Beth Pyatak PhD, OTR/L, CDCES, FAOTA (she/her)

Associations between various forms of activity engagement (e.g. work, leisure) and the experience of stress in workers have been widely documented. The mechanisms underlying these effects, however, are not fully understood. Our goal was to investigate if perceived whole day workload accounted for the relationships between daily frequencies of activities (i.e. work hours and leisure/rest) and daily stress. We analysed data from 56 workers with type 1 diabetes (T1D) who completed approximately two weeks of intensive longitudinal assessments. Daily whole day workload was measured with an adapted version of the National Aeronautics and Space Administration Task Load Index (NASA-TLX). A variety of occupations were reported, including lawyer, housekeeper and teacher. In multilevel path analyses, day-to-day changes in whole day workload mediated 67% (p < .001), 61% (p < .001), 38% (p < .001), and 55% (p < .001) of the within-person relationships between stress and work hours, rest frequency, active leisure frequency, and day of week, respectively. Our results provided evidence that whole day workload perception may contribute to the processes linking daily activities with daily stress in workers with T1D. Perceived whole day workload may deserve greater attention as a possible stress intervention target, ones that perhaps ergonomists would be especially suited to address.

Keywords. Workload, stress, rest, work hours, type 1 diabetes

Workload experienced over the whole day, not just work periods, may impact worker cognitive performance. We hypothesized that experiencing greater than typical whole day workload would be associated with lower visual processing speed and lower sustained attention ability, on the next day. To test this, we used dynamic structural equation modeling to analyze data from 56 workers with type 1 diabetes. For a two-week period, on smartphones they answered questions about whole day workload at the end of each day, and completed cognitive tests 5 or 6 times throughout each day. Repeated smartphone cognitive tests were used, instead of traditional one- time cognitive assessment in the laboratory, to increase the ecological validity of the cognitive tests. Examples of reported occupations in our sample included housekeeper, teacher, physician, and cashier. On workdays, the mean number of work hours reported was 6.58 (SD 3.5). At the within-person level, greater whole day workload predicted decreased mean processing speed the next day (standardized estimate=-0.10, 95% CI -0.18 to -0.01) using a random intercept model; the relationship was not significant and only demonstrated a tendency toward the expected effect (standardized estimate= -0.07, 95% CI -0.15 to 0.01) in a model with a random intercept and a random regression slope. Whole day workload was not found to be associated with next-day mean sustained attention ability. Study results suggested that just one day of greater than average workload could impact next day processing speed, but future studies with larger sample sizes are needed to corroborate this finding.

Keywords. Whole day workload; Sustained attention; Processing speed; Cognitive performance; Type 1 diabetes

Background. Type 1 diabetes (T1D) is a chronic condition affecting nearly 1.9 million people in the United States. Young adults (YAs) with T1D face unique challenges in managing their condition, experiencing poorer health and well-being than other age groups. The current study is evaluating the Resilient, Empowered, Active Living (REAL) intervention, previously shown to improve glucose levels and quality of life among YAs with diabetes, using telehealth delivery (REAL-T) to expand reach and accessibility. This paper reports on the methodology and baseline participant characteristics of the REAL-T study.

Methods. REAL-T is a two-arm randomized controlled trial that recruited 18–30 year olds with T1D via clinics and social media advertising. Data collection, which was adapted to be fully remote due to COVID-19, occurs every three months for one year. Participants receive either usual care or a 6-month telehealth occupational therapy intervention. The primary outcome is glycated hemoglobin (A1c); secondary outcomes include diabetes distress, quality of life, and continuous glucose monitor-derived measures.

Results. The study enrolled a diverse sample of 209 YAs with T1D. Analysis of baseline data indicates equivalence between the intervention and control groups. Study participants have notably higher diabetes distress and poorer mental well-being than similar populations.

Conclusion. The REAL-T study successfully adapted to remote implementation during the COVID-19 pandemic. By examining long-term outcomes, mediating pathways, and cost-effectiveness, the study will contribute knowledge of the impact of tailored interventions for YAs with T1D, designed to reduce disparities and improve health and well-being in this population.

Few studies have investigated the short-term, momentary relationships between physical activity (PA) and well-being. This study focuses on investigating the dynamic relationships between PA and affective well-being among adults with type 1 diabetes. Participants (n = 122) wore an accelerometer and completed daily EMA surveys of current activities and affective states (e.g., happy, stressed, excited, anxious) via smartphone over 14 days. Within-person, increased sedentary time was associated with less positive affect (r = − 0.11, p < 0.001), while more PA of any intensity was associated with greater positive affect and reduced fatigue, three hours later. Between-person, increased light PA was associated with increased stress (r = 0.21, p = 0.02) and diabetes distress (r = 0.30, p = 0.001). This study provides evidence that positive affect and fatigue are predicted by previous activity regardless of the different activities that people engaged in. Positive affect increased after engaging in PA. However, participants with higher amounts of light PA reported higher stress ratings.

Keywords. Ecological momentary assessments; Accelerometry; Physical activity; Mood; Type 1 diabetes

Relationships between activity engagement and health related quality of life (HRQOL) can differ based on the level of analyses. For instance, greater exercise on average may be linked with lower fatigue across individuals (between-person level), whereas the momentary experience of exercise may be associated with increased fatigue within an individual (within-person level). Disentangling the between- and within-person associations between everyday activities and HRQOL outcomes may provide insights for personalized lifestyle-oriented health promotion efforts for individuals with chronic conditions. The purpose of this paper was to examine the between- and within-person relationships between activity engagement and HRQOL relevant measures in a sample of 92 workers with type 1 diabetes (T1D), from whom we collected ecological momentary assessment (EMA) data 5–6 times daily over 14 days. At each EMA prompt, information was collected on the activity participants just engaged in, and HRQOL relevant metrics (e.g. mental health, blood glucose, fatigue, functioning). Momentary reports of “caring for others”, and more frequently “caring for others”, were both associated with decreased HRQOL. Reporting napping 10% or more of the time during a person’s waking hours, but not the momentary experience of napping, was associated with decreased HRQOL. Momentary reports of sleeping were associated with low activity satisfaction relative to other activities, but higher activity importance. Study results provided a quantitative representation of the lived experience of T1D covering multiple types of activity engagement, which potentially has health promotion implications for workers with T1D.

Keywords. Ecological momentary assessment; Health promotion; Human activities; Type 1 diabetes; Workers

Importance. Although occupational balance (OB) is a construct of importance to occupational therapy, existing OB assessments have not been validated in clinical populations.

Objective. To examine the validity and reliability of the 11-item version of the Occupational Balance Questionnaire (OBQ11) in U.S. adults with Type 1 diabetes.

Design. Data were analyzed from adults with Type 1 diabetes enrolled in a larger longitudinal study examining the relationships among blood glucose, emotion, and functioning. Dimensionality of the OBQ11 was assessed with item response theory (IRT); convergent validity was tested by examining whether associations between the OBQ11 and other constructs were consistent with a priori hypotheses.

Setting. Three outpatient clinical sites in the United States.

Participants. Data from 208 U.S. adults with Type 1 diabetes were included in the analyses (42% Latino, 29% White, 14% African American, 7% multiethnic, and 8% other).

Outcomes and Measures. Assessments administered include the OBQ11, Patient Health Questionnaire (depression), and Diabetes Self-Management Questionnaire.

Results. Overall, results from IRT models and correlational tests supported the reliability and validity of the OBQ11. For instance, higher scores on the OBQ11 were significantly associated with better self-ratings of diabetes management behaviors (r = .28, p < .001), lower depression symptoms (r = −.53, p < .001), and greater positive affect (r = .32, p < .001). A single-factor generalized partial credit model fit the OBQ11 acceptably well, supporting its unidimensionality.

Conclusions and Relevance. The OBQ11 may be a reliable and valid measure of OB appropriate for use in clinical populations such as adults with diabetes.

Keywords. adult, blood glucose, depressive disorders, diabetes mellitus, diabetes mellitus, type 1, diabetes mellitus, type 2, health, self-management, chronic disease, personal satisfaction

Background. Type one diabetes (T1D) management is challenging for adolescents and young adults (AYAs) due to physiological changes, psychosocial challenges, and increasing independence, resulting in increased diabetes distress and hemoglobin A1c (HbA1c). Alternative care models that engage AYAs and improve diabetes-related health outcomes are needed.

