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Phillips LA, More KR, Russell D, Kim HS. Evaluating the impact of individuals' morningness-eveningness on the effectiveness of a habit-formation intervention for a simple and a complex behavior. J Behav Med 2024; 47:804-818. [PMID: 39014034 DOI: 10.1007/s10865-024-00503-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/30/2024] [Indexed: 07/18/2024]
Abstract
Planning-based interventions are often used to help individuals form habits. Existing literature suggests a one-size-fits all approach to habit formation, but planning interventions may be optimized if tailored to individual differences and/or behavioral complexity. We test the hypothesis that planning to do a relatively complex behaviour (exercise) at a time that matches an individuals' diurnal preference will facilitate behavioral engagement; whereas for a simpler behaviour (calcium supplementation), the optimal time-of-day for a new behavior will occur in the morning. Young, women volunteers (N = 317) were randomly assigned to take calcium supplements or to exercise for 4 weeks and to control (no planning) or to one of three planning interventions (morning plan; evening plan; unassigned-time plan). Participants reported diurnal preference at baseline and habit strength and behavioral frequency weekly. Fitbit Zips and Medication Event Monitoring System Caps (MEMS) were used to objectively assess behavioral engagement. Multilevel modelling found that calcium-supplementation was greatest for morning-types in the morning-cue condition, whereas exercise was greatest for morning-types with morning cues and evening-types with evening cues. Habit-formation strategies may depend on diurnal preference and behavioral complexity. Future research can evaluate the role of other individual differences.
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Affiliation(s)
| | | | - Daniel Russell
- Department of Human Development and Family Studies, Iowa State University, Ames, USA
| | - Hyun Seon Kim
- Department of Psychology, Iowa State University, Ames, USA
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2
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Reboldi G, Angeli F, Verdecchia P. Antihypertensive drugs in the morning or the evening? A complicated question with no clear answer. J Hypertens 2024; 42:1684-1686. [PMID: 39196690 DOI: 10.1097/hjh.0000000000003816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2024]
Affiliation(s)
- Gianpaolo Reboldi
- Department of Medicine and Surgery, University of Perugia
- Division of Nephrology, Hospital S. Maria della Misericordia, Perugia
| | - Fabio Angeli
- Department of Medicine and Technological Innovation (DiMIT), University of Insubria, Varese Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS Tradate, Tradate
| | - Paolo Verdecchia
- Fondazione Umbra Cuore e Ipertensione-ONLUS
- Division of Cardiology, Hospital S. Maria della Misericordia, Perugia, Italy
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3
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Hetherington MM, Thomas JM, McLeod CJ. "I see it very much as an end-of-life food" - Barriers to oral nutritional supplement adherence, views from healthy older adults. Appetite 2024; 197:107327. [PMID: 38555018 DOI: 10.1016/j.appet.2024.107327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 04/02/2024]
Abstract
Malnutrition affects approximately one quarter of UK adults aged 65 years and over. As the global demographic shift continues, malnutrition is expected to increase. Oral nutritional supplements (ONS) are used both to prevent and to treat malnutrition. However, their effectiveness is compromised by poor adherence, and it is not well understood what contributes to this. Therefore, the current research was designed to explore ONS adherence from the parallel perspectives of ONS as a prescribed "medication" and as a food supplement/substitute. Eighteen older adults (13F, 5M; mean age = 73.4 yr; range: 70-80 yr) participated in focus groups (three in-person and one online), to investigate experiences of taking prescribed medications, including dietary supplements, and what should be factors to consider in supporting regular intake of ONS for trial development, as well as any potential improvements to products. Focus group sessions were recorded and then transcribed. Thematic Analysis was applied to the transcripts by the first author, and themes were discussed in depth, using exemplar quotes from participants. Five dominant themes were identified from the data: Disgust, Palatability and Acceptance; End-of-Life Care; Resistance to Medicines; Rituals and Reminders; and Real Food Displacement. Nutritional supplements were characterised as "disgusting", "manufactured", and associated with serious, chronic illness, as well as end-of-life care, in contrast to probiotics which were linked with health and wellness. The sweet taste of ONS was identified as a barrier to intake, given that it is generally associated with a signal to stop eating, and low hunger. As a group, participants tried to "avoid taking medicines", and viewed the need to have them negatively, yet most regularly took prescribed medication and/or vitamin supplements. Participants identified several, rituals and reminders to take medicines, including meal-based, or time-of-day-based prompts (e.g., before, with or after meals). To improve adherence, savoury products were suggested, as well as a more person-centred approach to individual nutritional needs and preferences. Overall, the group discussion mainly identified barriers to intake, but that improving taste, adding to "real food" (not replacing meals), and offering variety of flavour and form (e.g., savoury soups as well as sweet drinks) could be included in future trials to improve appeal and therefore intake. Future work should continue to explore how best to formulate, market and/or prescribe ONS, and how this might vary for malnutrition prevention vs treatment strategies.
