Browsing by Author "Sharp, Julia, committee member"

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Acute care rehabilitation utilization, access, and outcomes among hospitalized adults with traumatic brain injury
(Colorado State University. Libraries, 2024) Bukhari, Rayyan A., author; Graham, James, advisor; Weaver, Jen, committee member; Davalos, Deana, committee member; Sharp, Julia, committee member
Objective: The purpose of this dissertation was to conduct three research studies aimed at gaining a comprehensive understanding of the barriers and facilitators to equitable access to and timing of rehabilitation services, community discharge, and unplanned 90-day post-discharge hospital readmission among individuals hospitalized with Traumatic brain injury (TBI). Introduction: There are approximately 2.5 million TBI-related emergency department visits, 288,000 TBI-related hospitalizations, and 61,000 TBI-related deaths reported each year (Centers for Disease Control and Prevention, 2019). TBI is associated with high rates of disability, including limitations in performing basic activities of daily living (ADLs), such as self-care, and/or in performing physical tasks, such as mobility (Klima et al., 2019; Jessica Lo et al., 2021; Whiteneck et al., 2016). Individuals who are hospitalized with TBI should receive equitable access to multidisciplinary care, including rehabilitation services (occupational therapy [OT], and physical therapy [PT]) to address potential self-care issues, physical limitations, and cognitive deficits (National Academies of Sciences & Medicine, 2022). Early onset of acute care rehabilitation services can have positive long-term benefits for patients, including improved function, increased mobility, and enhanced quality of life (Andelic et al., 2012; Bernhardt et al., 2017; C. Y. Wang et al., 2021). A primary focus of acute care rehabilitation services is to improve patients' functional performance (Ejlersen Wæhrens & Fisher, 2007). Following acute care stays, community discharge is generally viewed as quality care indicator in acute care settings (Department of Health and Human Services [HHS], 2019). Readmission is a common concern for those who have chronic illnesses or injuries, and it is associated with higher healthcare expenses and lower quality of care (Jencks et al., 2009). Readmission rates after TBI contribute considerably to these costs, making lowering readmission rates a universal goal (Canner et al., 2016). Despite research advances and policy changes, barriers and challenges remain facing individuals with TBI (National Academies of Sciences & Medicine, 2022). Not all individuals with TBI have early access to rehabilitation services, are discharged to the community, or can avoid hospital readmission. Although several studies have addressed these issues in general population, variability in community and personal level factors among individuals with TBI need to be addressed (Office of Disease Prevention and Health Promotion & Services., 2020). Therefore, these dissertation studies are aimed at providing empirical support, further understanding, and increasing our knowledge around factors that influence individuals with TBI acute care rehabilitation services utilization and outcomes. Method: This dissertation is comprised of three studies. In Study One, we investigated how Social Determinants of Health (SDoH) impact access to and timing of rehabilitation services. Multivariable logistic and Cox regression analyses (i.e., time-to-event analyses) were used to calculate odds ratios for the likelihood of receiving OT and PT services, and hazard ratios for the duration to initiation of services among those who received these services. In Study Two, we explored whether the relationship between acute care OT/PT utilization and community discharge is moderated by functional or physical performance at discharge. Multivariable moderation logistic regression models were used to calculate odds ratios for the likelihood of community discharge among those who utilized OT/PT services. In both OT and PT models, we computed the main effect of OT/PT utilization on community discharge, the main effect of functional/physical (ADL/Mobility) performance scores at discharge on community discharge, and the moderating effect of ADL/mobility scores on the relationship between OT/PT utilization and community discharge. In Study Three, we examined the association between discharge functional status and unplanned hospital readmission. Logistic regression was performed to calculate odds ratios for the likelihood of unplanned 90-day hospital readmission among those who received rehabilitation services during their acute care stay. Results: In Study One, all community-level SDoH such as education attainment, income, and rurality did not show significant associations with access to or timing of acute rehabilitation services (p-values= 0.09 – 0.95). In Study Two, both ADL/mobility performance scores at discharge significantly moderated the relationship between OT/PT utilization and community discharge (ORs= 0.99, 95% CIs [0.98, 1.00]). In Study Three, neither discharge functional nor mobility scores were associated with readmission (p-values= 0.14 – 0.17). Among the three dissertation studies, several covariates such as age, presence of a significant other, race/ethnicity, health insurance type, TBI severity, length of stay, and comorbidity burden showed significant associations with access to or timing of acute rehabilitation services, community discharge, and readmission status (p-values= 0.04 – <0.001). Conclusion: Further investigations are needed to 1) ascertain whether our community-level SDoH variables, based on the first three digits of zip codes, adequately capture individual experiences and their impact on healthcare, or if community-level education, income, and rurality genuinely do not affect access to and timing of therapy services for hospitalized patients with TBI; 2) determine whether the consideration of ADL/mobility scores at discharge alone limits our understanding of the relationship, failing to encompass other patient-level factors that could either facilitate or impede a safe community discharge; and 3) determine whether discharge functional and mobility scores were too restrictive in capturing the full benefits of acute care rehabilitation services in reducing the risk of unplanned 90-day readmission risk in hospitalized patients with TBI.