Methods. A 15-month study evaluated an adaptation of the Colorado Young Adults with T1D (CoYoT1) Care model. CoYoT1 Care includes person-centered care, virtual peer groups, and physician training delivered via telehealth. AYAs (aged 16-25 years) were partially randomized to CoYoT1 or standard care, delivered via telehealth or in-person. As the study was ending, the COVID-19 pandemic forced all AYAs to transition to primarily telehealth appointments. This secondary analysis compares changes in clinic attendance, T1D-related distress, HbA1c, and device use between those who attended more than 50% of diabetes clinic visits via telehealth and those who attended more sessions in-person throughout the course of the study.

Results. Out of 68 AYA participants, individuals (n = 39, 57%) who attended most (>50%) study visits by telehealth completed more diabetes care visits (3.3 visits) than those (n = 29, 43%) who primarily attended visits in-person (2.5 visits; P = .007). AYAs who primarily attended visits via telehealth maintained stable physician-related distress, while those who attended more in-person visits reported increases in physician-related distress (P = .04).

Conclusions. Greater usage of telehealth improved AYA engagement with their care, resulting in increased clinic attendance and reduced physician-related diabetes distress. A person-centered care model delivered via telehealth effectively meets the needs of AYAs with T1D.

Objective. While there is evidence that functioning, or ability to perform daily life activities, can be adversely influenced by type 1 diabetes, the impact of acute fluctuations in glucose levels on functioning is poorly understood.

Research design and methods. Using dynamic structural equation modeling, we examined whether overnight glucose (coefficient of variation[CV], percent time <70 mg/dL, percent time >250 mg/dL) predicted seven next-day functioning outcomes (mobile cognitive tasks, accelerometry-derived physical activity, self-reported activity participation) in adults with type 1 diabetes. We examined mediation, moderation, and whether short-term relationships were predictive of global patient-reported outcomes.

Results. Overall next-day functioning was significantly predicted from overnight CV (P = 0.017) and percent time >250 mg/dL (P = 0.037). Pairwise tests indicate that higher CV is associated with poorer sustained attention (P = 0.028) and lower engagement in demanding activities (P = 0.028), time <70 mg/dL is associated with poorer sustained attention (P = 0.007), and time >250 mg/dL is associated with more sedentary time (P = 0.024). The impact of CV on sustained attention is partially mediated by sleep fragmentation. Individual differences in the effect of overnight time <70 mg/dL on sustained attention predict global illness intrusiveness (P = 0.016) and diabetes-related quality of life (P = 0.036).

Conclusions. Overnight glucose predicts problems with objective and self-reported next-day functioning and can adversely impact global patient-reported outcomes. These findings across diverse outcomes highlight the wide-ranging effects of glucose fluctuations on functioning in adults with type 1 diabetes.

Telehealth delivery of Lifestyle Redesign®, an occupational therapy intervention framework addressing health and quality of life among people with chronic conditions, is understudied. The objective of this study was to evaluate the effectiveness, satisfaction, and engagement of telehealth Lifestyle Redesign for young adults with diabetes. Using process data from two randomized controlled trials, we compared in-person and telehealth intervention effects. Among telehealth clients, effectiveness was assessed using pre-post changes in occupational performance, occupational satisfaction, and health management; a survey captured telehealth satisfaction. Attendance and engagement in in-person versus telehealth therapy were compared. Preliminary results indicate telehealth clients had significant increases in occupational performance, occupational satisfaction, and health management (all p < .02), and high levels of telehealth satisfaction. Intervention engagement (p = .59) and attendance (p = .42) were similar across treatment modalities. Telehealth delivery of Lifestyle Redesign occupational therapy is feasible and potentially efficacious, and continued advocacy is needed to ensure access to occupational therapy through telehealth.

This chapter will address diabetes and the related issues that the occupational therapy practitioner can address in primary care. The chapter will outline the basic role of the primary care physician, as well as the evaluation techniques and intervention strategies employed by the occupational therapy practitioner.

Background. The Glycemia Risk Index (GRI) was introduced as a single value derived from the ambulatory glucose profile that identifies patients who need attention. This study describes participants in each of the five GRI zones and examines the percentage of variation in GRI scores that is explained by sociodemographic and clinical variables among diverse adults with type 1 diabetes.

Methods. A total of 159 participants provided blinded continuous glucose monitoring (CGM) data over 14 days (mean age [SD] = 41.4 [14.5] years; female = 54.1%, Hispanic = 41.5%). Glycemia Risk Index zones were compared on CGM, sociodemographic, and clinical variables. Shapley value analysis examined the percentage of variation in GRI scores explained by different variables. Receiver operating characteristic curves examined GRI cutoffs for those more likely to have experienced ketoacidosis or severe hypoglycemia.

Results. Mean glucose and variability, time in range, and percentage of time in high, and very high, glucose ranges differed across the five GRI zones (P values < .001). Multiple sociodemographic indices also differed across zones, including education level, race/ethnicity, age, and insurance status. Sociodemographic and clinical variables collectively explained 62.2% of variance in GRI scores. A GRI score ≥84.5 reflected greater likelihood of ketoacidosis (area under the curve [AUC] = 0.848), and scores ≥58.2 reflected greater likelihood of severe hypoglycemia (AUC = 0.729) over the previous six months.

Conclusions. Results support the use of the GRI, with GRI zones identifying those in need of clinical attention. Findings highlight the need to address health inequities. Treatment differences associated with the GRI also suggest behavioral and clinical interventions including starting individuals on CGM or automated insulin delivery systems.

Occupational therapy (OT) has the potential to mitigate against the health risks associated with older adulthood but traditionally has been applied only after catastrophic health events. The Well Elderly study included a randomized controlled trial comparing preventive OT services to non-professionally led social activity and a non-treatment control condition in 361 independent-living, multiethnic older adults (60+ years old). Physical, social, and mental health outcomes were measured at baseline, 9 months (intervention end), and 15 months. Results showed significant benefits for the OT group in overall health, functional status, and life satisfaction compared with both control conditions. The social activity control group did not differ significantly in outcomes compared with the non-treatment control. This study provides support for preventive OT service provision to promote the health and well-being of independent-living older adults, above and beyond mere participation in group-based social activities.

Keywords. occupational therapy, older adult, independent living, Well Elderly, health promotion, well-being, function, social activity, life satisfaction

This chapter describes the OPTIMAL study, a randomized controlled trial of an occupational therapy-led community-based program for adults with multiple chronic conditions referred to the program from a network of primary care clinics. Participants in the OPTIMAL program, compared to those in a wait-list control condition, had improved activity participation, self-efficacy, and quality of life. The OPTIMAL study adds to the literature demonstrating that occupational therapy is effective in improving function and quality of life among individuals with chronic conditions. The chapter summarizes the study methodology and findings, reviews related literature, and provides an illustrative case example relating the findings of the OPTIMAL study to occupational therapy practice.

Keywords. occupational therapy, multiple chronic conditions, chronic disease management, primary care, self-management

This chapter outlines the findings of Donnelly et al.’s article describing the integration of occupational therapy on interprofessional primary healthcare teams. A case study approach was used to identify the structures and processes that support successful integration of occupational therapy within family health teams. The findings illustrate that key factors supporting integration include developing team members’ understanding of the role of occupational therapy in primary care, creating a culture of collaboration, and developing trust and understanding among team members. The chapter outlines key findings of the Donnelly et al. article, highlights related studies evaluating the role and outcomes of occupational therapy in primary care settings, and provides a descriptive case study relating the chapter content to current occupational therapy practice.

Keywords. primary healthcare, patient care team, interprofessional care, collaborative care, occupational therapy, organizational case study

50 Studies Every Occupational Therapist Should Know presents a curated collection of the most influential studies guiding occupational therapy practice today. The text is organized into six practice areas, following the American Occupational Therapy Association (AOTA) framework for OT practice: productive aging, health and wellness, work and industry, rehabilitation and disability, children and youth, and mental health. Each section contains a series of chapters, each of which outlines the design, findings, and implications of a key study from that area of practice. Each chapter also includes a case scenario designed to illustrate how the findings of the study relate to clinical practice. This text will be a valuable resource for occupational therapy students and practitioners seeking to understand the breadth, rigor, and trustworthiness of research informing occupational therapy practice, and for others interested in better understanding the profession.

Keywords. Occupational therapy, evidence-based practice, qualitative research, quantitative research, rehabilitation, allied health

Purpose. The purpose of this study was to analyze the impact of virtual group appointments (VGA) on self-reported health-related outcomes and care activities for young adults (YA) with type 1 diabetes (T1D).