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Affiliation(s)
| | - Jason M Thomas
- School of Psychology, College of Health and Life Sciences, Aston University, Birmingham, B4 7ET, UK
| | - Chris J McLeod
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, LE11 3TU, UK
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Giacchetti S, Laas E, Bachelot T, Lemonnier J, André F, Cameron D, Bliss J, Chabaud S, Hardy-Bessard AC, Lacroix-Triki M, Canon JL, Debled M, Campone M, Cottu P, Dalenc F, Ballesta A, Penault-Llorca F, Asselain B, Dumas E, Reyal F, Gougis P, Lévi F, Hamy AS. Association between endocrine adjuvant therapy intake timing and disease-free survival in patients with high-risk early breast cancer: results of a sub-study of the UCBG- UNIRAD trial. EBioMedicine 2024; 104:105141. [PMID: 38718683 PMCID: PMC11096868 DOI: 10.1016/j.ebiom.2024.105141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 04/04/2024] [Accepted: 04/16/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Circadian rhythms regulate cellular physiology and could influence the efficacy of endocrine therapy (ET) in breast cancer (BC). We prospectively tested this hypothesis within the UNIRAD adjuvant phase III trial (NCT01805271). METHODS 1278 patients with high-risk hormonal receptor positive (HR+)/HER2 negative (HER2-) primary BC were randomly assigned to adjuvant ET with placebo or everolimus. Patients prospectively reported in a diary the daily timing of ET intake among four 6-h slots (06:00-11:59 (morning), 12:00-17:59 (afternoon), 18:00-23:59 (evening), or 24:00-05:59 (nighttime). The association between ET timing and disease-free survival (DFS) was a prespecified secondary endpoint of the trial and the results of this observational study are reported here. FINDINGS ET timing was recorded by 855 patients (67.2%). Patients declaring morning (n = 465, 54.4%) or afternoon (n = 45, 5.4%) ET intake were older than those declaring evening (n = 339, 39.6%) or nighttime (n = 5, 0.6%) intake. With a median follow-up of 46.7 months, 118 patients had a local (n = 30) or metastasis relapse (n = 84), and 41 patients died. ET intake timing was not associated with DFS in the whole population (HR = 0.77, 95% CI [0.53-1.12]). The association between ET intake timing and DFS according to the stratification factors revealed interactions with ET agent (tamoxifen versus Aromatase inhibitors (AI) with an increased DFS in the group of evening/nighttime versus morning/afternoon tamoxifen intake (HR = 0.43, 95% CI [0.22-0.85]), while no association was found for AI intake (HR = 1.07, 95% CI [0.68-1.69]). The interaction between ET intake timing and ET agent remained in multivariable analysis (HR = 0.38 [0.16-0.91]). INTERPRETATION Tamoxifen intake in the evening/nighttime could be recommended in patients with high-risk HR+/HER2- BC while awaiting for results from further ET timing studies. FUNDING UNIRAD was Supported by a grant from the French Ministry of Health PHRC 2012 and received funding from La Ligue contre le Cancer, Cancer Research-UK, Myriad Genetics, and Novartis.
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Affiliation(s)
- Sylvie Giacchetti
- AP-HP, Hôpital Saint Louis, Senologie, Paris and Chronotherapy, Cancers, and Transplantation Unit, Faculty of Medicine, Paris-Saclay University, France; Chronotherapy, Cancers and Transplatation Unit, Faculty of Medicine, Paris-Saclay, Villejuif, France.
| | - Enora Laas
- Surgery Department, Institut Curie, Universite Paris Cite, Paris, France; RT2Lab, Residual Tumor and Response to Treatment, U932 "Immunity and Cancer", Universite Paris Cité, Paris, France
| | | | | | | | - David Cameron
- ICR-CTSU, Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Judith Bliss
- Medical Oncology, Western General Hospital, Edinburgh, United Kingdom
| | - Sylvie Chabaud
- Department of Clinical Research and Innovation, Centre Leon Berard, Lyon, France
| | | | | | - Jean-Luc Canon
- Medical Oncology, Grand Hopital de Charleroi, Charleroi, Belgium
| | - Marc Debled
- Medical Oncology, Institut Bergonie, Bordeaux, France
| | - Mario Campone
- Medical Oncology, Institut Cancerologie de l'Ouest, Saint Herblain, France
| | - Paul Cottu
- Medical Oncology, Institut Curie, Universite Paris Cite, Paris, France
| | - Florence Dalenc
- Medical Oncology, Oncopole Claudius Regaud, IUCT, Toulouse, France
| | | | - Frederique Penault-Llorca
- Centre Jean Perrin, Université Clermont Auvergne, INSERM, U1240 Imagerie Moléculaire et Stratégies Théranostiques, Clermont Ferrand, France
| | | | - Elise Dumas
- RT2Lab, Residual Tumor and Response to Treatment, U932 "Immunity and Cancer", Universite Paris Cité, Paris, France; Department of Mathematics, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland; (t)"Chronotherapy, Cancers, and Transplantation" Unit, Faculty of Medicine, Paris-Saclay University, Villejuif, France
| | - Fabien Reyal
- Surgery Department, Institut Curie, Universite Paris Cite, Paris, France; RT2Lab, Residual Tumor and Response to Treatment, U932 "Immunity and Cancer", Universite Paris Cité, Paris, France
| | - Paul Gougis
- RT2Lab, Residual Tumor and Response to Treatment, U932 "Immunity and Cancer", Universite Paris Cité, Paris, France
| | - Francis Lévi
- Chronotherapy, Cancers and Transplatation Unit, Faculty of Medicine, Paris-Saclay, Villejuif, France
| | - Anne-Sophie Hamy
- Medical Oncology, Institut Curie, Universite Paris Cite, Paris, France; RT2Lab, Residual Tumor and Response to Treatment, U932 "Immunity and Cancer", Universite Paris Cité, Paris, France