Open Access
Addressing the threat of frost damage on peach floral buds through large-scale cold hardiness phenotyping, dynamic weather modeling and non-targeted metabolomic and proteomic analysis
(Colorado State University. Libraries, 2023) Sterle, David, author; Minas, Ioannis, advisor; Sharp, Julia, committee member; Prenni, Jessica, committee member; Caspari, Horst, committee member
Cold damage to reproductive tissues is the greatest threat to the profitability of peach (Prunus persica) growers worldwide. Cold hardiness is the extent to which peach floral buds super-freeze without suffering lethal damage. Although no changes are visible externally to floral buds for much of the dormant season, cold hardiness fluctuates as they acclimate, deacclimate and respond to abiotic stressors such as temperature or drought. A greater understanding of the mechanisms involved in these fluctuations involves accurate and frequent measurement of the extent to which cold hardiness is changing, and the ambient weather factors influencing the changes, at different stages of the dormant season. Warmer or more erratic temperature changes during the dormant season threatens peach floral buds to more frequently receive frost damage if cold hardiness becomes misaligned with the timing of lethally cold weather events. Statistical analysis of the trends and forces impacting the cold hardiness of floral buds can help identify significant patterns. These patterns can be used to better understand the physiological mechanisms affecting cold hardiness changes, and they can be used to help predict the impact of weather conditions on cold hardiness. In addition to their use in a practical sense by growers to aid in frost management decisions, accurate cold hardiness prediction models can be used to estimate what effects foreseeable climate effects can have on the outlook of future peach production. Metabolic changes are known to occur in dormant plants, although the effects of the metabolome in peaches on cold hardiness are unknown. Changes associated with cold hardiness likely follow several trends. One such trend is the fluctuations of metabolic abundances across the season, which are more associated with the endodormancy, and ecodormancy phases and the prebloom phase. These trends likely take place every dormant season as buds undergo a steady process of acclimating and deacclimating. Another trend is the response floral buds exhibit in response to acute cold events, in order to rapidly increase cold hardiness. The study of this response necessitates the monitoring of cold hardiness as well as the metabolic shift to the weather event. The response can be further elucidated by comparing cold hardiness and metabolic changes between genotypes that have different cold hardiness phenotypes. By exploring changes a cold hardy genotype undergoes, geneticists may be able to target certain metabolic expressions that may increase the frost tolerance of future cultivars. Since frost damage can be so destructive to peach production, it is necessary to understand the risks to the peach industry moving forward surrounding climate change, and it is also necessary to understand the extent to which frost tolerance can be improved in future cultivars. This study uses a multifaceted approach to cold hardiness which involves improved and large-scale cold hardiness phenotyping using differential thermal analysis, dynamic weather prediction models and associated metabolic regulation understanding.
Open Access
An empathic avatar in task-driven human-computer interaction
(Colorado State University. Libraries, 2020) Wang, Heting, author; Beveridge, Ross, advisor; Ortega, Francisco, advisor; Sharp, Julia, committee member; Peterson, Christopher, committee member
In Human-Computer Interaction, it is difficult to give machines emotional intelligence to resemble human affects, such as the ability of empathy. This thesis presents our work of an emotionally expressive avatar named Diana that can recognize human affects, and show her empathy by using dynamic facial expressions. Diana's behaviors and facial expressions were modeled from Human-Human multimodal interactions to help to provide human-like perceptions in users. Specifically, we designed her empathic facial expressions as a linear combination of the action units in the Facial Action Coding System [1], with the action units that were previously found to improve the accuracy and judgments of human likeness. Our work studies the role of affect between a human and Diana working together in a blocks world. We first conducted an elicitation study to extract naturally occurring gestures from naive human pairs. The pair of human collaborated on a task remotely through video communication to build wooden blocks. The video footage of their interactions composed a dataset named EGGNOG [2]. We provided descriptive and statistical analysis of the affective metrics between human signalers and builders in EGGNOG. The metrics included measures of valence (positive or negative experience) and intensities of 7 basic emotions (joy, fear, disgust, anger, surprise, and contempt). We found: 1) Overall the signalers had a broader range of valence and showed more varied emotions than the builders. 2) The intensity of signalers' joy was greater than that in builders, indicating a happier signaler than a builder. 3) For individuals, the person was happier to act as a signaler in a task than act as a builder. Additionally, valence was more associated with a person's role in a task and less associated with personality traits. Other emotions were all weak and no significant difference was found between signalers and builders. To adapt to the user's affects in the later Human-Avatar interaction, we modeled Diana's empathic behaviors based upon findings in EGGNOG and the Appraisal theory [3]. We created a Demo mode of Diana whose affective states, i.e., facial expressions that simulated empathy, dynamically transitioned between 5 finite states (neutral, joy, sympathy, concentration, and confusion) with respect to the user's affects and gestures. We also created a Mimicry mode of Diana who mimicked the user's instant facial expressions. Human subject studies involving three modes of this avatar (Demo, Mimicry, and Emotionless) were conducted with 21 participants. The difference in votes from a 5-point Likert scale perception questionnaire or a NASA TLX perceived load survey was both statistically insignificant. However, compared to the Mimicry Diana and the Emotionless Diana, a descriptive analysis indicated users spent more time engaging with the empathic Diana, and both the Demo and Mimicry mode of Diana were preferred by users over the Emotionless Diana. Some participants commented about Diana's facial expressions as natural and friendly while 3 other participants were elicited uncomfortable feelings and mentioned the Uncanny Valley effect. Results indicated our approach of adding affects to Diana was perceived differently by different people and received both positive and negative feedback. Our work provided another implementable direction of the human-centered user interfaces with complex affective states. However, there was no evidence that the empathic facial expressions were more preferred by participants than the mimicked facial expressions. In the future, Diana's empathic facial expressions may be refined by modeling more human-like action unit movements with the help of deep learning networks, and the user perception in subjective reports may get improved.