Methods. Fifty-three YA (ages 18-25 years) with T1D participated in a randomized controlled trial (RCT) of the Colorado Young Adults with T1D (CoYoT1) Clinic intervention, encompassing telehealth (TH) with or without VGA. Both new patients (n = 32) and those who participated in a pilot phase (n = 26) were randomized to CoYoT1 Clinic (TH+VGA; n = 23) or TH-only (n = 35) and followed for 1 year. YA completed the Diabetes Distress Scale (DDS), Diabetes Strengths and Resilience (D-STAR), Self-Efficacy in Diabetes (SED), Self-Management of Type 1 Diabetes in Adolescence (SMOD-A), Center for Epidemiologic Studies Depression (CES-D), and EuroQol (EQ-5D) scales at baseline and study end.

Results. YA were 67% female, 84% white, 10% Latinx, and the mean age was 20.4 years old. At study end, participants in CoYoT1 Clinic reported significantly reduced diabetes distress compared to those in TH-only, who reported increased levels [Effect Size (ES) = −0.40, P = .02]. Specifically, CoYoT1 Clinic participants reported relative reductions in Physician (ES = −2.87, P = .02) and Regimen-related distress (ES = −0.35, P = .01). In addition, participants in CoYoT1 Clinic reported improved self-management of T1D-related problem solving (ES = 0.47, P = .051) and communication with care providers (ES = 0.39, P = .07).

Conclusions. Virtual group attendance in CoYoT1 Clinic was associated with significant improvements in diabetes-related distress. Long-term exposure to VGA should be investigated in YA with T1D and other pediatric chronic conditions.

Importance. Lifestyle Redesign® originated as a preventive occupational therapy intervention for healthy older adults, and it was found to be both effective and cost effective in the Well Elderly Studies initiated in the 1990s. Building on that empirical foundation, the scope of Lifestyle Redesign has been greatly expanded as a general intervention framework addressing prevention and chronic condition management in a wide range of populations, settings, and conditions. Yet until now, its full scope, defining characteristics, and supporting evidence have not been clearly and succinctly described, limiting its potential reach and impact.

Objective. To outline the definition and key characteristics of Lifestyle Redesign, provide a scoping review of its evidence base and future directions for research, describe its current applications, and make recommendations for its use in clinical practice.

Evidence Review. We searched PubMed and CINAHL, tables of contents of 10 occupational therapy journals, and citations in two seminal Lifestyle Redesign publications to identify articles published in 1997–2020 that described quantitative outcomes (for n ≥ 20) of interventions meeting the defining characteristics of Lifestyle Redesign.

Findings. Our scoping review yielded 12 publications providing supportive evidence for Lifestyle Redesign’s positive impact on a range of health and well-being outcomes among both well populations and those with chronic conditions.

Conclusions and Relevance. Lifestyle Redesign has the potential to meet a growing need in clinical and community settings for health care services that address prevention, health promotion, and chronic disease management.

Keywords. clients, health, life style, personal satisfaction

Our objective was to investigate the validity of four-item and six-item versions of the National Aeronautics and Space Administration Task Load Index (NASA-TLX, or TLX for short) for measuring workload over a whole day in the repeated measures context. We analyzed data on 51 people with type 1 diabetes from whom we collected ecological momentary assessment and daily diary data over 14 days. The TLX was administered at the last survey of every day. Confirmatory factor analysis fit statistics indicated that neither the TLX-6 nor TLX-4 were a unidimensional representation of whole day workload. In exploratory analyses, another set of TLX items we refer to as TLX-4v2 was sufficiently unidimensional. Raw sum scores from the TLX-6 and TLX-4v2 had plausible relationships with other measures, as evidenced by intra-person correlations and mixed-effects models. TLX-6 appears to capture multiple factors contributing to workload, while TLX-4v2 assesses the single factor of “mental strain.”

Background. While short-term blood glucose (BG) levels and variability are thought to underlie diminished function and emotional well-being in people with T1D, these relationships are poorly understood. The Function and Emotion in Everyday Life with T1D (FEEL-T1D) study focuses on investigating these short-term dynamic relationships among BG, function, and emotional well-being in adults with T1D.

Objective. To present the FEEL-T1D study design, methods, and study progress to date, including adaptations necessitated by the COVID-19 pandemic to implement the study fully remotely.

Methods. The FEEL-T1D study will recruit 200 adults 18-75 years old with T1D. Data collection includes a comprehensive survey battery, along with 14 days of intensive longitudinal data using blinded continuous glucose monitoring (CGM), ecological momentary assessments (EMA), ambulatory cognitive tasks, and accelerometers. All study procedures are conducted remotely, through mailing study equipment and using videoconferencing for study visits.

Results. To date, after 12 months of recruitment, 124 participants have enrolled in the FEEL-T1D study. Over 80% have provided concurrent CGM, EMA, and accelerometer data for at least 10 of the 14 days of data collection, and nearly 90% of EMA surveys have been completed, with minimal missing data.

Conclusions. Thus far, our reconfiguration of the FEEL-T1D protocol to be implemented remotely during the COVID-19 pandemic has been a success. The FEEL-T1D study will elucidate the dynamic relationships between blood glucose, emotional well-being, cognitive function and participation in daily activities. In doing so, it will pave the way for innovative just-in-time interventions and produce actionable insights to facilitate tailoring of diabetes treatment to optimize function and well-being among individuals with T1D.

Occupational health and safety is experiencing a paradigm shift from focusing only on health at the workplace toward a holistic approach and worker well-being framework that considers both work and non-work factors. Aligned with this shift, the purpose of this pilot study was to examine how, within a person, frequencies of high-workload and recovery activities from both work and non-work periods were associated with same day well-being measures. We analyzed data on 45 workers with type 1 diabetes from whom we collected activity data 5–6 times daily over 14 days. More frequent engagement in high-workload activities was associated with lower well-being on multiple measures including higher stress. Conversely, greater recovery activity frequency was mostly associated with higher well-being indicated by lower stress and higher positive affect. Overall, our results provide preliminary validity evidence for measures of high-workload and recovery activity exposure covering both work and non-work periods that can inform and support evaluations of worker well-being.

Keywords. workload; recovery; ecological momentary assessment; type 1 diabetes; workweek; healthy work design and well-being; future of work

Diet and food choices significantly impact teeth, including enamel quality and development of dental caries. However, studies focusing on diet and its relation to oral care in Latinx children with and without Autism Spectrum Disorders (ASD) have been minimally addressed in research. This qualitative study used an inclusive visual methodology to explore what Latinx caregivers learned about their child’s diet preferences and food routines in relation to their oral health. As a secondary aim, the study sought to explore whether notable differences in diet emerged between Latinx children with and without ASD. Participants were 32 Latinx caregivers from 18 families with children with and without Autism (n = 8 with a typically developing child and n = 10 with a child with ASD) who completed a food journal activity and photo elicitation interview. Interviews were thematically coded for themes pertaining to parents’ perceptions of their child’s diet and oral health. Findings of this study indicate that the process of taking photos helped Latinx caregivers to better situate the barriers and behaviors influencing everyday food routines in their children within the context of relating to their overall oral health. Via their active participation in the research process, parents were empowered to note strategies they could employ that would directly impact their child’s oral health outcomes, such as reducing juice intake and monitoring sugar consumption. Therefore, visual research methodologies are an important strategy for researchers to consider in order to empower participants to be part of the research process and part of the outcomes, and to offer better understanding of the lived experience of populations underrepresented in the literature, such as Latinx children with and without ASD and their families.

Keywords. Autism Spectrum Disorder; children; families; health disparities; Latinxs; nutrition; oral care; photo elicitation; qualitative

Background/Aims. Research is needed to identify promising recruitment strategies to reach and engage diverse young adults in diabetes clinical research. The aim of this study was to examine the relative strengths and weaknesses of three recruitment strategies used in a diabetes self-management clinical trial: social media advertising (Facebook), targeted mailing, and in-person solicitation of clinic patients.

Methods. Strategies were compared in terms of (1) cost-effectiveness (i.e. cost of recruitment/number of enrolled participants), (2) ability to yield participants who would not otherwise be reached by alternative strategies, and (3) likelihood of participants recruited through each strategy to adhere to study procedures. We further explored the appeal (overall and among age and gender subgroups) of social media advertisement features.

Results. In-person recruitment of clinic patients was overall the most cost-effective strategy. However, differences in demographic, clinical, and psychosocial characteristics of participants recruited via different strategies suggest that the combination of these approaches yielded a more diverse sample than would any one strategy alone. Once successfully enrolled, there was no difference in study completion and intervention adherence between individuals recruited by the three recruitment strategies.