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Lauffenburger JC, Tesfaye H, Solomon DH, Antman EM, Glynn RJ, Lee SB, Tong A, Choudhry NK. Investigating the ability to adhere to cardiometabolic medications with different properties: a retrospective cohort study of >500 000 patients in the USA. BMJ Open 2023; 13:e075840. [PMID: 37949625 PMCID: PMC10649612 DOI: 10.1136/bmjopen-2023-075840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVE Poor medication adherence remains highly prevalent and adversely affects health outcomes. Patients frequently describe properties of the pills themselves, like size and shape, as barriers, but this has not been evaluated objectively. We sought to determine the extent to which oral medication properties thought to be influential translate into lower objectively-measured adherence. DESIGN Retrospective cohort study. SETTING US nationwide commercial claims database, 2016-2019. PARTICIPANTS Among patients initiating first-line hypertension, diabetes or hyperlipidaemia treatment based on clinical guidelines, we measured pill size, shape, colour and flavouring, number of pills/day and fixed-dose combination status as properties. OUTCOME MEASURES Outcomes included discontinuation after the first fill (ie, never filling again over a minimum of 1-year follow-up) and long-term non-adherence (1-year proportion of days covered <0.80). We estimated associations between each property and outcomes, by therapeutic class (eg, statins), with multivariable logistic regression. RESULTS Across 604 323 patients, 14.6% discontinued after filling once (ie, were non-persistent), and 54.0% were non-adherent over 1-year follow-up. Large pill size was associated with non-adherence, except for thiazides (eg, metformin adjusted OR (aOR): 1.12, 95% CI: 1.06 to 1.18). Greater pill burden was associated with a higher risk of non-adherence across all classes (eg, metformin aOR: 1.58, 95% CI: 1.53 to 1.64 for two pills/day). Taking less than one pill/day was also associated with higher risk of non-adherence and non-persistence (eg, non-persistence statin aOR: 1.29, 95% CI: 1.20 to 1.38). Pill shape, colour, flavouring and combination status were associated with mixed effects across classes. CONCLUSIONS Pill burden and pill size are key properties affecting adherence for almost all classes; others, like size and combination, could modestly affect medication adherence. Clinical interventions could screen patients for potential intolerance to medication and potentially implement more convenient dosing schedules.
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Affiliation(s)
- Julie C Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Center for Healthcare Delivery Sciences, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Helen Tesfaye
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel H Solomon
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Elliott M Antman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Angela Tong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Niteesh K Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Center for Healthcare Delivery Sciences, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Phillips LA, Mullan BA. Ramifications of behavioural complexity for habit conceptualisation, promotion, and measurement. Health Psychol Rev 2023; 17:402-415. [PMID: 35382707 DOI: 10.1080/17437199.2022.2060849] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/28/2022] [Indexed: 11/04/2022]
Abstract
Behavioural theories, predictions, and interventions should be relevant to complex, real-world health behaviours and conditions. Habit theory and habit formation interventions show promise for predicting and promoting, respectively, longer-term behaviour change and maintenance than has been attained with theories and interventions focused only on deliberative behavioural factors. However, the concept of habit has largely been treated as uniform across different types of behaviours. In this conceptual review, we contend that the definitional aspects of habit differ at a conceptual level for simple versus more complex behaviours, with ramifications for prediction, promotion, and measurement of habits. Specifically, habits are defined as direct context-response associations learned through repeatedly rewarded responding - but what is meant by 'response' and 'reward' depends upon the complexity of the behaviour. We review literature that suggests (1) responses in complex habits have separable and substitutable components (vs a single and static, unitary component) and (2) rewards for complex habits are necessarily continued and intrinsic (vs temporary and extrinsic, respectively). We discuss some empirical and theoretical questions raised by these issues around behavioural complexity and habit. Lastly, we outline the ramifications of these issues for habit measurement (habit strength and habit formation) via self-report and objective measures.
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Phillips LA, Pironet A, Vrijens B. Evaluating Objective Metrics of habit strength for taking medications. J Behav Med 2023; 46:632-641. [PMID: 36662351 DOI: 10.1007/s10865-023-00392-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 01/03/2023] [Indexed: 01/21/2023]
Abstract
Habit strength for taking medication is associated with medication adherence. However, habit strength is typically measured via self-reports, which have limitations. Objective sensors may provide advantages to self-reports. To evaluate whether habit-strength metrics derived from objective sensor data (MEMS® Caps; AARDEX Group) are associated with self-reported habit strength and adherence (objective and self-reported) and whether objective and self-reported habit strength are independently associated with adherence. Patients (N = 79) on oral medications for type 2 diabetes completed self-reports of habit strength and medication adherence and used MEMS® Caps to take their prescribed medication for one month. MEMS® Caps data were used to create five objective metrics of habit strength (e.g., individual-level variance in pill timing) and quantify medication adherence (% days correct dosing). Consistency in behavior from week to week (versus across each day) had the greatest association with self-reported habit strength (r(78) = 0.29, p = 0.01), self-reported adherence (r(78) = 0.32, p = 0.005), and objective adherence (r(78) = 0.61, p < 0.001). Objective and self-reported habit strength were independently associated with adherence. Weekly pill-timing consistency may be more useful than daily pill-timing consistency for predicting adherence and understanding patients' medication-taking habits. Self-reports and objective metrics of habit strength may be measuring different constructs, warranting further research.