Open Access
Bayesian treed distributed lag models
(Colorado State University. Libraries, 2021) Mork, Daniel S., author; Wilson, Ander, advisor; Sharp, Julia, committee member; Keller, Josh, committee member; Neophytou, Andreas, committee member
In many applications there is interest in regressing an outcome on exposures observed over a previous time window. This frequently arises in environmental epidemiology where either a health outcome on one day is regressed on environmental exposures (e.g. temperature or air pollution) observed on that day and several proceeding days or when a birth or children's health outcome is regressed on exposures observed daily or weekly throughout pregnancy. The distributed lag model (DLM) is a statistical method commonly implemented to estimate an exposure-time-response function by regressing the outcome on repeated measures of a single exposure over a preceding time period, for example, mean exposure during each week of pregnancy. Inferential goals include estimating the exposure-time-response function and identifying critical windows during which exposures can alter a health endpoint. In this dissertation, we develop novel formulations of Bayesian additive regression trees that allow for estimating a DLM. First, we propose treed distributed lag nonlinear models to estimate the association between weekly maternal exposure to air pollution and a birth outcome when the exposure-response relation is nonlinear. We introduce a regression tree-based model that accommodates a multivariate predictor along with parametric control for fixed effects. Second, we propose a tree-based method for estimating the association between repeated measures of a mixture of multiple pollutants and a health outcome. The proposed approach introduces regression tree pairs, which allow for estimation of marginal effects of exposures along with structured interactions that account for the temporal ordering of the exposure data. Finally, we present a framework to estimate a heterogeneous DLM in the presence of a potentially high dimensional set of modifying variables. We present simulation studies to validate the models. We apply these methods to estimate the association between ambient pollution exposures and birth weight for a Colorado, USA birth cohort.
Open Access
Development, validation, and implementation strategies for the exercise in cancer evaluation and decision support (EXCEEDS) algorithm
(Colorado State University. Libraries, 2021) Covington, Kelley R., author; Bundy, Anita, advisor; Pergolotti, Mackenzi, advisor; Sharp, Julia, committee member; Leach, Heather, committee member
Background: Clinical practice guidelines recommend referral to cancer rehabilitation or exercise services (CRES) to optimize survivorship. Yet, ability to connect the right survivor with the right CRES at the right time is an ongoing challenge and barrier to utilization of these services. Objective: I aimed to develop a CRES decision support algorithm and used Delphi methodology to systematically: (1) evaluate the algorithm's acceptability and utility; and (2) establish consensus for implementation priorities including key stakeholders, platforms and strategies. Method: I performed a literature review and synthesis, then convened a multidisciplinary expert stakeholder group to participate in algorithm development. We worked iteratively and collaboratively until consensus was reached for content and format of the Exercise in Cancer Evaluation and Decision Support (EXCEEDS) algorithm and conceptual model. Then I recruited international clinical and research experts to participate in the two-part (three survey) online modified Delphi study. In Part 1, participants completed one survey including: (1) CRES recommendations for two randomized case studies in two conditions (using EXCEEDS vs. without EXCEEDS); (2) the Acceptability of Implementation Measure (AIM); and (3) open-ended feedback on the algorithm. Following this survey, I compared decision efficiency (accuracy and duration) between conditions (EXCEEDS vs. independently) for each case study using frequencies (hypothesis ≥75% accurate) and paired samples t-test (p <.05), then calculated consensus for each AIM domain ("meets approval", "is appealing", "welcome in my field/practice"; hypothesis ≥70% agreement) and overall score (hypothesized mean ≥ 4.0). These results were reported to participants in Part 2. I also performed inductive thematic analysis of open-ended feedback. In Part 2 of the Delphi study, participants completed a series of two surveys including ranking the following items using curated lists: (1) stakeholder group (1 -most likely to 7- least likely to benefit), (2) platform (1 - most likely to 6- least likely to be beneficial) and, implementation strategies (1 - most important to 15- least important for successful implementation). I performed preliminary analysis of each ranking using measures of central tendency (median and IQR), then calculated the proportion of participants who ranked each option as a high priority. Ten implementation strategies were ranked as high priority and returned to participants for the final survey where they rated each strategy in terms of effort associated with using the strategy (1 - low effort to 4 - high effort) and potential impact of the strategy on successful implementation of the EXCEEDS algorithm (1 – low impact to 4 - high impact). Following the Eisenhower Urgent-Important Matrix Method, I plotted the effort/impact scores in four quadrants representing effort and impact for each strategy to determine implementation priorities. Results: The final EXCEEDS algorithm combines biomedical and individual characteristics associated with need for supervised skilled CRES into 11 risk-stratified dichotomous (yes/no) questions, organized into two sections: (1) pre-exercise medical clearance recommendation, and (2) CRES triage recommendation. Delphi study participants (N=133) represented all CRES stakeholder groups (oncology, physical medicine and rehabilitation, exercise science, etc.). Loss to follow up between surveys ranged 28% (survey 3) to 43% (survey 2). When using the EXCEEDS algorithm, decision accuracy improved in six (of eight) conditions (75%) and duration improved in all conditions (N=4, p <.05). Consensus was achieved in three AIM domains (75%); overall AIM score was M=3.90 ± 0.473 (range = 1.0 – 5.0). Qualitative themes from participant feedback include: (1) algorithm strengths (n = 123, 40.9%), (2) implementation considerations (n=93, 30.5%), and (3) areas for revision (n=87, 28.5%). Oncology clinicians and administrators were the highest-ranked stakeholder group (Median=2.0, IQR= 1.0 – 3.75, 75.0% agreement) and the only one to achieve consensus. Open-access internet was the highest-ranked implementation platform (Median =2.0, IQR= 1.0 – 3.5, 72.4% agreement) and the only one to achieve consensus. Consensus was achieved for eight of the ten highest-ranked implementation strategies (80%, inter-rater agreement range = 93.4% - 71.1%). Two strategies were categorized as urgent/important: "develop educational materials" and "remind clinicians". Seven strategies were categorized important/not urgent. One strategy, "model and simulate change", was categorized as not important/not urgent. Conclusion: The EXCEEDS algorithm is an acceptable and efficient evidence-based solution to identify and connect the right survivor, with the right CRES, at the right time. Thus, implementation of the EXCEEDS algorithm guided by the consensus-based priorities identified in the Delphi study has the potential to improve CRES coordination and utilization. Future hybrid studies will be used to determine prospective efficacy and best practices for implementation.
Open Access
Exploring the impact of belonging on computer science enrollment using virtual reality
(Colorado State University. Libraries, 2021) Gaddy, Vidya, author; Ortega, Francisco R., advisor; Beveridge, J. Ross, committee member; Sharp, Julia, committee member; Interrante, Victoria, committee member
Student enrollment in STEM fields of study is critical for the future. Improving our understanding of what motivates young people to engage with material like computer programming is an essential aspect of increasing enrollment. Interest in a topic like Computer Science (CS) begins with a sense of belonging in the field. That essential sense of belonging tends to be quite evasive because it lacks a concrete definition. In this research, the goal was to dissect the main attributes associated with a sense of belonging and highlight the attributes that are key to a student's decision to enroll in CS. The attributes determined to be vital contributors to a sense of belonging were self-efficacy, family background, goal orientation, and demographic characteristics. In order to find which of these factors associated with belonging were most important, a Virtual Reality (VR) simulation and survey were designed. A simple simulated environment was used which had participants embody an avatar that was described as an undeclared first-year college student. While in the simulation, participants were prompted to listen to an audio message from the advising office which asked them if they would like to enroll in a CS course. In the pilot study (N=10), family background was the focus, randomizing avatar gender as well as the control condition and the family background condition between participants. The feedback received from participants informed all the improvements made to the main experiment. For the main experiment (N=24), there were four slightly different audio messages each highlighting one of the four factors associated with belonging in CS. Each participant listened to all four audio messages and answered survey questions about their response to the audio. A Likert Scaled survey was used to determine how likely the participants were to enroll in the CS course given each audio prompt. Results indicated that there was a strong positive reaction to the audio message highlighting goal orientation (p < 0.05) and a strong negative reaction to the audio highlighting demographic characteristics (p < 0.05). The responses toward family background and self-efficacy were more neutral. These results demonstrate that people are attracted to CS when they believe it will help them achieve their future goals in life. But perhaps more importantly, a person's demographic characteristics alone being highlighted will not be enough to increase enrollment in the field of CS.
Embargo
How are driving licensure status, delay in driving licensure, and driving exposure associated with alcohol and drug use, parental monitoring knowledge, peer alcohol and drug use, and health, education, and employment of emerging adults?