Conclusions. Ultimately, the utility of a recruitment strategy is defined by its ability to effectively attract people representative of the target population who are willing to enroll in and complete the study. Leveraging a variety of recruitment strategies appears to produce a more representative sample of young adults, including those who are less engaged in diabetes care.

A balance between stressful and restful occupations is an important component of lifestyle balance (LB). We argue that excessive physiological activation from the stress of everyday engagement in occupation, and/or inadequate engagement in restful occupations, can lead to negative health outcomes through accumulation of allostatic load (AL), or physiological wear and tear on the body. This physiological activation manifests as increased heart rate, blood pressure, and activation of the hypothalamic-pituitary-adrenal (HPA) axis, resulting in elevations in serum levels of hormones such as cortisol and catecholamines. “Stress,” as the term is used colloquially, is just one possible source of physiological activation. Other possible sources include cognitive challenges and high motivation tasks. The purpose of this paper is twofold: 1) to present an explanatory model for how the LB component of a “pattern of occupations with a balance between stressful and restful engagements” can affect health and 2) to discuss metrics to measure physiological activation from stress/rest and explore how these metrics relate to existing measures of lifestyle and occupational balance. We speculate that these metrics may relate to existing measures of lifestyle and occupational balance in ways that help explain the mechanisms underlying them, with the amount of physiological activation that individuals experience on a daily basis determining their long-term health outcomes. There remains a need to develop innovative lifestyle interventions that support management of stress related physiological activation to promote health and well-being.

Keywords. Occupational science; Life balance; Occupational balance; Restful occupations; Strenuous occupations; Physiological stress; Explanatory mechanisms; Allostatic load

The objective of this study is to assess the impact of inflammatory arthritis on young adults’ activity participation using quantitative and qualitative methods to advance the field’s conceptualization of functional status. Young adults diagnosed with juvenile idiopathic arthritis or rheumatoid arthritis completed (1) the Health Assessment Questionnaire-Disability Index to determine functional status and (2) the day reconstruction method to explore experiential dimensions of function, including functional performance, functional satisfaction, and severity of arthritis symptoms during activities on the previous day. Bivariate analyses were conducted to examine relationships between functional status, experiential variables, and demographic variables. Open-ended questions were provided for participants to report ways that arthritis affected their participation that were not otherwise reflected within survey questions; responses were numerically coded using summative content analysis. Among 37 participants (24.8 ± 3.3 years old), 70% reported moderate-to-severe disability. On average, participants experienced pain, stiffness, or fatigue for more than 50% of their waking hours. Functional status significantly correlated with functional performance (r = − 0.39, p = 0.02) and satisfaction (r = − 0.39, p = 0.02), yet did not correlate with stiffness or fatigue severity or duration of symptoms throughout the day. Participants described strategies that improved their ability to participate in certain activities but reduced their overall quality of activity engagement and caused emotional distress. Young adults with arthritis may experience more significant functional limitations than previously reported. Traditional measures of functional assessment may not capture experiential components of activity that affect participation, such as severity of stiffness or fatigue or the duration of symptoms throughout the day.

Keywords. Health status, Quality of life, Juvenile idiopathic arthritis, Rheumatoid arthritis, Young adult, Patient reported outcome

As more individuals from diverse backgrounds are diagnosed with Type 1 Diabetes (T1D), the need to address resulting disparities in diabetes outcomes among these populations also escalates. Although young adulthood proves challenging for all patients with diabetes, young adults (YA) from racial/ethnic minorities and low socioeconomic backgrounds face even greater T1D management obstacles. The poorer outcomes in these populations drive an urgent need for alternative care models to improve YA's engagement in their T1D clinical care and address barriers to improved health outcomes. Previous telemedicine initiatives for T1D have yielded positive diabetes care results, especially in YA, offering one promising way to reach this high-risk population. To serve these patients better, an established and successful home telehealth group appointment model, “CoYoT1 Clinic” (Colorado Young Adults with T1D), was adapted to provide care to YA with T1D at a large urban children's hospital in Southern California. At this location, ~70% of patients have public/no insurance, and 85% are racial/ethnic minorities. In this paper, we report the process of adapting the CoYoT1 Clinic model and designing a randomized controlled trial (RCT) to evaluate its efficacy. The adapted model uses meticulous study-design methods that incorporate patient advisors, quantitative and qualitative data collection, collaboration with local stakeholders, intervention development, and patient randomization into a factorial design analyzing telemedicine versus in-person and patient-centered versus standard care. The new model addresses the needs of high-risk YA in Southern California, with the goal of increasing access to care, improving follow-up frequency, and strengthening patient and provider satisfaction.

Keywords. Young adults; Telehealth; Group appointments; Type 1 diabetes; Shared medical appointments; Telemedicine

Purpose. Medically underserved adults with spinal cord injury (SCI) remain at high risk of incurring medically serious pressure injuries even after receiving education in prevention techniques. The purpose of this research is to identify circumstances leading to medically serious pressure injury development in medically underserved adults with SCI during a lifestyle-based pressure injury prevention program, and provide recommendations for future rehabilitation approaches and intervention design.

Methods. This study entailed a qualitative secondary case analysis of treatment notes from a randomized controlled trial. Participants were 25 community-dwelling, medically underserved adults with SCI who developed medically serious pressure injuries during the course of the intervention of the RCT.

Results and conclusions. Among the 25 participants, 40 unique medically serious pressure injuries were detected. The six themes related to medically serious pressure injury development were: (1) lack of rudimentary knowledge pertaining to wound care; (2) equipment and supply issues; (3) comorbidities; (4) non-adherence to prescribed bed rest; (5) inactivity; and (6) circumstances beyond the intervention’s reach. Together, these factors may have undermined the effectiveness of the intervention program. Modifications, such as assessing health literacy levels of patients prior to providing care, providing tailored wound care education, and focusing on equipment needs, have potential for altering future rehabilitation programs and improving health outcomes.

Keywords. Spinal cord injuries, pressure injury, lifestyle, intervention, cultural diversity

Objective. To examine characteristics of caregiving from the perspectives of adolescents and young adults (AYAs) with spinal cord injuries (SCIs) and their informal caregivers to address outstanding gaps in knowledge relating to definitions of caregiving and its associated practices for this population.

Methods. A multiphase qualitative design was applied, using phenomenological and narrative methods to capture data in participants' homes and communities. Participants were recruited from rehabilitation hospitals and community organizations throughout Los Angeles County, California. Inclusion criteria for AYAs included being 15–22 years old, having acquired an SCI within the previous 5 years, and using a wheelchair for mobility. The AYAs nominated persons they identified as primary caregivers to also participate. Data were collected through individual and group interviews as well as activity observations.

Results. Data from the 17 participants (9 AYAs and 8 informal, primary caregivers) revealed ways in which the meaning of caregiving varied among dyads. Caregiving practices extended beyond physical assistance to include support for a range of day-to-day activities spanning from practical needs to facilitating developmental trajectories. Although AYAs expressed ideas about preferred caregiver characteristics, care partnerships appeared to be guided more by availability than preference.

Conclusion. Phenomenological analysis revealed that the meaning of “caregiving” and its associated practices are highly individualized for AYAs with SCIs. Caregiving is rooted in personal needs related to effects of SCI and developmental goals. Everyday practices are shaped by individual relationships and the beliefs of AYAs and their caregivers. Addressing influences of caregiving on long-term health and function may require attention to developmental processes, caregiver “fit,” and ways care is, or can be, distributed throughout broader networks according to personal needs and preferences.

As a result of various barriers, several pediatric populations are at risk for poor oral health, including children with disabilities and children from under-represented populations, such as Latinos. To this end, this study aimed to better understand the factors that affect the oral health experiences of 32 Latino parents/caregivers from 18 families (n = 8 with a typically developing child and n = 10 with a child with Autism). Using a qualitative descriptive methodology, each family was interviewed twice. Interviews were audio-recorded, transcribed verbatim, and coded thematically to identify the individual, social, systemic, and culturally rooted factors contributing to oral health disparities in the families. The three themes that arose were “Why would I want to start trouble?”: Latino parents’ dissatisfaction with dental treatments, costs, and fear of the dentist and health care providers because of their ethnic minority status as key factors inhibiting receipt of dental care; “We have to put our children first”: prioritizing the oral care activities of their children over their own individual oral care needs; and “We always keep baking soda around”: familial and cultural influences on oral care habits. Understanding the oral health beliefs and experiences of Latino parents and caregivers of children with and without autism is critical for developing targeted prevention and intervention programs and reducing oral health disparities.

