Make My Day : exploring engaging occupations in stroke prevention and promotion of health

Abstract

Background: Stroke is one of the major causes of disease burden worldwide. Most stroke cases are attributed to modifiable risk factors, such as high blood pressure, overweight, smoking, physical inactivity, and poor diet, making promoting an overall healthy lifestyle an essential strategy for stroke prevention. While multifactorial lifestyle interventions in a primary healthcare setting have been useful in addressing risk factors to prevent cardiovascular diseases (CVDs), such approaches specifically designed for primary stroke prevention are scarce in a Swedish setting. Applying an occupational perspective, incorporating and sustaining engaging occupations in everyday life has not previously been explored, and such an approach's feasibility has not been evaluated. Engaging occupations have been characterized by their high meaningfulness, intense participation, and importance for a person’s well-being. They are therefore important to explore in the context of addressing and improving risk factors for stroke and as part of a model for stroke prevention in primary healthcare.

Aim: To generate knowledge about engaging occupations in stroke prevention and promoting health among people at risk for stroke. To explore and evaluate the feasibility and implementation process of Make My Day (MMD), a digitally augmented stroke prevention intervention in primary healthcare.

Methods: The Medical Research Council’s (MRC) guidance for developing and evaluating complex interventions has been used in this thesis. In the exploration and development of MMD, key theoretical underpinnings were studied. In Study I, interviews were conducted with persons at risk for stroke who also had been diagnosed with a transient ischemic attack (TIA) (n=6). Study II built on data from observations and interviews with persons at moderate to high risk for stroke (n=6) participating in Study III. In addition, data on the same topic from Study I was extracted and used to answer the aim of Study II. Data in both Studies I and II was analyzed using a constant comparative method. Study III was a pilot randomized controlled trial (RCT) evaluating the feasibility of MMD among persons at risk for stroke (n=29). Both descriptive and inferential statistics were used to analyze the data. Study IV was a process evaluation conducted alongside the pilot RCT evaluating the intervention's reach, fidelity, dose, and contextual factors derived from logbooks and reflective field notes. Descriptive statistics was applied. To analyze data on acceptability derived from interviews and reflective field notes, a constant comparative method was used.

Results: Studies I-IV illustrate that the utilization of engaging occupations in stroke prevention is feasible. Engaging occupations as means and goals was supportive in promoting healthy lifestyle changes in everyday life among persons at risk for stroke. This was partly because of the motivational element of engaging occupations (Study I). Changing lifestyle habits was, however complex and imbued with barriers ranging from the individual to societal level. New ways of doing in everyday life could be facilitated by developing a self-monitoring routine in tandem with engaging in and reflecting on one’s occupations in everyday life (Study II). In learning and changing ways of doing, engaging in a personally relevant mHealth app was supportive. When the digital environment corresponds with literacy levels, previous experiences, and needs in terms of automatizations, self-monitoring became enjoyable and more accessible to integrate into everyday life for persons at risk for stroke. Moreover, Study III showed that the MMD intervention was feasible through its timely recruitment of participants, overall high response rates and study completion, and sensitivity to change in key outcomes, such as stroke risk reduction and occupational performance. In addition, Study IV illustrated the acceptability of MMD among persons at risk for stroke and health professionals. Key mediators were the high willingness to and belief in working with the framework of MMD. Key challenges were time management, heterogeneity in group compositions, and the reimbursement system.

Conclusions: This thesis demonstrates the feasibility of a digitally augmented stroke prevention intervention and the usefulness of engaging occupations when promoting healthy lifestyle changes. The knowledge gained may be transferable to interventions addressing the prevention of other CVDs, also caused by modifiable risk factors. However, sustainable implementation of prevention like MMD relies on personally relevant approaches and on addressing aspects on the organizational and socio-political level so that preventative interventions such as MMD are reimbursed.