(Colorado State University. Libraries, 2023) Gao, Xiang, author; Li, Kaigang, advisor; Vaca, Federico E., committee member; Sharp, Julia, committee member; DeYoung, Wendy, committee member
Independence and mobility facilitated by driving privileges could have a major impact on alcohol and drug use, parental monitoring knowledge, peer alcohol and drug use, and health, education, and employment of emerging adults. Driving privileges may provide emerging adults with the ability to move more freely, and that mobility may affect their access to drugs and alcohol. It may also mean that emerging adults with driving privileges were more likely to be in environments where alcohol and drugs were available. Parents of emerging adults with driving privileges may be more involved in monitoring their child's driving activities, resulting in higher levels of parental monitoring knowledge. Emerging adults with driving privileges were more likely to report a higher level of peer alcohol and drug use because having access to a car allowed them to spend more time with their peers and engage in alcohol and drug use. On the other hand, driving privileges may have positive impacts on the health, education, and employment of emerging adults. Having the ability to travel to places of employment and educational institutions may open more opportunities and allow for greater access to resources. This could lead to improved academic and professional outcomes. Overall, driving privileges may have both positive and negative impacts on alcohol and drug use, parental monitoring knowledge, peer alcohol and drug use, and health, education, and employment of emerging adults. It was important to consider these trade-off impacts when considering how to best support emerging adults in their development. My dissertation explored how were driving licensure status, delay in driving licensure, and driving exposure associated with alcohol and drug use, parental monitoring knowledge, peer alcohol and drug use, and health, education, and employment of emerging adults. Data was collected from a nationally representative sample of U.S. emerging adults starting at grade 10th for a seven-year longitudinal assessment. Having driving licensure in high school, no delay in driving licensure, and higher driving exposure were associated with higher levels of alcohol and drug use, higher levels of parental monitoring knowledge, higher levels of peer alcohol and drug use, better health, higher levels of education attainment, and more working hours in emerging adulthood. My dissertation could inform policymakers and practitioners on the importance of driving privileges in promoting the well-being of emerging adults.
Open Access
Instrument development of the Vocational Fit Assessment – Self-Report and content validity procedures
(Colorado State University. Libraries, 2022) Thum, Marisa, author; Persch, Andrew, advisor; Atler, Karen, committee member; Sharp, Julia, committee member
People with intellectual and developmental disabilities (PwIDD) are unemployed in the United States at rates much higher than that of the general population. Current job matching practices rely largely on proxy-report of worker abilities, resulting in decreased opportunity for self-determination. As Patient Reported Outcome Measures rise in popularity in other fields as a means of directing patient-centered care, job matching assessments should follow to support client-directed services. The Vocational Fit Assessment (VFA) is an existing tool which compares proxy-reported worker abilities with job demands and creates job matching reports that guide and support job matching decisions. The aims of this thesis were to 1) adapt the existing Vocational Fit Assessment (VFA) into a format that is appropriate for self-report by people with intellectual and developmental disabilities and 2) develop content validity procedures to assess the adapted assessment, the Vocational Fit Assessment – Self-Report.
Open Access
Randomization tests for experiments embedded in complex surveys
(Colorado State University. Libraries, 2022) Brown, David A., author; Breidt, F. Jay, advisor; Sharp, Julia, committee member; Zhou, Tianjian, committee member; Ogle, Stephen, committee member
Embedding experiments in complex surveys has become increasingly important. For scientific questions, such embedding allows researchers to take advantage of both the internal validity of controlled experiments and the external validity of probability-based samples of a population. Within survey statistics, declining response rates have led to the development of new methods, known as adaptive and responsive survey designs, that try to increase or maintain response rates without negatively impacting survey quality. Such methodologies are assessed experimentally. Examples include a series of embedded experiments in the 2019 Triennial Community Health Survey (TCHS), conducted by the Health District of Northern Larimer County in collaboration with the Department of Statistics at Colorado State University, to determine the effects of monetary incentives, targeted mailing of reminders, and double-stuffed envelopes (including both English and Spanish versions of the survey) on response rates, cost, and representativeness of the sample. This dissertation develops methodology and theory of randomization-based tests embedded in complex surveys, assesses the methodology via simulation, and applies the methods to data from the 2019 TCHS. An important consideration in experiments to increase response rates is the overall balance of the sample, because higher overall response might still underrepresent important groups. There have been advances in recent years on methods to assess the representativeness of samples, including application of the dissimilarity index (DI) to help evaluate the representativeness of a sample under the different conditions in an incentive experiment (Biemer et al. [2018]). We develop theory and methodology for design-based inference for the DI when used in a complex survey. Simulation studies show that the linearization method has good properties, with good confidence interval coverage even in cases when the true DI is close to zero, even though point estimates may be biased. We then develop a class of randomization tests for evaluating experiments embedded in complex surveys. We consider a general parametric contrast, estimated using the design-weighted Narain-Horvitz-Thompson (NHT) approach, in either a completely randomized design or a randomized complete block design embedded in a complex survey. We derive asymptotic normal approximations for the randomization distribution of a general contrast, from which critical values can be derived for testing the null hypothesis that the contrast is zero. The asymptotic results are conditioned on the complex sample, but we include results showing that, under mild conditions, the inference extends to the finite population. Further, we develop asymptotic power properties of the tests under moderate conditions. Through simulation, we illustrate asymptotic properties of the randomization tests and compare the normal approximations of the randomization tests with corresponding Monte Carlo tests, with a design-based test developed by van den Brakel, and with randomization tests developed by Fisher-Pitman-Welch and Neyman. The randomization approach generalizes broadly to other kinds of embedded experimental designs and null hypothesis testing problems, for very general survey designs. The randomization approach is then extended from NHT estimators to generalized regression estimators that incorporate auxiliary information, and from linear contrasts to comparisons of nonlinear functions.