Keywords: Latinos; oral care; health disparities; children; culture; autism spectrum disorder

Importance. Primary health care is rapidly developing as an occupational therapy practice area. Yet, to date, little evidence supports occupational therapy’s feasibility and efficacy in primary care settings.

Objective. To report on the implementation and preliminary clinical outcomes of a Lifestyle Redesign® (LR)–occupational therapy (LR–OT) diabetes management intervention in a primary care clinic.

Design. Patients were randomized to be offered LR–OT or to a no-contact comparison group (data not reported). We assessed implementation outcomes using mixed methods.

Setting. Safety-net primary care clinic.

Participants. Clinic providers and staff; English- or Spanish-speaking clinic patients ages 18–75 yr with diabetes and a current hemoglobin A1c (HbA1c) ≥ 9.0%.

Intervention. Eight 1-hr individual sessions of LR–OT focused on diabetes management.

Outcomes and Measures. Clinical and health behavior outcomes were assessed via electronic medical record (EMR) review and self-report surveys of patients receiving LR–OT at initial evaluation and discharge. We assessed implementation outcomes (acceptability, appropriateness, feasibility, fidelity, efficiency, and timeliness) using patient and staff surveys, interviews, focus groups, and observations.

Results. Seventy-three patients were offered LR–OT: 51 completed one or more sessions, and 38 completed the program. Clinical outcomes among program completers indicate beneficial changes in HbA1c, diabetes self-care, and health status. Implementation challenges included a need for patient and staff education, securing adequate workspace, and establishing a referral process. Factors contributing to implementation success included strong buy-in from clinic leadership, colocation, and shared EMR documentation.

Conclusions and Relevance. LR–OT is a feasible approach to enhancing service delivery and clinical outcomes in primary care.

What This Article Adds. This study provides insight into factors that may create challenges or contribute to the success of implementing occupational therapy services within primary health care settings. In addition, this study provides preliminary evidence of occupational therapy’s effectiveness in improving clinical outcomes among ethnically diverse, low-income patients with diabetes in a safety-net primary care setting.

Purpose. To assess the impact of a home telemedicine clinic model (CoYoT1 Clinic) on psychosocial and behavioral outcomes designed for young adults (YAs) with type 1 diabetes (T1D).

Methods. YAs self-selected to participate in the CoYoT1 Clinic or serve as a usual care control. CoYoT1 Clinic visits consisted of an individual appointment with a provider and a group appointment with other YAs with T1D using home telemedicine. Psychosocial and behavioral functioning was assessed by 4 measures: Diabetes Distress Scale, Self-Efficacy for Diabetes Scale, Self-Management of Type 1 Diabetes in Adolescence Scale, and Center for Epidemiologic Studies Depression Scale.

Results. Forty-two patients participated in the CoYoT1 Clinic and 39 patients served as controls. CoYoT1 participants reported lower levels of distress (P = .03), increased diabetes self-efficacy (P = .01), and improved ability to communicate with others about diabetes (P = .04) over the study period compared to controls. YA males in the control group reported increases in depressive symptoms (P = .03) during the study period, but CoYoT1 participants showed no changes.

Conclusion. Group home telemedicine for YAs with T1D positively affects diabetes distress, self-efficacy, and diabetes-specific communication. These positive findings have the potential to also affect the YAs’ long-term diabetes outcomes. Further investigation of the model is needed.

Patients are experts on their own lives and the ways in which an illness, injury, or disability affects their health, activity, and quality of life. With its longstanding foundations in participatory action research, patient engagement has been gaining momentum across health care and related research. This momentum is supported by investments from several key research and federal policy–related organizations, including the Patient-Centered Outcomes Research Institute, National Institutes of Health, and Agency for Healthcare Research and Quality. Occupational therapy practitioners are uniquely positioned to champion patient collaborations. In this article, we discuss ways in which patient perspectives can be embraced in occupational therapy research, and we share insights from a research planning collaborative with adolescents and young adults that was led by occupational therapy researchers.

Type 1 diabetes and type 2 diabetes are prevalent endocrine conditions, with over 25,000 youth newly diagnosed with diabetes each year. Late adolescence and young adulthood is a particularly risky time for youth with diabetes. In addition to the normative challenges experienced during this developmental period, most youth with diabetes also must transfer from pediatric to adult health care. This chapter reviews key developmental and psychosocial considerations that may influence diabetes management and evidence-based guidelines informing the treatment of transition-aged youth with type 1 diabetes or type 2 diabetes. Specific recommendations to support transition efforts at the patient, provider, and health-care system levels are presented, and key resources to facilitate developmentally tailored, continuous care for youth with diabetes are highlighted.

Keywords. Type 1 diabetes, Type 2 diabetes, Transition to adult care, Health-care delivery, Adolescents, Young adults, Psychosocial screening, Adolescent development

Background. Pressure injuries negatively impact quality of life and participation for individuals with spinal cord injury (SCI).

Objective. To examine the factors that may protect against the development of medically serious pressure injuries in adults with SCI.

Methods. A qualitative analysis was conducted using treatment notes regarding 50 socioeconomically disadvantaged individuals who did not develop medically serious pressure injuries during a 12-month pressure injury prevention intervention program.

Results. Eight types of potentially protective factors were identified: meaningful activity, motivation to prevent negative health outcomes, stability/resources, equipment, communication and self-advocacy skills, personal traits, physical factors, and behaviors/activities.

Conclusions. Some protective factors (e.g., personal traits) may be inherent to certain individuals and nonmodifiable. However, future interventions for this population may benefit from a focus on acquisition of medical equipment and facilitation of sustainable, health-promoting habits and routines. Substantive policy changes may be necessary to facilitate access to adequate resources, particularly housing and equipment, for socioeconomically disadvantaged individuals with SCI. Further research is needed to understand the complex interplay of risk and protective factors for pressure injuries in adults with SCI, particularly in underserved groups.

Context/Objective. Medically serious pressure injuries (MSPrIs), a common complication of spinal cord injury (SCI), have devastating consequences on health and well-being and are extremely expensive to treat. We aimed to test the efficacy of a lifestyle-based intervention designed to reduce incidence of MSPrIs in adults with SCI.

Design. A randomized controlled trial (RCT), and a separate study wing involving a nonrandomized standard care control group.

Setting. Rancho Los Amigos National Rehabilitation Center, a large facility serving ethnically diverse, low income residents of Los Angeles County.

Participants. Adults with SCI, with history of one or more MSPrIs over the past 5 years: N=166 for RCT component, N=66 in nonrandomized control group.

Interventions. The Pressure Ulcer Prevention Program, a 12-month lifestyle-based treatment administered by healthcare professionals, largely via in-home visits and phone contacts.

Outcome Measures. Blinded assessments of annualized MSPrI incidence rates at 12 and 24 months, based on: skin checks, quarterly phone interviews with participants, and review of medical charts and billing records. Secondary outcomes included number of surgeries and various quality-of-life measures.

Results. Annualized MSPrI rates did not differ significantly between study groups. At 12 months, rates were .56 for intervention recipients, .48 for randomized controls, and .65 for nonrandomized controls. At follow-up, rates were .44 and .39 respectively for randomized intervention and control participants.

Conclusions. Evidence for intervention efficacy was inconclusive. The intractable nature of MSPrI threat in high-risk SCI populations, and lack of statistical power, may have contributed to this inability to detect an effect.

Trial Registration. ClinicalTrials.gov NCT01999816.

IMPORTANCE: A recent reanalysis of data from the Well Elderly (WE) 2 study purportedly indicated that the intervention did not achieve clinically meaningful or statistically significant effects; this article addresses these criticisms.

OBJECTIVE: To contextualize the WE 2 study as targeting a nonclinical population and demonstrate that the intervention produced substantively important, statistically significant effects.

DESIGN: Secondary analysis of WE 2 intervention-based pre–post change scores.

SETTING: The original trial occurred primarily in senior centers and senior housing facilities in greater Los Angeles.

PARTICIPANTS: Independent-living older adults (N = 324) who were assessed before and after intervention.

INTERVENTION: The WE intervention, a version of the Lifestyle Redesign® (LR) approach, was administered by occupational therapists over 6 mo by means of group and individual sessions.

OUTCOMES AND MEASURES: The 36-item Short Form Health Survey, the Life Satisfaction Index–Z, and the Center for Epidemiologic Studies Depression Scale.

RESULTS: The WE intervention was associated with statistically significant improvement on 10 of 12 outcome variables that were examined.

