Computer-based interventions for stroke survivors: A systematic review.

Physical, behavioral, and social outcomes after stroke are determined by the complex interaction of external states (eg, mobility) and internal states (eg, emotional distress). Improving these outcomes, collectively called health-related quality of life (HRQOL), requires their accurate measurement. To identify important HRQOL constructs that are associated with poststroke recovery and assess whether the Stroke-Specific Quality of Life (SSQOL) Scale, which measures 12 physical and psychosocial outcomes, adequately captures HRQOL for survivors of stroke. This qualitative study was conducted between October 1, 2023, and December 31, 2024, at 2 US comprehensive stroke centers. Stroke survivors and caregivers participated in 2 consecutive focus group sessions: the first on physical well-being and the second on emotional well-being. All stroke survivors completed the SSQOL survey. Physical and emotional well-being in recovery after stroke. Identification of themes regarding HRQOL constructs and their coherence with the SSQOL Scale. The framework method was used for qualitative analysis, and joint displays were used to assess coherence between qualitative themes and SSQOL Scale domains. A total of 41 participants (median age, 55 years [range, 27-77 years]; 22 women [54%]) were recruited nationally; the cohort comprised 30 stroke survivors and 11 caregivers. Qualitative analysis demonstrated 5 key HRQOL constructs crucial to physical and emotional well-being in recovery. Reduced physical functioning and reduced social participation were key external states associated with recovery. Loss of independence, feelings of shame, and the fear of uncertainty were key internal states associated with HRQOL. This analysis confirms that the SSQOL Scale adequately captures the external states associated with HRQOL (reduced physical functioning and reduced social participation). However, internal states were only partially captured by SSQOL Scale. This qualitative study of lived experiences among stroke survivors and caregivers suggested that internal states shape recovery but were not fully captured in a validated, widely used HRQOL assessment, highlighting a potential gap that may be unaddressed in routine poststroke care. Future studies are required to understand which combination of validated assessments may provide more comprehensive assessments of HRQOL during poststroke recovery.

Introduction: Health-related quality of life is a significant outcome of stroke survivors’ recovery. The 49-item English version of the Stroke Specific Quality of Life Scale (SSQOL) (Williams et al., 2009) is a stroke-specific assessment of stroke survivors’ health-related quality of life in 12 domains. However there has been no Chinese version of the scale for Chinese stroke survivors in Hong Kong. Aim: To examine the reliability and validity of the Chinese version of Stroke Specific Quality of Life Scale (SSQOL-C) in stroke survivors. Methods: SSQOL was translated into Chinese and blind back-translated by independent bilingual baccalaureate nursing students. Content validity was reviewed by an expert panel which consisted of one nurse academic, one nurse manager, three advanced practice nurses, and two registered nurses. A cross-sectional study was conducted to validate the translated version. A convenience sample of 135 adult stroke survivors were recruited from three community centres and a stroke support group in Hong Kong. Internal consistency analysis was performed. Pearson’s correlation coefficients were calculated between SSQOL-C, SF-36, and Frenchay Activities Index (FAI) to determine the convergent validity. Results: Content validity index of SSQOL-C was 0.99. SSQOL-C had high internal consistency with Cronbach’s alpha of 0.94 for the total scale, and between 0.65 and 0.90 for the 12 domains. The total SSQOL-C scores showed significant positive correlations with SF-36 physical health (r=0.58, p<0.01) and mental health (r=0.54, p<0.01) component scores, and FAI score (r=0.59, p<0.01). SSQOL-C physical subtotal scores showed significant positive correlations with SF-36 physical health (r=0.55, p<0.01) and mental health (r=0.43, p<0.01) component scores, and FAI score (r=0.54, p<0.01). SSQOL-C psychosocial subtotal scores showed significant positive correlations with SF-36 physical health (r=0.52, p<0.01) and mental health (r=0.56, p<0.01) component scores, and FAI score (r=0.56, p<0.01). Conclusion: The results showed SSQOL-C had good content and convergent validity, and reliability in Chinese stroke survivors. Further evaluation of factor structure of SSQOL-C will be conducted to determine its validity.