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De Keyser H, Vuong V, Kaye L, Anderson WC, Szefler S, Stempel DA. Is Once Versus Twice Daily Dosing Better for Adherence in Asthma and Chronic Obstructive Pulmonary Disease? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2087-2093.e3. [PMID: 37088377 PMCID: PMC10330551 DOI: 10.1016/j.jaip.2023.03.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Patients with asthma and chronic obstructive pulmonary disease (COPD) may be prescribed once- or twice-daily dosing of controller inhalers. OBJECTIVE To assess differences in controller adherence by dosing schedule and age. METHODS Electronic medication monitors (EMMs) captured the date and time of inhaler actuations over 90 days in patients using the Propeller Health platform. Prescribed inhaler schedule was self-reported. Once- versus twice-daily schedule comparisons were assessed retrospectively using regressions adjusting for age. RESULTS A total of 6294 patients with asthma and 1791 patients with COPD were included. On average, once-daily users had significantly higher median (interquartile range [IQR]) daily adherence than twice-daily users (asthma: 63.3 [IQR: 31.1, 86.7]% vs 50.3 [IQR: 21.1, 78.3]%, P < .001; COPD: 83.3 [IQR: 57.2, 95.6]% vs 64.7 [IQR: 32.8, 88.9]%, P < .001). This pattern persisted in all age groups, with the exception of 4- to 17-year-olds in asthma. The lowest adherence was in the young adult population (18- to 29-year-olds). The percentage of patients who achieved ≥80% adherence was significantly higher among once- versus twice-daily users in asthma (34.3% vs 23.6%, P < .001) and COPD (54.8% vs 38.6%, P < .001). The adjusted odds of once- versus twice-daily users achieving ≥80% adherence was 1.36 (95% confidence interval: 1.19-1.56, P < .001) in asthma and 1.73 (95% confidence interval: 1.38-2.17, P < .001) in COPD. Most once-daily patients with COPD took their medication in the morning versus at night; there was no difference in morning versus afternoon/evening administration in all other asthma and COPD groups. CONCLUSION Patients with asthma and COPD who were prescribed once-daily versus twice-daily medications were more likely to adhere to their inhalers. Patients with COPD had higher adherence than those with asthma, possibly reflecting, in part, the older cohort age. The effect of greater adherence on exacerbations is a topic for future analysis.
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Affiliation(s)
- Heather De Keyser
- Breathing Institute, Children's Hospital Colorado and Adult and Child Center for Outcomes Research and Dissemination Science, University of Colorado, Aurora, Colo.
| | - Vy Vuong
- Medical Affairs, ResMed Science Center, San Francisco, Calif
| | - Leanne Kaye
- Medical Affairs, ResMed Science Center, San Francisco, Calif
| | - William C Anderson
- Allergy and Immunology Section, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colo
| | - Stanley Szefler
- Breathing Institute, Children's Hospital Colorado and Adult and Child Center for Outcomes Research and Dissemination Science, University of Colorado, Aurora, Colo
| | - David A Stempel
- Clinical and Medical Affairs, Propeller Health, Madison, Wis
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Gardner B, Arden MA, Brown D, Eves FF, Green J, Hamilton K, Hankonen N, Inauen J, Keller J, Kwasnicka D, Labudek S, Marien H, Masaryk R, McCleary N, Mullan BA, Neter E, Orbell S, Potthoff S, Lally P. Developing habit-based health behaviour change interventions: twenty-one questions to guide future research. Psychol Health 2023; 38:518-540. [PMID: 34779335 DOI: 10.1080/08870446.2021.2003362] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Habitual behaviours are triggered automatically, with little conscious forethought. Theory suggests that making healthy behaviours habitual, and breaking the habits that underpin many ingrained unhealthy behaviours, promotes long-term behaviour change. This has prompted interest in incorporating habit formation and disruption strategies into behaviour change interventions. Yet, notable research gaps limit understanding of how to harness habit to change real-world behaviours. METHODS Discussions among health psychology researchers and practitioners, at the 2019 European Health Psychology Society 'Synergy Expert Meeting', generated pertinent questions to guide further research into habit and health behaviour. RESULTS In line with the four topics discussed at the meeting, 21 questions were identified, concerning: how habit manifests in health behaviour (3 questions); how to form healthy habits (5 questions); how to break unhealthy habits (4 questions); and how to develop and evaluate habit-based behaviour change interventions (9 questions). CONCLUSIONS While our questions transcend research contexts, accumulating knowledge across studies of specific health behaviours, settings, and populations will build a broader understanding of habit change principles and how they may be embedded into interventions. We encourage researchers and practitioners to prioritise these questions, to further theory and evidence around how to create long-lasting health behaviour change.
