Habit Formation in an Occupational Therapy Self-Management ...

Habit Formation in an Occupational Therapy Self-Management ...

Habit Formation in an Occupational Therapy SelfManagement Intervention: The Resilient, Empowered, Active Living (REAL Diabetes) Study BETH PYATAK, PHD, OTR/L, CDE CHAN DIVISION OF OCCUPATIONAL SCIENCE AND OCCUPATIONAL THERAPY UNIVERSITY OF SOUTHERN CALIFORNIA WHAT IS OCCUPATIONAL THERAPY (OT)? Facilitates participation in everyday activities (occupations) Addresses disconnects between the activities we: Want, need, or are expected to do And what we actually DO in our everyday lives HABITS IN OCCUPATIONAL THERAPY Performance patterns are the habits, routines, roles, and rituals used in the process of engaging in occupations or activities that can support or hinder

occupational performance. Habits refers to specific, automatic behaviors; they may be useful, dominating, or impoverished. Routines are established sequences of occupations or activities that provide Occupational a structureTherapy for daily American Association. OT Practice Framework: Domain and Process (3rd Edition). Am J Occup Ther. 2014;68(Supplement_1):S1-S48. HABITS IN OCCUPATIONAL THERAPY OT has important potential role in chronic disease care through its emphasis on modifying personal habits relevant to disease management Despite strong theoretical and conceptual understanding of habit, OT lacks empirical research connecting habit theory to OT treatment and outcomes HABITS IN OCCUPATIONAL THERAPY

The role of OT in chronic disease management has been described as facilitating patients' consistent, habitual, and correct performance of health management tasks through the integration of these tasks into daily routines. The emphasis on developing consistent diabetes selfcare habits and routines forms the overarching focus of the intervention. (Pyatak et al., 2017, p. 10) DIABETES SELF-MANAGEMENT Diabetes is the quintessential selfmanaged chronic disease (Wiley et al., 2014) Seven key self-care behaviors: Healthy eating Physical activity Taking medications Self-monitoring Problem solving Healthy coping Risk reduction

TYPES OF DIABETES TYPE 1 DIABETES (T1D) TYPE 2 DIABETES (T2D) 5-10% of diabetes cases Increasing incidence Genetic/ environmental risk factors; behavior does not play role Cannot be delayed/ prevented Autoimmune disorder leading to insulin deficiency 90-95% of diabetes cases Increasing incidence

Genetic/behavioral risk factors Progressive; may be delayed or prevented Disorder of insulin resistance Initial treatment with oral medication, then once-daily YOUTHONSET T2D Less responsive to treatment than T2D Earlier initiation of intensive insulin therapy Earlier onset of complications Poorer prognosis (disability/morta lity) than T1D or T2D

DIABETES SELF-MANAGEMENT MONITORING BLOOD GLUCOSE (SMBG) 6-10x daily for people on intensive insulin regimen (83% of REAL participants) 1-2x daily for other medication regimens Upon waking, before meals, before bed, when symptoms of high or low blood TAKING MEDICATIONS Intensive insulin

regimen: many doses daily; variable Fixed insulin regimen: 1-4 doses daily; consistent Oral medications: varies, typically 1-2x daily before morning/ evening meal HEALTHY EATING Reducing sugary beverage intake Substituting junk food with healthier meal/ snack choices Accurate/ consistent serving sizes/ carbohydrate

counts DIABETES SELF-MANAGEMENT Ha bit s Motivation Knowledge and skills Access to care/supplies/ medications REAL DIABETES STUDY: RESILIENT, EMPOWERED, ACTIVE LIVING WITH DIABETES Life history Daily routine Readiness to change Understanding diabetes Performing diabetes self-care activities Communicating with providers