Background: Visual arts-based interventions may have potential effects on post-stroke physical and psychosocial outcomes, but the current evidence is unclear. Objectives: (1)To determine the effects of visual arts-based interventions on physical and psychosocial outcomes among stroke survivors, and (2)to identify the best practice of visual arts-based interventions that have optimal effects on physical and psychosocial outcomes among stroke survivors. Methods: Seventeen databases were searched. Two reviewers independently screened for the eligible studies, appraised methodological quality assessment, and extracted data. Methodological quality was assessed using the revised Cochrane risk of bias tool for randomised trials. Meta-analysis was conducted using Review Manager 5.4, and narrative synthesis was performed if there was insufficient data for meta-analysis. Grading of Recommendations Assessment, Development and Evaluation was adopted to assess the certainty of evidence. Results: Seven studies were included in this review. The pooled results suggested that visual arts-based interventions had significant effects on activities of daily living (SMD: 0.96, 95%CI: 0.24 to 1.69, p =0.009, I 2 =87%), upper limb function (SMD: 0.83, 95%CI: 0.42 to 1.24, p <0.0001; I 2 =6%), and depressive symptoms (SMD: -1.14, 95%CI: -1.67 to -0.61, p <0.0001, I 2 =70%). While the effect on hand function (SMD: 0.47, 95% CI: -0.43 to 1.37, p =0.31; I 2 =82%) and anxiety (SMD: -0.80, 95%CI: -1.71 to 0.11, p =0.08; I 2 =86%) were non-significant. Narrative synthesis showed that the effects of visual arts-based intervention on self-efficacy, social participation, and quality of life were uncertain. This review also found that five non-visual art activities with education, task orientation, sharing, feedback, and support as parts of the component of visual arts-based interventions might contribute to the benefits of physical and psychosocial outcomes after stroke. Conclusion: This review found that stroke survivors may benefit from visual arts-based interventions to improve physical and psychosocial outcomes. However, the quality of evidence was relatively low, further rigorous randomised controlled trials are recommended to strengthen the current evidence.

Pediatric massive burn survivors experience significant impairment in long-term physical function and psychosocial distress. Pediatric patients from the United States and Mexico with major burns likely receive similar care during the initial hospitalization given that many U.S. burn centers treat children with injuries from Mexico. However, follow-up care may differ, possibly affecting physical and psychosocial outcomes. This retrospective cohort study investigated differences in psychological and physical outcomes between pediatric burn patients residing in the United States and those residing in Mexico. Analysis included 100 patients, aged 8-17 years, residents of the United States or Mexico, who were hospitalized for burn injuries between 2015 and 2023 and enrolled in the Burn Model System database. Patient-Reported Outcomes Measures Information System measures of physical and psychological functioning were analyzed. Using univariate analyses, there was a significant difference in severity of burns, with the patients from Mexico having a greater total surface area of burn and an increased likelihood of amputation. Differences in the mechanism of burn, length of hospital stay, and ventilator days were not statistically significant when controlled for TBSA. Linear regression analyses examining the association between physical outcomes and country of residence (controlling for age, sex, TBSA, etiology of burn, and amputation) showed a significant difference in physical function outcomes at 6 months (P = .012) but no difference in fatigue, pain interference, or pain intensity. Analysis of psychosocial outcomes showed no significant difference in anger, depression, anxiety, or peer relationships at 6 months.

The primary aim was to examine the prevalence of poststroke depression in Chinese stroke survivors six months after discharge from a rehabilitation hospital. A second aim was to determine whether six-month poststroke depression was associated with psychological, social and physical outcomes and demographic variables. There has been increasing recognition of the influence of depression on poststroke recovery. While some previous studies report associations between depression and social, psychological, physical and clinical outcomes, few studies had sufficient sample sizes for regression analysis thereby limiting the clinical applicability of their findings. A cross-sectional design was used. Data were collected from 124 male and 86 female stroke survivors (mean age 71.7, SD 10.2 years). The Geriatric Depression Scale was used to measure depression, the State Self-esteem Scale to measure state self-esteem, the London Handicap Scale to measure participation restriction, the Social Support Questionnaire to measure satisfaction with social support and the Modified Barthel Index to measure functional ability. Forty-two survivors (20.5%) reported mild and 33 (16.1%) reported severe depression. The presence of depression was associated with low levels of state self-esteem, social support satisfaction and functional ability. Logistic regression analysis revealed that these variables were statistically significant in predicting the probability of having depression (p < 0.05). Analyses in the present study revealed distinct patterns of correlates of depression, and the results were in agreement with prior studies that depression has a consistent positive association with physical disability, living arrangements and social support and no significant association with the different types of brain lesion. There is a need, routinely, to assess stroke survivors for depression and, where necessary, to intervene with the aim of enhancing psychological and social well-being.