Open Access
Rasch analysis of the evaluation in Ayres sensory integration (EASI)
(Colorado State University. Libraries, 2022) Grady, Patricia, author; Bundy, Anita, advisor; Lane, Shelly, committee member; Hepburn, Susan, committee member; Sharp, Julia, committee member
Sensory Integration (SI) refers to the neurological process by which a person takes in sensory information, interprets this information, and uses it to inform movement and goal-directed action (Ayres, 1989). For children with a variety of diagnoses, as well as some children who are otherwise typically developing, SI may be impaired or delayed (Bundy & Lane, 2020a). Occupational therapists and other clinicians who treat children with sensory integration (SI) dysfunction face a dearth of appropriate instruments to evaluate SI function. The Evaluation in Ayres Sensory Integration (EASI; Mailloux et al., 2018) is a novel assessment tool that may allow therapists to evaluate SI in a way that is aligned with SI theory. EASI consists of 21 individual tests that measure constructs of SI. The EASI authors have collected normative data for children across the globe. However, this data must be assessed for validity and reliability before it can be used as the basis for normative scoring on the EASI. In this dissertation, I used Rasch analysis to evaluate data with 19 of the 21 tests. The Rasch model is a latent-trait psychometric model that (1) transforms ordinal-level data to interval-level data and (2) allows users to assess evidence for construct validity (unidimensionality and invariance) and internal reliability (Bond, Yan & Heene, 2020). For each of the 19 tests, I evaluated item fit statistics, rating scale fit statistics, person fit statistics, principal components analysis (PCA) of standardized residuals, differential item functioning (DIF) based on sex, person reliability index and strata. The dataset for this study comprised 2653 children from 51 countries; all data were collected by trained EASI examiners. Overall, results revealed promising evidence for construct validity and internal reliability of data collected using 16 of the19 EASI tests evaluated in this dissertation. However, across many tests, I observed lower-than-desired person fit statistics and reliability. Notably, these results were not far from the desired values. I hypothesized that these findings are the result of the overall high ability level of the normative population. EASI is designed to evaluate children with lower-than-average or poor SI function; therefore, these findings are not unexpected nor are they particularly concerning. Three EASI tests (Proprioception: Force, Proprioception: Joint Position, and Balance) required substantial revision as a result of these analyses; each had threats to construct validity that exceeded my expectations. In this dissertation, I provided potential solutions for these three tests; future studies will evaluate the extent to which these solutions resolve concerns. In conclusion, the normative data form an acceptable basis for creating norm-based scores for clinical interpretation. However, larger studies must be conducted with clinical populations to ensure that the tests can differentiate between children with and without SI dysfunction. Further, future studies should investigate the role of culture, language and other factors on the validity of EASI test scores.
Open Access
Reexamining occupational and physical therapists' use of the "6-Clicks" assessment in acute care as a tool to inform discharge location recommendations
(Colorado State University. Libraries, 2018) Fawaz, Emily O'Connor, author; Pergolotti, Mackenzi, advisor; Malcolm, Matthew, committee member; Sharp, Julia, committee member
Background: The "6-Clicks" is a functional status measure used in acute care rehabilitation settings to inform discharge recommendations. Research is limited examining the assumption of first versus last score on outcomes measures and other factors known to influence discharge recommendation. The purpose of this study was to address those gaps in research. Methods: Hospital electronic medical record data from adults admitted to a neurosciences unit between June 2014 and June 2016 were analyzed retrospectively. Logistic regression models were used to compare initial and final "6-Clicks" score for both the Daily Activity and Basic Mobility forms used in acute care as predictors of a home versus not-home discharge. Hierarchical linear regression models were used to examine the impact of predisposing, enabling and illness level factors on discharge location. Results: 1513 individuals were included; 55% of which were discharged home. Final scores were significantly higher than initial scores. Compared to those discharged home, individuals had significantly lower scores across both forms. Final scores were stronger predictors than initial scores. "6-clicks" score, length of stay, and having Medicaid emerged as significant predictors of discharge location. Conclusions: Final "6-Clicks" scores may indicate a more appropriate discharge location based on current status rather. Recommendations based on factors other than need, such as payer type, may have severe implications, potentially on readmission and disparities in quality of care.