CONCLUSIONS AND RELEVANCE: Because the WE intervention was hypothesized to reduce age-related decline and followed a population-oriented approach, the expectation that average results would be clinically meaningful was inappropriate. The intervention produced positive effects across a wide array of outcome domains. In settings in which clinical meaningfulness is an appropriate index of intervention outcomes, evidence suggests that LR produces effects that are clinically meaningful. As an evidence-based intervention, LR should be considered useful both in population-oriented contexts and in addressing discrete health conditions.

WHAT THIS ARTICLE ADDS: Valid analyses demonstrate that the positive experimental effects of the WE 2 study are, in fact, genuine and cost-effective, and LR in clinically oriented contexts has produced statistically significant, clinically meaningful results. Clearly and accurately representing the evidence base of occupational therapy in prevention and chronic care is of critical importance to advance the field as a whole.

Medication non-adherence occurs in more than half of children with chronic conditions. Unfortunately, most strategies for improving adherence have had limited success in the pediatric population highlighting the need for novel interventions that establish healthy self-management habits for children and adolescents. In this paper we discuss innovative strategies to improve adherence by embedding a medical regimen within a pet care routine, thereby capitalizing on the benefits of a structured habit while providing opportunities for development of autonomy in children and fostering collaborative parent interactions.

Objective. To assess the efficacy of a manualized occupational therapy (OT) intervention (Resilient, Empowered, Active Living with Diabetes [REAL Diabetes]) to improve glycemic control and psychosocial well-being among ethnically diverse young adults with low socioeconomic status (SES) who have type 1 or type 2 diabetes.

Research Design and Methods. Eighty-one young adults (age 22.6 ± 3.5 years; hemoglobin A_1c [HbA_1c] = 10.8%/95 mmol/mol ± 1.9%/20.8 mmol/mol) were randomly assigned to the REAL Diabetes intervention group (IG) or an attention control group (CG) over 6 months. IG participants received biweekly sessions guided by a manual composed of seven content modules; CG participants received standardized educational materials and biweekly phone calls. Blinded assessors collected data at baseline and 6 months. The primary outcome was HbA_1c; secondary outcomes included diabetes self-care, diabetes-related quality of life (QOL), diabetes distress, depressive symptoms, and life satisfaction. Change scores were analyzed using Wilcoxon rank sum tests.

Results. Intent-to-treat analyses showed that IG participants showed significant improvement in HbA_1c (-0.57%/6.2 mmol/mol vs. +0.36%/3.9 mmol/mol, P = 0.01), diabetes-related QOL (+0.7 vs. +0.15, P = 0.04), and habit strength for checking blood glucose (+3.9 vs. +1.7, P = 0.05) as compared with CG participants. There was no statistically significant effect modification by sex, ethnicity, diabetes type, recruitment site, or SES. No study-related serious adverse events were reported.

Conclusions. The REAL Diabetes intervention improved blood glucose control and diabetes-related QOL among a typically hard-to-reach population, thus providing evidence that a structured OT intervention may be beneficial in improving both clinical and psychosocial outcomes among individuals with diabetes.

Background. The transition of young adults with type 1 diabetes (T1D) from pediatric to adult care is challenging and frequently accompanied by worsening of diabetes-related health. To date, there are no reports which prospectively assess the effects of theory-based psycho-behavioral interventions during the transition period neither on glycemic control nor on psychosocial factors that contribute to poor glycemic control. Therefore, the overall aim of this study was to develop and pilot test an integrative group intervention based on the underlying principles of self-determination theory (SDT), in young adults with T1D.

Methods. Fifty-one young adults with T1D participated in an education and case management-based transition program, of which 9 took part in the Diabetes Empowerment Council (DEC), a 12-week holistic, multimodality facilitated group intervention consisting of “council” process based on indigenous community practices, stress-reduction guided imagery, narrative medicine modalities, simple ritual, and other integrative modalities. Feasibility, acceptability, potential mechanism of effects, and bio-behavioral outcomes were determined using mixed qualitative and quantitative methods.

Results. The intervention was highly acceptable to participants, though presented significant feasibility challenges. Participants in DEC showed significant reductions in perceived stress and depression, and increases in general well-being relative to other control participants. Reduction in perceived stress, independent of intervention group, was associated with reductions in hemoglobin A1C. A theoretical model explaining the effects of the intervention included the promotion of relatedness and autonomy support, 2 important aspects of SDT.

Conclusions. The DEC is a promising group intervention for young adults with T1D going through transition to adult care. Future investigations will be necessary to resolve feasibility issues, optimize the multimodality intervention, determine full intervention effects, and fully test the role of the underlying theoretical model of action.

Objective. We investigated the feasibility and acceptability of an occupational therapy intervention targeting diabetes management for underserved young adults.

Method. Eight participants completed the intervention and a battery of assessments at baseline and after the intervention. At completion, the participants and occupational therapist were interviewed about their experiences with the study. Four categories of assessment questions were used to guide the study: process, resource, management, and scientific.

Results. Successes included recruitment; fulfillment of tasks by staff and partnering clinics; adequate space, financial support, and equipment; and meaningfulness of the intervention for participants. Challenges included scheduling participants for the intervention and follow-up focus groups and providing client centeredness and flexibility while reducing burden on the intervener.

Conclusion. This feasibility study allowed us to make necessary revisions to our study protocol before implementing a larger pilot study.

Purpose. The purpose of this study was to evaluate relationships between behavioral and psychosocial constructs, A1C, and diabetes-dependent quality of life (DQoL) among low-socioeconomic status, ethnically diverse young adults with diabetes.

Methods. Using baseline data of 81 participants in the Resilient, Empowered, Active Living (REAL) randomized controlled trial, behavioral, cognitive, affective, and experiential variables were correlated with A1C and DQoL while adjusting for demographic characteristics, and these relationships were examined for potential effect modification.

Results. The data indicate that depressive symptoms and satisfaction with daily activities are associated with both A1C and DQoL, while diabetes knowledge and participation in daily activities are associated with neither A1C nor DQoL. Two constructs, diabetes distress and life satisfaction, were associated with DQoL and were unrelated to A1C, while 2 constructs, self-monitoring of blood glucose and medication adherence, were associated with A1C but unrelated to DQoL. These relationships were largely unchanged by adjusting for demographic characteristics, while numerous effect modifications were found.

Conclusion. The data suggest that when tailoring interventions, depressive symptoms and satisfaction with daily activities may be particularly fruitful intervention targets, as they represent modifiable risk factors that are associated with both A1C and DQoL.

Introduction. Occupational scientists are tasked with the responsibility of examining the relationship between occupational engagement and health, yet as occupations are explored in situ, these concepts only become more complex. For example, lifestyle trade-offs occur when individuals make conscious decisions between two competing sets of actions: actions taken in promotion of physical health versus actions in agreement with an identity-driven biography. In this study, these dilemmas are viewed as parts of an ongoing occupational challenge to balance physical health with subjective well-being in everyday life.

Methods. Anselm Strauss’s concepts of body state and biographical moment are conceptualized as analytic tools to study dimensions within which occupation is performed. A descriptive, single-case analysis of a young adult diagnosed with diabetes is presented as an exemplar of how Strauss’s tools may be utilized.

Results. Four themes emerged within the presented narrative: (1) by the book versus reality, (2) testing the boundaries of diabetes, (3) diabetes burnout and the struggle for perfection, and (4) the inevitable merge between body and biography.

Conclusion. Sadie’s narrative exemplifies the multiple contexts in which agentic decisions to engage in specific occupations are made. Sadie’s experiences of diabetes burnout and actions taken while “on vacation” are not uncommon within chronic illness literature and warrant further analyses that consider physical and psychological domains of health. By dismantling situational factors using analytic tools, such as Strauss’s body state and biographical moment, occupational scientists may further understand lived experiences and clarify the link between occupation and health.

Purpose. We identified and treated young adults with type 1 diabetes who had been lost to follow-up during their transfer from pediatric to adult care, comparing their clinical, psychosocial, and health care utilization outcomes to participants receiving continuous care (CC) throughout the transition to adult care.

Methods. Individuals in their last year of pediatric care (CC group, n = 51) and individuals lost to follow-up in the transfer to adult care ("lapsed care" [LC] group, n = 24) were followed prospectively for 12 months. All participants were provided developmentally tailored diabetes education, case management, and clinical care through a structured transition program.

Results. At baseline, LC participants reported lapses in care of 11.6 months. Compared with CC participants, they had higher hemoglobin A1C (A1C; p = .005), depressive symptoms (p = .05), incidence of severe hypoglycemia (p = .005), and emergency department visits (p = .004). At 12-month follow-up, CC and LC participants did not differ on the number of diabetes care visits (p = .23), severe hypoglycemia (no events), or emergency department visits (p = .22). Both groups' A1C improved during the study period (CC: p = .03; LC: p = .02). LC participants' depressive symptoms remained elevated (p = .10), and they reported a decline in life satisfaction (p = .007). There was greater loss to follow-up in the LC group (p = .04).