Health-related quality of life (HRQoL) after stroke tends to vary across studies or across stages of stroke. It is useful to use the health utility score to compare HRQoL across studies. Physical activity after stroke also tends to vary similarly. The purpose of the present study was to determine associations between the health utility score and physical activity outcomes in stroke survivors. This cross-sectional study recruited stroke survivors who could ambulate outside, free of assistance. We assessed the health utility score with the EuroQoL 5-Dimension 3-Level questionnaire. The physical activity outcomes were the number of steps taken and duration of moderate-to-vigorous physical activity (MVPA) as measured with an accelerometer. Multiple linear regression analyses were used to determine whether the physical activity outcomes were independently associated with the health utility score. Fifty patients (age: 68.0 years; 40 men, 10 women) were included. Multiple linear regression analysis showed the health utility score to be significantly associated with the number of steps taken (β = 0.304, p = 0.035) but not with MVPA. This is the first study to examine the association between the health utility score and objectively measured physical activity in stroke survivors. Promoting physical activity especially by increasing the number of steps taken might be a priority goal in improving a patient’s health utility score after stroke.

Because stroke causes diverse functional deficits, understanding the long-term recovery pattern of each functional domain may inform prognosis and therapeutic strategies. To observe long-term changes in functional status and residual disability in survivors of first-time stroke. This cohort study was an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation. Between August 2012 and May 2015, 7858 of 10 636 screened patients with first-time strokes from 9 district hospitals in Korea provided informed consent to participate. Data were analyzed from September 2021 through February 2022. First-time stroke. Study data include multifaceted face-to-face functional assessments obtained at 8 to 9 points until 60 months after stroke onset. The Korean Mini-Mental State Examination (K-MMSE), Fugl-Meyer Assessment, Functional Ambulatory Category, American Speech-Language-Hearing Association National Outcome Measurement System Swallowing Scale, and Short Korean version of the Frenchay Aphasia Screening Test were performed from 7 days to 60 months after stroke. The Korean Modified Barthel Index was measured from 3 months to 60 months after stroke. A total of 4443 patients (2649 men [59.62%]; mean [SD] age 62.13 [12.43] years) who underwent repeated functional assessments for 60 months after stroke (3508 patients with ischemic and 935 patients with hemorrhagic stroke) were included. Overall, functions plateaued between 12 and 18 months after stroke and declined after 30 months; for example, mean (SD) K-MMSE improved from 7 days (22.89 [7.89]) to 12 months (26.03 [5.48]) (P < .001), plateaued until 36 months (26.03 [5.84]), and decreased to 48 months (26.02 [5.82]) (P < .001). Interaction associations were found between time after stroke and age, stroke severity, and stroke type in functional assessment outcomes. For example, mean (SE) FMA for ages 65 years or younger vs older than 65 years was 81.64 (0.63) vs 80.69 (0.68) at 7 days and 91.28 (0.47) vs 88.46 (0.58) at 6 months (P for interaction < .001), and for IS vs HS, it was 84.46 (0.47) vs 69.02 (1.24) at 7 days and 91.20 (0.38) vs 85.51 (0.98) at 6 months (P for interaction < .001). Mean (SE) FMA was 94.39 (0.21) at 7 days and 97.57 (0.14) at 6 months for mild stroke, 44.69 (1.18) at 7 days and 70.43 (1.21) at 6 months for moderate stroke, and 13.22 (0.99) at 7 days and 48.07 (2.62) at 6 months for severe stroke (P for interaction < .001). Factors associated with activities of daily living independence at 60 months included older age (β per 1-year increase = -0.35; standard error [SE], 0.03; P < .001), male sex (β = 2.12; SE, 0.73; P = .004), and hemorrhagic stroke type (β vs ischemic stroke = 2.35; SE, 0.81; P = .004). This study found that long-term recovery patterns in multifaceted functional domains differed from one another and varied by patient age, stroke severity, and stroke type. Understanding the diversity of long-term functional recovery patterns and factors associated with these outcomes in survivors of stroke may help clinicians develop strategies for effective stroke care and rehabilitation.