Open Access
Structural analysis along the Ouray fault, southwestern Colorado: implications for the kinematic development of the late Paleozoic Ancestral Rocky Mountains
(Colorado State University. Libraries, 2021) Johnson, Erinn P., author; Singleton, John, advisor; Sutton, Sally, committee member; Sharp, Julia, committee member
The Ouray fault in southwest Colorado provides insight into the geometry and kinematics of deformation during the formation of the late Paleozoic Ancestral Rocky Mountains (ARM). The Ouray fault strikes WNW-ESE and dips subvertically to steeply south, juxtaposing the Paleoproterozoic Uncompahgre Group on the south side against Mississippian-Pennsylvanian strata on the north side. Kinematic data from the Ouray fault, adjacent small-scale faults, the observed offset, and folds in Paleozoic strata indicate that the Ouray fault records sinistral transpression. Using the average 15° W-plunging slickenlines from the principal slip plane, we estimate the total oblique sinistral displacement of the fault to be ~600 to 800 m. The uniformly overlapping Mesozoic strata atop the projected trace of the Ouray fault indicate that the fault is a preserved ARM structure not reactivated during the Laramide orogeny. The Ouray fault is oriented subparallel to the Uncompahgre Group bedding and follows the weaker Uncompahgre phyllite for most of its length, suggesting the preexisting structures within the Uncompahgre Group greatly influenced the orientation of the Ouray fault. N-S- to NW-SE-striking joints and quartz veins in all geologic units spanning the Paleoproterozoic to the Cenozoic postdate slip on the Ouray fault and likely formed during Cenozoic magmatism. A sample of calcite from the principal slip plane of the Ouray fault yielded a U-Pb date of 39.3 ± 6.2 Ma. I interpret this date to record resetting by late Eocene hydrothermal fluid flow. The record of strain around the Ouray fault may be representative of the southwestern margin of the Ancestral Uncompahgre uplift in Colorado. This study supports recent tectonic models for the ARM system which propose that ARM uplift was driven by NE-SW compression during the Pennsylvanian and Permian periods.
Open Access
The impact of referent display on interaction proposals during multimodal elicitation studies
(Colorado State University. Libraries, 2021) Williams, Adam S., author; Ortega, Francisco R., advisor; Beveridge, Ross, committee member; Sharp, Julia, committee member
Elicitation studies have become a popular method of participatory design. While traditionally used for finding unimodal gesture-based inputs elicitation has been increasingly used for deriving multimodal interaction techniques. This is concerning as there has been no work that examines how well elicitation methods transfer from unimodal gesture use to multimodal combinations of inputs. This work details a comparison between two elicitation studies that were similar in design apart from the way participants were prompted for interaction proposals. Referents (e.g., commands to be executed) were shown as either text or animations. Interaction proposals for speech, gesture, and gesture+speech input modalities were elicited. Based on the comparison of these studies and other existing elicitation studies the concern of referent display priming uses proposed interaction techniques is brought to light. The results from these elicitation studies were not reproduced. Gesture proposals were the least impacted. With high similarity in the overall proposal space. Speech was biased to have proposals imitating the text as displayed an average of 69.36%. The time between gesture and speech initiation in multimodal use was 166.51% longer when prompted with text. The second contribution of this work is a consensus set of mid-air gesture inputs for use with generic object manipulations in augmented reality environments. This consensus set was derived from the elicitation study that used text-based referent displays which were found to be less biasing on participant gesture production than the animated referents.
Open Access
Understanding user interactions in stereoscopic head-mounted displays
(Colorado State University. Libraries, 2022) Williams, Adam S., author; Ortega, Francisco R., advisor; Beveridge, Ross, committee member; Gersch, Joe, committee member; Sharp, Julia, committee member
Interacting in stereoscopic head mounted displays can be difficult. There are not yet clear standards for how interactions in these environments should be performed. In virtual reality there are a number of well designed interaction techniques; however, augmented reality interaction techniques still need to be improved before they can be easily used. This dissertation covers work done towards understanding how users navigate and interact with virtual environments that are displayed in stereoscopic head-mounted displays. With this understanding, existing techniques from virtual reality devices can be transferred to augmented reality where appropriate, and where that is not the case, new interaction techniques can be developed. This work begins by observing how participants interact with virtual content using gesture alone, speech alone, and the combination of gesture+speech during a basic object manipulation task in augmented reality. Later, a complex 3-dimensional data-exploration environment is developed and refined. That environment is capable of being used in both augmented reality (AR) and virtual reality (VR), either asynchronously or simultaneously. The process of iteratively designing that system and the design choices made during its implementation are provided for future researchers working on complex systems. This dissertation concludes with a comparison of user interactions and navigation in that complex environment when using either an augmented or virtual reality display. That comparison contributes new knowledge on how people perform object manipulations between the two devices. When viewing 3D visualizations, users will need to feel able to navigate the environment. Without careful attention to proper interaction technique design, people may struggle to use the developed system. These struggles may range from a system that is uncomfortable and not fit for long-term use, or they could be as major as causing new users to not being able to interact in these environments at all. Getting the interactions right for AR and VR environments is a step towards facilitating their widespread acceptance. This dissertation provides the groundwork needed to start designing interaction techniques around how people utilize their personal space, virtual space, body, tools, and feedback systems.
