-stroke depression and emotional problems can negatively affect stroke recovery and rehabilitation [50][51][52][53] even after 6 months among individuals with mild to moderate stroke [54]; therefore, these findings are important. Aiming to explain these positive changes, we can suggest a few directions. Depression has a long-term negative effect on functional outcomes post stroke [55,56], and low functional ability may lead to an impact in depression, revealing a vicious cycle between the two constructs [57,58]. Therefore, possibly by improving activities of daily living and achieving their occupational goals (as we previously reported) [27], participants might have improved their emotional state. Executive function deficits are also associated with depression [59,60]; therefore, by teaching the use of cognitive strategies (for 'initiation', 'inhibition', 'planning', and 'decision making'), participants might have felt more control and also improved their behavioral and emotional status.
The FaC o T group improved their self-perception to participate in daily activities at T2 as well at T3 compared with the control group. Individuals with (mild) stroke are often unaware of the precise impairments and the impact on their function and health [61,62]. The psycho-education aspect within FaC o T helped to uncover the participants' hidden dysfunctions and link them to the stroke, making them aware of the consequences. Participants may have gained control over the situation as they became increasingly aware of both their abilities and limitations. Additionally, the use of the negative and positive personas within the sessions may have increased their awareness regarding how their self-perception may impact their daily living [63], leading to more improvement in the FaC o T participants.
Our study has several limitations. Our main limitation is that our control group did not receive an alternative intervention but rather received standard care. Therefore, although assessments pre, post, and at follow-up were administered, including defining occupational goals, the effects of meeting and talking with a supportive and compassionate therapist were not controlled for in this study. Participants were heterogeneous in terms of time since stroke, but most participants were in the chronic stage post stroke. Our 3-month follow-up period was relatively short; future research should include a longer follow-up period. We assessed the emotional and behavioral status and self-perception of individuals using subscales of acceptable assessments. Further research should also include full self-report questionnaires.

Conclusions
FaC o T has efficacy in enhancing the self-efficacy, emotional-behavioral status, and the self-perception of individuals with mild stroke compared with standard care. Therefore, the implementation of FaC o T as a community-based rehabilitation program should be considered for individuals with mild stroke, who usually do not receive formal rehabilitation.