Stroke presents significant challenges for both survivors and caregivers, particularly in resource-limited settings like Zimbabwe. Identifying factors contributing to caregiver burden strain (CBS) is crucial to enhance support strategies. This longitudinal study identified caregiver and stroke survivor characteristics associated with CBS among caregivers in Harare, Zimbabwe. Altogether 188 stroke survivors and their caregivers participated with CBS assessed at 3 months and 12 months using the Caregivers Strain Index. Multiple linear regression was used to evaluate the association of explanatory variables with CBS. Model fit was evaluated using the Akaike's Information Criterion and R 2. Caregivers experiencing anxiety or depression showed increased CBS at 3 months (β = 2.46, p < 0.001) and 12 months (β = 2.73, p = 0.016). Work adjustments were associated with higher CBS at 3 months (β = 3.84, p < 0.001). Caregivers feeling overwhelmed had significantly higher CBS at 3 months (β = 3.36, p < 0.001). Stroke survivors' poor physical outcomes and reliance on health insurance were associated with CBS at 12 months (β = 4.34, p = 0.006). Caring for married stroke survivors was associated with reduced CBS (β = -2.83, p < 0.001). Caregiver anxiety, depression, work adjustments and poor physical and social outcomes in stroke survivors contributed to increased CBS. Targeted interventions addressing mental health and social support are essential to reduce CBS. Multifaceted interventions that address caregiver mental health and social support are vital to reduce CBS and improve outcomes in resource-constrained settings like Zimbabwe.

Background Post-stroke recovery is demanding. Increasing studies have examined the effectiveness of self-management programs for stroke survivors. However no systematic review has been conducted to summarize the effectiveness of theory-based stroke self-management programs. Objectives The aim is to present the best available research evidence about effectiveness of theory-based self-management programs on community-dwelling stroke survivors’ recovery. Inclusion criteria Types of participants All community-residing adults aged 18 years or above, and had a clinical diagnosis of stroke. Types of interventions Studies which examined effectiveness of a self-management program underpinned by a theoretical or conceptual framework for community-dwelling stroke survivors. Types of studies Randomized controlled trials. Types of outcomes Primary outcomes included health-related quality of life and self-management behaviors. Secondary outcomes included physical (activities of daily living), psychological (self-efficacy, depressive symptoms), and social outcomes (community reintegration, perceived social support). Search Strategy A three-step approach was adopted to identify all relevant published and unpublished studies in English or Chinese. Methodological quality The methodological quality of the included studies was assessed using the Joanna Briggs Institute critical appraisal checklist for experimental studies. Data Collection A standardized JBI data extraction form was used. There was no disagreement between the two reviewers on the data extraction results. Data Synthesis There were incomplete details about the number of participants and the results in two studies, which makes it impossible to perform meta-analysis. A narrative summary of the effectiveness of stroke self-management programs is presented. Results Three studies were included. The key issues of concern in methodological quality included insufficient information about random assignment, allocation concealment, reliability and validity of the measuring instruments, absence of intention-to-treat analysis, and small sample sizes. The three programs were designed based on the Stanford Chronic Disease Self-management program and were underpinned by the principles of self-efficacy. One study showed improvement in the intervention group in family and social roles three months after program completion, and work productivity at six months as measured by the Stroke Specific Quality of Life Scale (SSQOL). The intervention group also had an increased mean self-efficacy score in communicating with physicians six months after program completion. The mean changes from baseline in these variables were significantly different from the control group. No significant difference was found in time spent in aerobic exercise between the intervention and control groups at three and six months after program completion. Another study, using SSQOL, showed a significant interaction effect by treatment and time on family roles, fine motor tasks, self-care, and work productivity. However there was no significant interaction by treatment and time on self-efficacy. The third study showed improvement in quality of life, community participation, and depressive symptoms among the participants receiving the stroke self-management program, Stanford Chronic Disease Self-management program, or usual care six months after program completion. However, there was no significant difference between the groups. Conclusions There is inconclusive evidence about the effectiveness of theory-based stroke self-management programs on community-dwelling stroke survivors’ recovery. However the preliminary evidence suggests potential benefits in improving stroke survivors’ quality of life and self-efficacy.