Conclusions. Our study suggests that, for young adults with a history of lapses in care, a structured transition program is effective in lowering A1C, reducing severe hypoglycemia and emergency department utilization, and improving uptake of routine diabetes care. Loss to follow-up and psychosocial concerns remain significant challenges in this population.

Overview. This paper describes the study protocol used to evaluate the Resilient, Empowered, Active Living with Diabetes (REAL Diabetes) intervention and reports on baseline characteristics of recruited participants. REAL Diabetes is an activity-based intervention designed to address the needs of young adults diagnosed with type 1 (T1D) or type 2 diabetes (T2D) from low socioeconomic status or racial/ethnic minority backgrounds. The REAL intervention incorporates tailored delivery of seven content modules addressing various dimensions of health and well-being as they relate to diabetes, delivered by a licensed occupational therapist.

Methods. In this pilot randomized controlled trial, participants are assigned to the REAL Diabetes intervention or an attention control condition. The study's primary recruitment strategies included in-person recruitment at diabetes clinics, mass mailings to clinic patients, and social media advertising. Data collection includes baseline and 6-month assessments of primary outcomes, secondary outcomes, and hypothesized mediators of intervention effects, as well as ongoing process evaluation assessment to ensure study protocol adherence and intervention fidelity.

Results. At baseline, participants (n=81) were 51% female, 78% Latino, and on average 22.6years old with an average HbA1c of 10.8%. A majority of participants (61.7%) demonstrated clinically significant diabetes distress and 27.2% reported symptoms consistent with major depressive disorder. Compared to participants with T1D, participants with T2D had lower diabetes-related self-efficacy and problem-solving skills. Compared to participants recruited at clinics, participants recruited through other strategies had greater diabetes knowledge but weaker medication adherence.

Discussion. Participants in the REAL study demonstrate clinically significant medical and psychosocial needs.

Objective. In this study, we systematically reviewed the effectiveness of educational interventions falling within the scope of occupational therapy practice for people with rheumatoid arthritis (RA). These interventions included disease education, joint protection and energy conservation, psychosocial techniques, pain management, and a combination category.

Method. Two databases, MEDLINE and CINAHL, and select journals were searched for randomized controlled trials published between January 2002 and June 2015. Qualitative synthesis was used for between-study comparisons.

Results. Twenty-two studies, with approximately 2,600 participants, were included. The interventions were found to have strong evidence for constructs that dealt with increasing coping with pain and fatigue as well as maintaining positive affect. There was limited or no evidence supporting the effectiveness of these interventions on most other measured constructs.

Conclusion. Interventions in which a combination of educational techniques is used may complement pharmacological therapies in the care of people with RA. Future research is needed to identify specific mechanisms of change.

This paper describes the case of an after-school program, focused on providing enrichment opportunities for neighborhood youth, jointly administered through an academic division and residential community within a large urban research university. The program, originally conceived as an activity-based after-school program for middle school youth, expanded in scope in response to both community and student needs. The resident faculty fellow in this community served as a liaison between the academic division and office of residential education, helping maintain continuity and facilitating effective student leadership of the program. In this case, we detail the origins and evolution of the program, including strategies used to resolve challenges that arose over several years of program implementation.

Objective. To evaluate the efficacy of a structured transition program compared with usual care in improving routine follow-up, clinical, and psychosocial outcomes among young adults with type 1 diabetes.

Research Design and Methods. Eighty-one young adults in their last year of pediatric care were recruited from three clinics. Intervention group (IG) participants (n = 51) received a structured transition program incorporating tailored diabetes education, case management, group education classes, and access to a newly developed young adult diabetes clinic and transition website. Control group (CG) participants (n = 30) received usual care. The primary outcome was the number of routine clinic visits. Secondary outcomes included glycemic control, hypoglycemia, health-care use, and psychosocial well-being. Assessments were conducted at baseline, and 6 and 12 months.

Results. Limitations in CG follow-up prevented direct comparisons of adult care visits; however, at the 12-month follow-up among IG participants discharged from pediatric care (n = 32), 78% had one or more adult visits. Among IG participants, the total number of clinic visits did not differ between those who transitioned and those who remained in pediatric care (3.0 ± 1.24 vs. 3.11 ± 0.94, P = 0.74). IG compared with CG participants had improved glycemic control (-0.40 ± 1.16% vs. 0.42 ± 1.51% [4.4 ± 12.7 mmol/mol vs. 4.6 ± 16.5 mmol/mol], P = 0.01), incidence of severe hypoglycemia (0.0% vs. 16%, P = 0.02), and global well-being (P = 0.02) at 12 months.

Conclusions. A structured transition program was successful in facilitating transition to adult care without a decrease in clinical follow-up. Compared with usual care, the transition program facilitated improvements in glycemic control, hypoglycemia, and psychosocial well-being.

This article reports on the development of a manualized occupational therapy intervention for diabetes management. An initial theoretical framework and core content areas for a Stage 1 intervention manual were developed based on an in-depth needs assessment and review of existing literature. After evaluation by a panel of experts and completion of a feasibility study, the intervention was revised into a Stage 2 manual in preparation for a randomized study evaluating the intervention's efficacy. In developing the initial manual, we delineated core theoretical principles to allow for flexible application and tailoring of the intervention's content areas. Expert panel feedback and feasibility study results led to changes to the intervention structure and content as we developed the Stage 2 manual. Through describing this process, we illustrate the dynamic evolution of intervention manuals, which undergo revisions due to both theoretical and practical considerations at each stage of the research-to-clinical practice pipeline.

Purpose. The purpose of the study was to identify attitudes and topics relevant to peer mentoring as an adherence-promoting intervention for adolescents and young adults (YAs) with type 1 diabetes (T1D).

Methods. Self-administered survey data were collected in 2 diabetes clinics from a convenience sample of adolescents as prospective mentees (ages 13-18) and YAs as prospective mentors (ages 19-25) with T1D. Survey topics included demographics, disease history, glycemic control, adherence, depression, barriers to disease management, social support, and interest in peer mentoring. Descriptive statistical analyses, thematic coding, and stepwise multivariate logistic regression were performed.

Results. A majority of the 54 adolescents and 46 YAs expressed interest in a peer mentoring program. Having supportive friends and living in a large household positively predicted adolescent interest in having a peer mentor. Approximately one-third of all participants experienced social barriers to diabetes management. For adolescents, barriers included inflexible schedules, unfamiliar foods, and the embarrassment of checking blood glucose in front of others. Young adults reported barriers in tracking food consumption and remembering to check blood glucose. Various diabetes management skills were in high demand by adolescents, who especially desired to learn about managing T1D on their own and in college. Participants were open to multiple communication modes, including in-person meetings, phone, text messaging, and social media.

Conclusions. Many adolescents and young adults with T1D are interested in peer mentoring as a way to facilitate learning and sharing essential diabetes management skills and experiences.

Pressure ulcers (PrUs) are a major burden to patients with spinal cord injury (SCI), affecting their psychological, physical, and social well-being. Lifestyle choices are thought to contribute to the risk of developing PrUs. This article focuses on the interaction between lifestyle choices and the development of PrUs in community settings among participants in the University of Southern California-Rancho Los Amigos National Rehabilitation Center Pressure Ulcer Prevention Study (PUPS II), a randomized controlled trial of a lifestyle intervention for adults with SCI. We conducted a secondary cross-case analysis of treatment notes of 47 PUPS II participants and identified four patterns relating PrU development to lifestyle changes: positive PrU changes (e.g., healing PrUs) with positive lifestyle changes, negative or no PrU changes with positive lifestyle changes, positive PrU changes with minor lifestyle changes, and negative or no PrU changes with no lifestyle changes. We present case studies exemplifying each pattern.

Aim. To examine challenges contributing to disruptions in care during the transition from paediatric to adult care among young adults with Type 1 diabetes who are primarily in ethnic minority groups and have low socio-economic status.

Methods. Participants (n = 20) were newly enrolled patients in a transition clinic for young adults with Type 1 diabetes with a history of loss to medical follow-up. Participants completed qualitative semi-structured interviews detailing their transition experiences in addition to demographic, HbA1c and psychosocial measures. Descriptive statistics were completed for quantitative data, and narrative thematic analysis of interviews was used to identify common themes. A mixed-method analysis was used to identify the associations between stressors identified in interviews and clinical and psychosocial variables.