Advocating at work, school, and in the community Fitting diabetes care into everyday life Setting Goals Living with Diabetes Access and Advocacy Activities and Routines Habits and routines Getting support from friends and family Connecting to

others with diabetes Diabetes burnout Stress management Identifying resources Planning for the future Social Support Emotional Well-Being Long Term Health REAL INTERVENTION CONCEPTUAL MODEL quality of life

nd a o c e s tco ry ou mes diabetes distress depressive symptoms REAL STUDY PARTICIPANTS Variable Age (years) Participants 22.6 (3.5) Gender (% female)

63% Race/Ethnicity - 78% 10% 10% % Hispanic/Latino % African American % White Neighborhood income below FPL Diabetes type (% T1D) Diabetes duration (years) A1C (goal for most adults with diabetes: <7%) Medication adherence (days/week as recommended) 23.8% 75% 9.7 (5.8) 10.8 (1.9) 5.9 (1.8)

SMBG adherence (days/week as 3.3 (2.7) recommended) Pyatak EA et al. Contemp Clin Trials. 2017;54:8-17. STUDY FLOW Screened for eligibility (n=241) Enrollment Excluded (n=160) Randomized (n=81) Allocation OT intervention group (n=41) Received tx (4 sessions) (n=31) Average 8.7 5.2 sessions Attention control group (n=40) Received attn control (4) (n=33) Average 8.4 3.9 phone calls

Follow-Up Completed testing (n=35) A1C testing only (n=3) Lost to follow-up (n=3) Completed testing (n=37) A1C testing only (n=0) Lost to follow-up testing (n=3) REAL STUDY OUTCOMES A1C 0.36 diabetes-related quality of life 0.7 -0.57 0.15 Treatment p=0.0 1

Control Treatment Control p=0.0 4 REAL STUDY OUTCOMES habit strength: checking blood sugar habit strength: taking medication 3.94 2.12 1.65 0.95 Treatment Control Treatment Control p=0.0

5 p=0.3 2 SRBAI: Self-Reported Behavioral Automaticity Index INTERVENTION PROCESS: GOALS Blood glucose checking/tracking (2) 44 Nutrition/meal preparation (2/4) 28 Exercise (4) 18 Medication tracking (2) 16 Carbohydrate/meal tracking (2/4)

15 Health system navigation (3) 11 Managing diabetes supplies (2) 8 Stress management (6) 8 Social support/communication (5) 6 Action steps to access healthcare (3) 6 Communicating with care providers (3)

6 INTERVENTION PROCESS: ACTIVITIES Most Common Treatment Activities Making & Breaking Habits Blood Sugar in Context Communicating with Providers Health System Navigation Tracking Getting Support Medication Regimens Stress Management Applying Blood Sugar Knowledge Blood Sugar Checking Unexpected Events Tailoring Daily Routines Nutrition Education 130 110 80 76 71 67

58 54 49 45 44 42 40 HABIT IN THE REAL INTERVENTION Self-monitoring Environmental cues Scaffolded cues (e.g. text message reminders) Naturalistic cues (e.g. sticky notes, changing environment) Chaining with existing habits Substituting alternate behaviors [Client] identified beforedinner [blood sugar] checks as a new habit to target. She identified the following ideas to support the new habit loop (she plans to implement the starred ideas this week): *ask her boyfriend to remind her

*Leave her diabetes bag out at the dinner table *Leave a post-it at work *Leave a post-it in phone case Check after work before leaving the office Make a phone alarm [Client] identified evening meals/snacking as a problem and requested that we complete the 'how to create a habit' worksheet. Problem-solved potential cues and rewards. [Client] created an environmental cue and decided to also post his son's picture on the sign to remind him of the longterm reward of injecting bolus insulin with evening meals and snacks. NEXT STEPS AND QUESTIONS Larger-scale study incorporating:

Long-term follow-up Refine conceptual model; test mediating pathways Better measures for medication adherence, blood glucose self-monitoring habits? Refining intervention For example: Recommending 2-3 behavior change goals, preferably all actions or all inactions Habit strategies for medication adherence?

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