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Affiliation(s)
- Benjamin Gardner
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Madelynne A Arden
- Centre for Behavioural Science and Applied Psychology, Department of Psychology, Sociology & Politics, Sheffield Hallam University, Sheffield, UK
| | - Daniel Brown
- Department of Applied Psychology, Griffith University, Brisbane, Australia
| | - Frank F Eves
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - James Green
- School of Allied Health and Physical Activity for Health Research Cluster (Health Research Institute), University of Limerick, Limerick, Ireland
| | - Kyra Hamilton
- Griffith University and Menzies Health Institute Queensland, Mt Gravatt, Qld, Australia
| | - Nelli Hankonen
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
| | - Jennifer Inauen
- Department of Health Psychology and Behavioral Medicine, Institute of Psychology, University of Bern, Bern, Switzerland
| | - Jan Keller
- Division Health Psychology, Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany
| | - Dominika Kwasnicka
- Faculty of Psychology, SWPS University of Social Sciences and Humanities, Wrocław, Poland.,NHMRC CRE in Digital Technology to Transform Chronic Disease Outcomes, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Sarah Labudek
- Network Aging Research (NAR), Heidelberg University, Heidelberg, Germany
| | - Hans Marien
- Department of Psychology, Utrecht University, Utrecht, The Netherlands
| | - Radomír Masaryk
- Institute of Applied Psychology, Faculty of Social and Economic Sciences, Comenius University Bratislava, Bratislava, Slovakia
| | - Nicola McCleary
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Barbara A Mullan
- Behavioural Science and Health Research Group, Curtin University, Perth, Australia
| | - Efrat Neter
- Department of Behavioral Sciences, Ruppin Academic Center, Emeq Hefer, Israel
| | - Sheina Orbell
- Department of Psychology, University of Essex, Essex, UK
| | - Sebastian Potthoff
- Department of Social Work, Education, and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Phillippa Lally
- Research Department of Behavioural Science and Health, University College London, London, UK
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10
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Stone JY, Mayberry LS, Clouse K, Mulvaney S. The Role of Habit Formation and Automaticity in Diabetes Self-Management: Current Evidence and Future Applications. Curr Diab Rep 2023; 23:43-58. [PMID: 36749452 DOI: 10.1007/s11892-023-01499-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW Diabetes is a chronic condition that requires consistent self-management for optimal health outcomes. People with diabetes are prone to burnout, cognitive burden, and sub-optimal performance of self-management tasks. Interventions that focus on habit formation have the potential to increase engagement by facilitating automaticity of self-management task performance. The purpose of this review is to (1) clarify the conceptualizations of habit formation and behavioral automaticity in the context of health behavior interventions, (2) review the evidence of habit in relation to behaviors relevant to diabetes self-management, and (3) discuss opportunities for incorporating habit formation and automaticity into diabetes self-management interventions. RECENT FINDINGS Modern habit research describes a habit as a behavior that results over time from an automatic mental process. Automatic behaviors are experienced as cue-dependent, goal-independent, unconscious, and efficient. Habit formation requires context-dependent repetition to form cue-behavior associations. Results of diabetes habit studies are mixed. Observational studies have shown positive associations between habit strength and target self-management behaviors such as taking medication and monitoring blood glucose, as well as glycemic outcomes such as HbA1c. However, intervention studies conducted in similar populations have not demonstrated a significant benefit of habit-forming interventions compared to controls, possibly due to varying techniques used to promote habit formation. Automaticity of self-management behaviors has the potential to minimize the burden associated with performance of self-management tasks and ultimately improve outcomes for people with diabetes. Future studies should focus on refining interventions focused on context-dependent repetition to promote habit formation and better measurement of habit automaticity in diabetes self-management.
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Affiliation(s)
- Jenine Y Stone
- Vanderbilt University, 461 21st Avenue South, Nashville, TN, 37240, USA.
- AMCR Institute, Escondido, CA, USA.
| | | | - Kate Clouse
- Vanderbilt University, 461 21st Avenue South, Nashville, TN, 37240, USA
| | - Shelagh Mulvaney
- Vanderbilt University, 461 21st Avenue South, Nashville, TN, 37240, USA
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Reach G, Calvez A, Sritharan N, Boubaya M, Lévy V, Sidorkiewicz S, Fiani M. Patients' Perceived Importance of Medication and Adherence in Polypharmacy, a Quantitative, Cross-Sectional Study Using a Questionnaire Administered in Three Doctors' Private Practices in France. Drugs Real World Outcomes 2023:10.1007/s40801-023-00361-7. [PMID: 36997772 DOI: 10.1007/s40801-023-00361-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Among the determinants of nonadherence, polypharmacy (common in people with multiple pathologies and especially in elderly patients), plays a major role. OBJECTIVE In patients who are subject to polypharmacy involving different classes of medications, the first aim is to assess the impact of medication importance given by patients on (i) medication adherence and (ii) the respective effect of intentionality and habit in medication importance and medication adherence. The second objective is to compare the importance given to medication and adherence in the different therapeutic classes. PATIENTS AND METHODS Patients taking 5-10 different medications for at least 1 month were included in a cross-sectional survey in three private practices in one region in France. RESULTS This study included 130 patients (59.2 % female) with 851 medications in total. The mean ± standard deviation (SD) age was 70.5 ± 12.2 years. The mean ± SD of medications taken was 6.9 ± 1.7. Treatment adherence had a strong positive correlation with the patient-perceived medication importance (p < 0.001). Counter-intuitively, taking a large number of medications (≥7) was associated with being fully adherent (p = 0.02). A high intentional nonadherence score was negatively associated with high medication importance (p = 0.003). Furthermore, patient-perceived medication importance was positively associated with taking treatment by habit (p = 0.03). Overall nonadherence more strongly correlated with unintentional nonadherence (p < 0.001) than with intentional nonadherence (p = 0.02). Compared to the antihypertensive class, a decrease in adherence by medication was observed in psychoanaleptics (p < 0.0001) and drugs used in diabetes class (p = 0.002), and a decrease in importance in lipid-modifying agents class (p = 0.001) and psychoanaleptics (p < 0.0001). CONCLUSION The perception of the importance of a medicine is associated with the place of intentionality and habit in patient adherence. Therefore, explaining the importance of a medicine should become an important part of patient education.