Results. Three categories of challenges contributing to loss to follow-up were identified: psychosocial challenges, health provider and health system challenges and developmental challenges. Participants experienced a high degree of stressful life circumstances which were associated with higher HbA1c (r = 0.60, P = 0.005), longer duration of loss to follow-up (r = 0.51, P = 0.02), greater emergency department utilization (r = 0.45, P = 0.05), and lower life satisfaction (r = -0.62, P = 0.003).

Conclusions. A confluence of challenges, including stressful life circumstances, healthcare system barriers and the developmental trajectory of young adulthood, contributes to a high risk of loss to follow-up and poor health in this population of young adults with Type 1 diabetes. An integrated approach to transition addressing medical and psychosocial needs may facilitate improved follow-up and health outcomes in clinical settings.

Purpose. The purpose of this study was to investigate how an intergenerational legacy of type 2 diabetes affected the knowledge, attitudes, and treatment strategies of Hispanic young adults with diabetes.

Methods. Eight Hispanic young adults (ages 18-30 years) participated in a series of in-home longitudinal qualitative interviews, and 11 of their family members completed single in-home interviews, regarding their diabetes management practices. Interview transcripts were analyzed thematically by a team of researchers.

Results. Five themes emerged that characterized the influence of an intergenerational legacy of diabetes on young adults: food and family (how meal preparation and eating are shared within families), doing together (activity participation is contingent on others’ participation), knowledge and expectations (expectations for the future and understandings of diabetes are shaped by family members), miscarried helping (well-intentioned actions have negative consequences), and reciprocal support (children and parents support each other’s diabetes care).

Conclusions. Hispanic young adults’ knowledge, attitudes, and self-care practices related to diabetes are strongly influenced by the diabetes management practices of family members with diabetes, which often depart from current standards of diabetes care. Care providers should consider family members as a potentially significant influence, either positive or negative, on the diabetes self-care practices of this population.

Background. Randomized trials of complex, non-pharmacologic interventions implemented in home and community settings, such as the University of Southern California (USC)-Rancho Los Amigos National Rehabilitation Center (RLANRC) Pressure Ulcer Prevention Study (PUPS), present unique challenges with respect to (1) participant recruitment and retention, (2) intervention delivery and fidelity, (3) randomization and assessment, and (4) potential inadvertent treatment effects.

Purpose. We describe the methods employed to address the challenges confronted in implementing PUPS. In this randomized controlled trial, we are assessing the efficacy of a complex, preventive intervention in reducing the incidence of, and costs associated with, the development of medically serious pressure ulcers in people with spinal cord injury.

Methods. Individuals with spinal cord injury recruited from RLANRC were assigned to either a 12-month preventive intervention group or a standard care control group. The primary outcome is the incidence of serious pressure ulcers with secondary endpoints including ulcer-related surgeries, medical treatment costs, and quality of life. These outcomes are assessed at 12 and 24 months after randomization. Additionally, we are studying the mediating mechanisms that account for intervention outcomes.

Results. PUPS has been successfully implemented, including recruitment of the target sample size of 170 participants, assurance of the integrity of intervention protocol delivery with an average 90% treatment adherence rate, and enactment of the assessment plan. However, implementation has been replete with challenges. To meet recruitment goals, we instituted a five-pronged approach customized for an underserved, ethnically diverse population. In intervention delivery, we increased staff time to overcome economic and cultural barriers to retention and adherence. To ensure treatment fidelity and replicability, we monitored intervention protocol delivery in accordance with a rigorous plan. Finally, we have overcome unanticipated assessment and design concerns related to (1) determining pressure ulcer incidence/severity, (2) randomization imbalance, and (3) inadvertent potential control group contamination.

Limitations. We have addressed the most daunting challenges encountered in the recruitment, assessment, and intervention phases of PUPS. Some challenges and solutions may not apply to trials conducted in other settings.

Conclusions. Overcoming challenges has required a multifaceted approach incorporating individualization, flexibility, and persistence, as well as the ability to implement needed mid-course corrections.

Aims. To determine the disclosure rates of psychosocial issues affecting routine diabetes care.

Methods. A total of 20 young adults were interviewed regarding the impact of psychosocial stressors on their diabetes care. The interviewer, endocrinologist and case manager reported the prevalence rates of psychosocial stressors. Disclosure rates were compared to determine the prevalence of psychosocial issues and the different patterns of disclosure.

Results. Participants reported a high number of psychosocial stressors, which were associated with poorer glycaemic control (r = 0.60, P = 0.005). Approximately half of all disclosed stressors (50.9%) were identified in routine care; other stressors were identified only through intensive case management and/or in-depth interviews.

Conclusions. Identifying psychosocial stressors in routine care, and providing referrals to psychological or social services, is a significant unmet need and may improve glycaemic control among certain populations with diabetes. Systematic mechanisms of capturing this information, such as by screening surveys, should be considered.

Purpose. The purpose of this study was to explore motivations underlying nonadherent treatment decisions made by young adults with type 1 diabetes.

Methods. Eight emerging adults each completed a series of semi-structured interviews concerning their approaches to diabetes care, relationships with clinicians, and everyday activities and routines. A narrative thematic analysis was used to develop initial themes and refine them through continued data collection and review of the research literature.

Results. Five themes were identified as motivating nonadherence: (1) efforts to mislead health care providers, (2) adherence to alternative standards, (3) treatment fatigue and burnout, (4) social support problems, and (5) emotional and self-efficacy problems.

Conclusion. Instances of nonadherence generally involved a combination of the five identified themes. Participants reporting nonadherence also described difficulties communicating with care providers regarding their treatment. Nonjudgmental communication between providers and emerging adults may be particularly important in promoting positive health outcomes in this population.

Randomized controlled trials (RCTs) are considered the criterion standard in research design for establishing treatment efficacy. However, the rigorous and highly controlled conditions of RCTs can be difficult to attain when conducting research among individuals living with a confluence of disability, low socioeconomic status, and being a member of a racial/ethnic minority group, who may be more likely to have unstable life circumstances. Research on effective interventions for these groups is urgently needed, because evidence regarding approaches to reduce health disparities and improve health outcomes is lacking. In this methodologic article, we discuss the challenges and lessons learned in implementing the Lifestyle Redesign for Pressure Ulcer Prevention in Spinal Cord Injury study among a highly disadvantaged population. These issues are discussed in terms of strategies to enhance recruitment, retention, and intervention relevance to the target population. Recommendations for researchers seeking to conduct RCTs among socioeconomically disadvantaged, ethnically diverse populations are provided.

I present the findings of a study aimed at developing an in-depth understanding of how engagement in occupation influences young adults’ ability to effectively manage diabetes and, conversely, how their diabetes self-management strategies shape their occupational participation. The qualitative interview-based study of 8 people ages 19–25 with Type 1 diabetes revealed that study participants often experienced tension between diabetes self-management and participation in valued occupations, which required them to make calculated decisions about how to balance these competing priorities in their everyday lives. Seven themes are discussed in detail that characterized the relationship between participating in valued occupations and attending to the complex factors that dictate successful diabetes self-management. This research offers a preliminary framework for occupational therapists to assist young adults with diabetes and other chronic illnesses in reconciling these competing demands.

Approximately 23.6 million people in the United States are living with diabetes, a disease that is a leading cause of disabling conditions including blindness, kidney failure, amputations, heart disease, and stroke. Although these complications of diabetes can be delayed or prevented through intensive diabetes self-management (DSM), maintaining control of the disease can be burdensome and negatively impact quality of life. Occupational therapy has a largely untapped potential to assist individuals who struggle with managing diabetes in the context of everyday life, yet there is little discussion of DSM in the occupational therapy literature. The author conducts a systematic review of the existing occupational therapy literature on diabetes, examines the current state of DSM interventions, and discusses a potential role for occupational therapy using programs such as Lifestyle Redesign®.

Rap music and hip-hop culture represents a contested space within contemporary culture in the United States, often stigmatized by members of the dominant culture as an offshoot of inner city gang and drug culture. However, this dismissal fails to consider the complex historical, social, and political factors that have contributed to the development and evolution of this form of cultural expression. This article argues that rap music constitutes a resistive occupation, employed by marginalized Black American youth to communicate thoughts and concerns that are often discounted by the dominant culture, and in doing so makes a significant contribution to Black American identities and culture. To support that perspective, the authors critically analyze the conceptualization of ‘culture’ in occupational science, reinterpreting the term through a postcolonial lens that considers the influence of power, domination, and resistance in the production of culture.