Introduction: In stroke survivors, variables associated with lower quality of life (QOL) include hemiplegia, lower functional status, degree of walking ability, speed of gait, and overall walking dysfunction. The iStride TM Gait Solution, a home-use gait treatment device, has been shown to improve gait speed and other functional parameters in stroke survivors. This analysis discusses the relationship found between gait speed parameters and self-reported QOL after treatment with the iStride TM Gait Solution. Methods: Nineteen subjects were treated with the iStride TM device in their home environment for a targeted 12 sessions over four weeks. QOL was measured using the Stroke Specific Quality of Life Scale (SS-QOL) and gait speed was measured using the 10 Meter Walk Test (10MWT) at comfortable pace. Outcome measures were assessed at baseline and one-week post-treatment. Results: Results showed a statistically significant improvement from baseline to one-week follow-up for 10MWT (p=0.0001) and SS-QOL (p=0.007). The relationship between these variables appeared to be more dependent on the % improvement of gait speed and the ending gait speed being above the mean baseline speed (0.575 m/s) than the absolute improvement in gait speed. For example, subjects starting below the mean gait speed improved 23 points (14.8%) on SS-QOL (gait speed improvement = 0.22m/s) compared to 11.7 points (8%) on SS-QOL (gait speed improvement = 0.33 m/s). In addition, subjects that improved from the home ambulator category to limited community ambulator improved an average of 15.3 points (10.2%) on SS-QOL while subjects improving from limited community ambulator to full community ambulator improved only 4.8 points (4.6%) SS-QOL, despite a 0.16 m/s larger gait speed improvement. Conclusions: The results of this analysis indicate that larger gains in QOL may be achieved by focusing on patients reaching a gait speed above approximately 0.575 m/s. Our findings also support the importance of helping home ambulator stroke survivors achieve limited community ambulator status. These findings may guide clinicians who desire to improve the QOL of their patients to select effective treatment methods targeting gait speed improvement.

Effects of peer support interventions on physical and psychosocial outcomes among stroke survivors: A systematic review and meta-analysis

Objective: The objectives of this study were 1) to translate and make cultural adaptations to the English version of the SIPSO questionnaire to create a Chinese (Cantonese) version, 2) evaluate the internal consistency, test-retest reliability the C-SIPSO questionnaire, and 3) compare the SIPSO-C scores of stroke survivors with different demographic characteristics to establish the discriminant validity of the questionnaire Design: Translation of questionnaire, cross sectional study. Setting: University-based clinical research laboratory. Subjects Community-dwelling chronic stroke survivors. Interventions: Not applicable. Main measures: Subjective Index of Physical and Social Outcome, Geriatric Depression Scale, 10-metre Walk test. Results: Two bilingual professional translators translated the SIPSO questionnaire independently. An expert panel comprising five registered physiotherapists verified the content validity of the final version (C-SIPSO). C-SIPSO demonstrated good internal consistency (Cronbach’s α = 0.83) and excellent test-retest reliability (ICC3,1 = 0.866) in ninety-two community dwelling chronic stroke survivors. Stroke survivors scored higher than 10 in the Geriatric Depression Scale (U = 555.0, P < 0.001) and with the comfortable walking speed lower than 0.8ms–1 (U = 726.5; P = 0.012) scored significantly lower on SIPSO-C. Conclusion: SIPSO-C is a reliable instrument that can be used to measure the level of community integration in community-dwelling stroke survivors in Hong Kong and southern China. Stroke survivors who were at high risk of minor depression and with limited community ambulation ability demonstrated a lower level of community integration as measured with SIPSO-C