Embargo
Vocational rehabilitation assistive technology, access, supported employment, and employment outcomes for transition-aged young adults with cognitive disabilities
(Colorado State University. Libraries, 2024) Alshamrani, Khalid, author; Graham, James, advisor; Roll, Marla, advisor; Jennings, Louise, committee member; Sharp, Julia, committee member
Objective: The purpose of this dissertation was to conduct three research studies aimed at understanding the barriers and facilitators to equitable access to vocational rehabilitation (VR) assistive technology (AT), its utilization in supported employment (SE), and the resulting competitive integrated employment (CIE) outcomes of transition-aged young adults (TAYA) with cognitive disabilities. Introduction: TAYA with disabilities face significantly higher rates of unemployment and underemployment than their peers without disabilities. For TAYA with cognitive disabilities, these disparities are even more pronounced, making them one of the most excluded groups from the labor force. Despite cognitive disabilities being the largest disability group served by state VR programs, this population continues to face poor employment outcomes upon exiting these programs. Although there is growing evidence of AT's potential to improve employment outcomes, AT support remains underutilized for TAYA with cognitive disabilities, with notable disparities in its utilization. Methods: Study One employed a retrospective cross-sectional study using Rehabilitation Services Administration Case Service Report (RSA-911) data from 2017 to 2019, a period before the COVID-19 pandemic impacted state VR service operations. Multivariable logistic regression analysis was conducted to examine the main and interaction effects of various sociodemographic variables commonly considered in disparities research on the likelihood of receiving AT services among TAYA with disabilities participating in state VR programs. This study provides a baseline understanding of disparities and access to AT services among TAYA with disabilities served by state VR programs in a pre-pandemic context. Study Two was a qualitative study. We conducted focus groups to gather insights from four key stakeholder groups—VR policymakers and funders, VR service providers, employers, and TAYA with cognitive disabilities and their families. The focus was on exploring their perspectives and experiences related to the transition to virtual support and how TAYA with cognitive disabilities accessed and utilized AT devices and services for facilitating their CIE during and following the COVID-19 pandemic. All focus group sessions were held virtually and video recorded and analyzed using thematic analysis. Study Three was another retrospective cross-sectional study using RSA-911 data from July 2017 to June 2022. We investigated how the receipt of AT and/or SE services was independently associated with obtaining CIE at program exit, and how the probabilities of achieving CIE varied across the pre-COVID, during COVID, and post-COVID periods among TAYA with cognitive disabilities served by state VR programs. Multivariable logistic regression analysis was used to calculate odds ratios for the likelihood of obtaining CIE at program exit among TAYA with cognitive disabilities who received the two VR services (AT, SE). To assess whether the relationships between these two VR services and CIE outcomes varied over time, interaction terms between the COVID-19 pandemic periods variable (pre-, during, and post-pandemic) and the two VR services of interest were included in the model. Results: Study One revealed that less than 3% of TAYA with disabilities received AT services. The following client characteristics were associated with a lower likelihood of receiving AT services for TAYA with disabilities: unemployed, minority, significant disability, older in age, TAYA with mental and cognitive disabilities, and not enrolled in PSE. Study Two identified key findings from focus group sessions, highlighting positive overall experiences with using mainstream mobile devices and applications. Areas for improvement beyond the pandemic include enhancing AT access through state Medicaid waivers, providing VR providers with training opportunities to deliver effective AT support to TAYA with cognitive disabilities seeking CIE who need and could benefit from such support, and ensuring the technology employed and used is accessible and usable by this population. In Study Three, more than half (55.9%) of TAYA with cognitive disabilities in the study sample did not achieve CIE at program exit. Only 1.4% received AT services and 10.7% received SE services. Overall, the receipt of AT and SE showed positive and significant associations with achieving CIE at program exit compared to those who did not receive these services. In addition, there were higher probabilities of achieving CIE outcomes during and post-COVID compared to the pre-COVID period. Conclusion: The findings from this dissertation highlight the underutilization of AT support among TAYA with disabilities served by state VR programs, particularly in addressing their job-seeking needs and transitions from education to CIE. The shift to virtual support, accelerated by the COVID-19 pandemic, increased access to mainstream mobile devices and applications for TAYA job seekers with cognitive disabilities. Before the COVID-19 pandemic, AT support access was primarily focused on supporting TAYA with cognitive disabilities who were participating in academic programs or being employed for job retention, with limited AT support for job seekers. During the pandemic, however, TAYA job seekers with cognitive disabilities had access to mainstream mobile devices and applications within the VR system. Such access allowed this population to acquire skills in using mobile devices and applications for pursuing their CIE opportunities, access job training resources, continue receiving virtual supports, and engage in virtual job interviews with potential employers. The intersection of AT and SE offers an opportunity to enhance CIE outcomes for TAYA with cognitive disabilities. The probability of achieving CIE was higher among this population receiving SE and AT support during and post-COVID than pre-COVID. This underscores the need for continued efforts to improve targeted transition policies and practices, enhance the services and supports for TAYA with cognitive disabilities, and provide AT training opportunities to VR personnel who serve this population. Increasing AT training in rehabilitation educational programs and in-service training could enhance VR AT service utilization. Further research is needed to generate evidence supporting AT use in vocational settings and to develop guidelines for its incorporation into employment transition processes. Such efforts are essential to ensuring that TAYA with cognitive disabilities have equitable opportunities and the support they need for employment success.
Open Access
Wearable fitness trackers in physical activity research: accuracy assessment and effects on motivation and engagement
(Colorado State University. Libraries, 2021) Nuss, Kayla, author; Li, Kaigang, advisor; Nelson, Tracy, advisor; Sharp, Julia, committee member; Marchant, Tasha, committee member
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