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Affiliation(s)
- Gérard Reach
- Health Education and Promotion Laboratory (LEPS UR 3412), Sorbonne Paris Nord University, 74 rue Marcel Cachin 93017, Bobigny Cedex, France.
| | - Aurélie Calvez
- Department of General Practice, University of Picardy Jules Verne, Amiens, France
| | | | - Marouane Boubaya
- Department of Clinical Research, CHU Avicenne, APHP, Bobigny, France
| | - Vincent Lévy
- Department of Clinical Research, CHU Avicenne, APHP, Bobigny, France
| | - Stéphanie Sidorkiewicz
- Department of General Medicine, University of Paris Cité, 75014, Paris, France
- University of Paris Cité, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), INSERM, UMR 1153, 75004, Paris, France
| | - May Fiani
- Health Education and Promotion Laboratory (LEPS UR 3412), Sorbonne Paris Nord University, 74 rue Marcel Cachin 93017, Bobigny Cedex, France
- Department of General Practice, University of Picardy Jules Verne, Amiens, France
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Li Y, Schofield E, Hay JL. Unpacking Habit With Bayesian Mixed Models: Dynamic Approach to Health Behaviors With Interchangeable Elements, Illustrated Through Multiple Sun Protection Behaviors. THE QUANTITATIVE METHODS FOR PSYCHOLOGY 2023; 19:265-280. [PMID: 39323564 PMCID: PMC11423781 DOI: 10.20982/tqmp.19.3.p265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
Analytics for behavioral habit typically model one behavior at a time, despite the fact that habit often involves multiple cooccurring behaviors, such as food choices and physical activities, where interrelated behaviors are often equally recommended. We propose a novel Mixed-Effects Dynamic hAbit model (MEDA) to simultaneously model multiple related, habitual behaviors. As an illustrative example, MEDA was applied to real-time assessments of sun protection (sunscreen, shade, hat, and protective clothing) reported twice daily by first-degree relatives of melanoma patients who are themselves at an elevated risk of skin cancer. MEDA aims to explicate habits in sun protection under varying environmental cues (e.g., sunny and hot weather). We found consistent between-group differences (e.g., men responding to weather cues more consistently than women) and interactions between cooccurring behaviors (e.g., being in shade discourages sunscreen wearing, more so in men than women). Moreover, MEDA transcends conventional methods to address longstanding challenges-how cue to action and volitional choices differ by groups or even by individual persons. Such nuances in interrelated habitual behaviors are relevant in numerous other applications, such as recommended dietary or physical activity behaviors. These methods best inform personalized behavioral interventions targeting individual preferences for precision behavioral intervention.
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Affiliation(s)
- Yuelin Li
- Department of Psychiatry & Behavioral Sciences,Memorial Sloan Kettering Cancer Center
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center
| | - Elizabeth Schofield
- Department of Psychiatry & Behavioral Sciences,Memorial Sloan Kettering Cancer Center
| | - Jennifer L Hay
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center
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13
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Fowers R, Berardi V, Huberty J, Stecher C. Using mobile meditation app data to predict future app engagement: an observational study. J Am Med Inform Assoc 2022; 29:2057-2065. [PMID: 36164826 PMCID: PMC9667187 DOI: 10.1093/jamia/ocac169] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 08/19/2022] [Accepted: 09/20/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Meditation with mobile apps has been shown to improve mental and physical health. However, regular, long-term meditation app use is needed to maintain these health benefits, and many people have a difficult time maintaining engagement with meditation apps over time. Our goal was to determine the length of the timeframe over which usage data must be collected before future app abandonment can be predicted accurately in order to better target additional behavioral support to those who are most likely to stop using the app. METHODS Data were collected from a randomly drawn sample of 2600 new subscribers to a 1-year membership of the mobile app Calm, who started using the app between July and November of 2018. App usage data contained the duration and start time of all meditation sessions with the app over 365 days. We used these data to construct the following predictive model features: total daily sessions, total daily duration, and a measure of temporal similarity between consecutive days based on the dynamic time warping (DTW) distance measure. We then fit random forest models using increasingly longer periods of data after users subscribed to Calm to predict whether they performed any meditation sessions over 2-week intervals in the future. Model fit was assessed using the area under the receiver operator characteristic curve (AUC), and an exponential growth model was used to determine the minimal amount of data needed to reach an accurate prediction (95% of max AUC) of future engagement. RESULTS After first subscribing to Calm, 83.1% of the sample used the Calm app on at least 1 more day. However, by day 350 after subscribing, 58.0% of users abandoned their use of the app. For the persistent users, the average number of daily sessions was 0.33 (SD = 0.02), the average daily duration of meditating was 3.93 minutes (SD = 0.25), and the average DTW distance to the previous day was 1.50 (SD = 0.17). The exponential growth models revealed that an average of 64 days of observations after subscribing to Calm are needed to reach an accurate prediction of future app engagement. DISCUSSION Our results are consistent with existing estimates of the time required to develop a new habit. Additionally, this research demonstrates how to use app usage data to quickly and accurately predict the likelihood of users' future app abandonment. This research allows future researchers to better target just-in-time interventions towards users at risk of abandonment.