Purpose To examine the effectiveness of self-directed, off-the-shelf information and communications technology (ICT)-based interventions in improving the quality of life, physical and psychosocial outcomes of community-dwelling stroke survivors and their support persons (SP). Methods Medline, EMBASE, CINAHL and Cochrane databases were searched (2006–19th June 2020) for randomized controlled trials, controlled trials, controlled before and after studies, or interrupted time series studies that met the eligibility criteria. The quality of included studies was assessed. Interventions effectiveness was narratively synthesized, as was participant adherence and acceptability. Results Seventeen studies were eligible. Three studies were rated as low risk of bias across all methodological review criteria. Nine studies reported on interventions delivered using self-directed computer programs, two studies utilized internet or web-based support programs and six studies used mobile phone interventions. Few studies reported on intervention acceptability or adherence. Those that did generally reported good acceptability, although adherence was variable. Fifteen studies reported significant positive effects for at least one outcome examined including stroke-specific outcomes, physical outcomes, behavioural outcomes and health service use. No studies found an effect for psychosocial wellbeing. Conclusion ICT-based interventions are likely to provide benefit to stroke survivors and their SPs. However, there is a need for further robustly designed intervention studies that include larger sample sizes, longer follow-up, and outcomes for SPs. Implications for Rehabilitation ICT-based interventions with minimal clinician supervision are likely to provide some benefits to stroke survivors and their SPs. There is insufficient evidence to allow recommendations to rehabilitation professionals regarding the type, length and intensity of ICT-based interventions for specific targeted outcomes. Rehabilitation professionals should use professional judgement prior to recommending ICT-based interventions to stroke survivors and their SPs.

BackgroundThe stroke-specific quality of life 2.0 (SSQOL 2.0) scale is a valid, reliable instrument which has been widely used as a patients reported outcome measure among stroke survivors. However, the SSQOL scale has not been validated and used in any Ethiopian language. This study aimed to translate, culturally adapt, and test the psychometric properties of the SSQOL scale 2.0 in Amharic, which is the official and working language with about 34 million (23%) speakers in Ethiopia.MethodsThe adapted English version of the SSQOL 2.0 scale was translated into Amharic and then back-translated to English. An expert committee translated and created a final Amharic version of SSQOL (SSQOL-AM) scale. Pre-field testing (pilot and cognitive debriefing) was conducted with 15 post-stroke subjects. The SSQOL-Am was administered to 245 stroke survivors from four referral hospitals to determine the psychometric properties. Cronbach’s alpha and Intra-class correlation coefficient were used to calculate the internal consistency and test–retest reliability, spearman’s correlation for the convergent validity of the SSQOL-Am scale. The Standard Error of Measurement (SEM), Minimum Detectable Change (MDC), Bland Altman Limit of Agreement (LOA), Confirmatory Factor Analysis, and Exploratory Factor Analysis were also determined.ResultsThe SSQOL-Am demonstrated excellent test–retest reliability (ICC = 0.93), internal consistency (Cronbach’s alpha = 0.96), SEM 0.857, MDC 1.94, and good LOA. As postulated, the mobility domain of the tool demonstrated a significantly strong correlation with the physical function domain of the SF-36 (rho = 0.70, p < 0.001).ConclusionsThe SSQOL-Am is a valid and reliable outcome measure. The tool can be used in both clinical practice and research purposes with Amharic speaking post-stroke survivors.

Menopausal women are one of the fastest growing demographic groups globally. Virtual interventions have emerged as alternate avenues for menopausal women to manage and cope with their symptoms. The purpose of this review is to summarize existing research on the potential effects of virtual interventions for menopause management. This systematic review was written in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, PsychINFO, CINAHL, AgeLine, ERIC, ProQuest, Nursing and Allied Health Database, PsychARTICLES, and Sociology Database were used for literature search and searched from conception to December 2021. Original studies, including randomized controlled trials and quasi-experimental studies, were included if they evaluated a virtual intervention for menopause management and investigated the effects of these interventions on physical and psychosocial outcomes and/or the feasibility of these interventions among menopausal women. Included studies were published in peer-reviewed journals and assessed for quality using the Critical Appraisal Skills Program Checklists. A total of 16 articles were included in this review. Virtual interventions have the potential to improve physical health outcomes including body weight/body mass index/waist circumference, pain, blood pressure, and cholesterol. However, conflicting results were identified for the outcomes of vasomotor and endocrine symptoms, sleep, and sexual functioning. Virtual interventions might also improve psychosocial outcomes, including knowledge and patient-physician communication, although conflicting results were again identified for treatment decision-making ability, quality of life, and anxiety and depression. Virtual interventions were feasible in terms of being usable and cost-effective, and eliciting satisfaction and compliance among menopausal women. Virtual interventions might have the potential to improve the physical and psychosocial health outcomes of menopausal women, although some conflicting findings arose. Future studies should focus on including diverse menopausal women and ethnic minorities, conducting research within low- to middle-income countries and communities, further exploring intervention design to incorporate features that are age and culture sensitive, and conducting full randomized controlled trials to evaluate the effects of the interventions.