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Affiliation(s)
- Rylan Fowers
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
| | - Vincent Berardi
- Department of Psychology, Chapman University, Orange, California, USA
| | - Jennifer Huberty
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
| | - Chad Stecher
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
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14
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Mackenzie IS, Rogers A, Poulter NR, Williams B, Brown MJ, Webb DJ, Ford I, Rorie DA, Guthrie G, Grieve JWK, Pigazzani F, Rothwell PM, Young R, McConnachie A, Struthers AD, Lang CC, MacDonald TM. Cardiovascular outcomes in adults with hypertension with evening versus morning dosing of usual antihypertensives in the UK (TIME study): a prospective, randomised, open-label, blinded-endpoint clinical trial. Lancet 2022; 400:1417-1425. [PMID: 36240838 PMCID: PMC9631239 DOI: 10.1016/s0140-6736(22)01786-x] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/10/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Studies have suggested that evening dosing with antihypertensive therapy might have better outcomes than morning dosing. The Treatment in Morning versus Evening (TIME) study aimed to investigate whether evening dosing of usual antihypertensive medication improves major cardiovascular outcomes compared with morning dosing in patients with hypertension. METHODS The TIME study is a prospective, pragmatic, decentralised, parallel-group study in the UK, that recruited adults (aged ≥18 years) with hypertension and taking at least one antihypertensive medication. Eligible participants were randomly assigned (1:1), without restriction, stratification, or minimisation, to take all of their usual antihypertensive medications in either the morning (0600-1000 h) or in the evening (2000-0000 h). Participants were followed up for the composite primary endpoint of vascular death or hospitalisation for non-fatal myocardial infarction or non-fatal stroke. Endpoints were identified by participant report or record linkage to National Health Service datasets and were adjudicated by a committee masked to treatment allocation. The primary endpoint was assessed as the time to first occurrence of an event in the intention-to-treat population (ie, all participants randomly assigned to a treatment group). Safety was assessed in all participants who submitted at least one follow-up questionnaire. The study is registered with EudraCT (2011-001968-21) and ISRCTN (18157641), and is now complete. FINDINGS Between Dec 17, 2011, and June 5, 2018, 24 610 individuals were screened and 21 104 were randomly assigned to evening (n=10 503) or morning (n=10 601) dosing groups. Mean age at study entry was 65·1 years (SD 9·3); 12 136 (57·5%) participants were men; 8968 (42·5%) were women; 19 101 (90·5%) were White; 98 (0·5%) were Black, African, Caribbean, or Black British (ethnicity was not reported by 1637 [7·8%] participants); and 2725 (13·0%) had a previous cardiovascular disease. By the end of study follow-up (March 31, 2021), median follow-up was 5·2 years (IQR 4·9-5·7), and 529 (5·0%) of 10 503 participants assigned to evening treatment and 318 (3·0%) of 10 601 assigned to morning treatment had withdrawn from all follow-up. A primary endpoint event occurred in 362 (3·4%) participants assigned to evening treatment (0·69 events [95% CI 0·62-0·76] per 100 patient-years) and 390 (3·7%) assigned to morning treatment (0·72 events [95% CI 0·65-0·79] per 100 patient-years; unadjusted hazard ratio 0·95 [95% CI 0·83-1·10]; p=0·53). No safety concerns were identified. INTERPRETATION Evening dosing of usual antihypertensive medication was not different from morning dosing in terms of major cardiovascular outcomes. Patients can be advised that they can take their regular antihypertensive medications at a convenient time that minimises any undesirable effects. FUNDING British Heart Foundation.
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Affiliation(s)
- Isla S Mackenzie
- MEMO Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Amy Rogers
- MEMO Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Neil R Poulter
- School of Public Health, Imperial College London, London, UK
| | - Bryan Williams
- NIHR University College London Hospitals Biomedical Research Centre and University College London, London, UK
| | | | - David J Webb
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Ian Ford
- The Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - David A Rorie
- MEMO Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Greg Guthrie
- MEMO Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - J W Kerr Grieve
- Department of Neurology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Filippo Pigazzani
- MEMO Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Robin Young
- The Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Alex McConnachie
- The Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Allan D Struthers
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Thomas M MacDonald
- MEMO Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK.
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Stecher C, Berardi V, Fowers R, Christ J, Chung Y, Huberty J. Identifying App-Based Meditation Habits and the Associated Mental Health Benefits: Longitudinal Observational Study. J Med Internet Res 2021; 23:e27282. [PMID: 34734826 PMCID: PMC8603170 DOI: 10.2196/27282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/26/2021] [Accepted: 09/10/2021] [Indexed: 01/19/2023] Open
Abstract
Background Behavioral habits are often initiated by contextual cues that occur at approximately the same time each day; so, it may be possible to identify a reflexive habit based on the temporal similarity of repeated daily behavior. Mobile health tools provide the detailed, longitudinal data necessary for constructing such an indicator of reflexive habits, which can improve our understanding of habit formation and help design more effective mobile health interventions for promoting healthier habits. Objective This study aims to use behavioral data from a commercial mindfulness meditation mobile phone app to construct an indicator of reflexive meditation habits based on temporal similarity and estimate the association between temporal similarity and meditation app users’ perceived health benefits. Methods App-use data from June 2019 to June 2020 were analyzed for 2771 paying subscribers of a meditation mobile phone app, of whom 86.06% (2359/2771) were female, 72.61% (2012/2771) were college educated, 86.29% (2391/2771) were White, and 60.71% (1664/2771) were employed full-time. Participants volunteered to complete a survey assessing their perceived changes in physical and mental health from using the app. Receiver operating characteristic curve analysis was used to evaluate the ability of the temporal similarity measure to predict future behavior, and variable importance statistics from random forest models were used to corroborate these findings. Logistic regression was used to estimate the association between temporal similarity and self-reported physical and mental health benefits. Results The temporal similarity of users’ daily app use before completing the survey, as measured by the dynamic time warping (DTW) distance between app use on consecutive days, significantly predicted app use at 28 days and at 6 months after the survey, even after controlling for users’ demographic and socioeconomic characteristics, total app sessions, duration of app use, and number of days with any app use. In addition, the temporal similarity measure significantly increased in the area under the receiver operating characteristic curve (AUC) for models predicting any future app use in 28 days (AUC=0.868 with DTW and 0.850 without DTW; P<.001) and for models predicting any app use in 6 months (AUC=0.821 with DTW and 0.802 without DTW; P<.001). Finally, a 1% increase in the temporal similarity of users’ daily meditation practice with the app over 6 weeks before the survey was associated with increased odds of reporting mental health improvements, with an odds ratio of 2.94 (95% CI 1.832-6.369). Conclusions The temporal similarity of the meditation app use was a significant predictor of future behavior, which suggests that this measure can identify reflexive meditation habits. In addition, temporal similarity was associated with greater perceived mental health benefits, which demonstrates that additional mental health benefits may be derived from forming reflexive meditation habits.
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Affiliation(s)
- Chad Stecher
- College of Health Solutions, Arizona State University, Phoenix, AZ, United States
| | - Vincent Berardi
- Department of Psychology, Chapman University, Orange, CA, United States
| | - Rylan Fowers
- College of Health Solutions, Arizona State University, Phoenix, AZ, United States
| | - Jaclyn Christ
- College of Health Solutions, Arizona State University, Phoenix, AZ, United States
| | - Yunro Chung
- College of Health Solutions, Arizona State University, Phoenix, AZ, United States
| | - Jennifer Huberty
- College of Health Solutions, Arizona State University, Phoenix, AZ, United States
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16
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Beltran-Bless AA, Vandermeer L, Ibrahim MFK, Hutton B, Shorr R, Savard MF, Clemons M. Does the Time of Day at Which Endocrine Therapy Is Taken Affect Breast Cancer Patient Outcomes? ACTA ACUST UNITED AC 2021; 28:2523-2528. [PMID: 34287262 PMCID: PMC8293101 DOI: 10.3390/curroncol28040229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 06/25/2021] [Accepted: 07/04/2021] [Indexed: 12/05/2022]
Abstract
Background: Non-compliance and non-persistence with endocrine therapy for breast cancer is common and usually related to treatment-induced side effects. There are anecdotal reports that simply changing the time of day when taking endocrine therapy (i.e., changing morning dosing to evening dosing or vice versa) can reduce side effects. Literature review: We conducted a literature review to evaluate whether changing the timing of tamoxifen and/or aromatase inhibitor administration impacted patient outcomes. No randomized control trials or prospective cohort studies that looked at time of day of endocrine therapy were identified through our review of literature from 1947 until August 2020. Conclusions: Given the rates of endocrine therapy non-compliance and non-persistence reported in the literature, ranging from 41–72% and 31–73%, respectively, simply changing the time of day when medications are taken could be an important strategy. We could identify no trials evaluating the effect of changes in timing of administration of endocrine therapy on breast cancer patient outcomes. Randomized control trials are clearly indicated for this simple and cost-effective intervention.
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Affiliation(s)
- Ana-Alicia Beltran-Bless
- Division of Medical Oncology, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, ON K1H 8L6, Canada; (A.-A.B.-B.); (M.-F.S.)
- Ottawa Hospital Research Institute, Ottawa, ON K1Y 4E9, Canada; (L.V.); (B.H.)
| | - Lisa Vandermeer
- Ottawa Hospital Research Institute, Ottawa, ON K1Y 4E9, Canada; (L.V.); (B.H.)
| | - Mohammed F. K. Ibrahim
- Division of Clinical Sciences, Medical Oncology, Northern Ontario School of Medicine, Thunder Bay, ON P7B 5E1, Canada;
| | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, ON K1Y 4E9, Canada; (L.V.); (B.H.)
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON K1G 5Z3, Canada
| | - Risa Shorr
- Ottawa Hospital, Ottawa, ON K1H 8L6, Canada;
| | - Marie-France Savard
- Division of Medical Oncology, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, ON K1H 8L6, Canada; (A.-A.B.-B.); (M.-F.S.)
- Ottawa Hospital Research Institute, Ottawa, ON K1Y 4E9, Canada; (L.V.); (B.H.)
| | - Mark Clemons
- Division of Medical Oncology, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, ON K1H 8L6, Canada; (A.-A.B.-B.); (M.-F.S.)
- Ottawa Hospital Research Institute, Ottawa, ON K1Y 4E9, Canada; (L.V.); (B.H.)
- Correspondence: ; Tel.: +1-613-737-7700
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