Impact of Routines and Rituals on Burden of Treatment, Patient Training, Cognitive Load, and Anxiety in Self-Injected Biologic Therapy

Abstract

Background: Self-injection of biologics is a mainstay of chronic disease treatment, yet the process of self-injection often causes persistent apprehension and anxiety, distinct from needle phobia. While literature alludes to the role that routines and rituals play in self-injection, there is no comprehensive study on the routines and rituals self-injectors employ, nor of the process by which they are discovered and ingrained. Methods: We conducted a mixed-method, observational pilot ethnography study of 27 patients with plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis with and without prior biologic self-injection experience. Patients submitted self-made videos, photos, and projective exercises of an actual biologic self-injection and completed validated instruments to assess burden of treatment. Videos and photos containing routine and ritual elements were thematically categorized based on functional and emotional benefit, and analyzed for differences based on current biologic, dosing frequency, time on current biologic, and burden of treatment measures. Results: During patients' initial at-home injections, training gaps became apparent, leading to a process of experimentation aimed at reducing pain/anxiety, increasing confidence, and building a consistent injection process. Routines were present in 27/27 (100%) patients and anchored the time, place, and process for injection, and incorporated approved use steps for the injection device. Ritual elements served as emotional coping strategies for patients and were present in 21/27 (77.8%) of patients. Conclusion: Our findings suggest that providing patients device training using adult learning principles, teaching routines and rituals concurrently, and providing at-home opportunities for practice with a device trainer may be useful strategies to reduce anxiety, avoid unnecessary experimentation, and improve adherence to injection therapy. While further studies are needed to generalize our findings, we posit that routine and ritual elements can be incorporated into existing patient-clinician interactions or novel digital interventions through mobile medical applications, smart training devices, and connected injection ecosystems.

International Survey to Evaluate Current Options for Subcutaneous Injection of Methotrexate (MTX) and a New Button-Free MTX Autoinjector

“… 47 Besides supporting the use of the new MTX autoinjector, the guidance may be an occasion to improve patient education which is a strong predictor of adherence. 48 , 49 In general, the availability of various devices is advantageous to meet the individual needs of different patients. 17 , 42 , 50 However, switching back and forth should be avoided.…”

Preferences and Perspectives of Specialist Multiple Sclerosis Nurses and Patients with Multiple Sclerosis Regarding the New RebiSmart® 3.0 Autoinjector versus Other Assistive Devices

“…Coyne et al reported that device training based on adult learning principles, routines, and rituals and at-home practice with a device trainer may reduce anxiety and unnecessary experimentation and improve injection therapy compliance. 31 These device trainers can be well-informed MS nurses and can provide support to pwMS to help them cope with their needle-related fears. While pwMS can be trained on the self-injection technique, routines and rituals are mostly selfdiscovered by the pwMS, and when these are anchored with timely guidance and continual educational support, they may help pwMS gain more confidence regarding the self-injection process.…”

“…While pwMS can be trained on the self-injection technique, routines and rituals are mostly selfdiscovered by the pwMS, and when these are anchored with timely guidance and continual educational support, they may help pwMS gain more confidence regarding the self-injection process. 31 Since MS nurses typically have more frequent clinical contact with pwMS than physicians, they can play a crucial role in educating pwMS about the disease and treatment they are receiving. This survey allowed us to understand the MS nurses' perspective on the key features of the RebiSmart 3.0 device that pwMS should be given additional information about that may potentially facilitate a smooth transition to it from their existing device or to start it as their first device.…”

Preferences and perspectives of MS nurses and patients with multiple sclerosis regarding the new RebiSmart® 3.0 autoinjector versus other assistive devices

“…[17] Coyne et al reported that device training based on adult learning principles, routines, and rituals and athome practice with a device trainer may reduce anxiety and unnecessary experimentation and improve injection therapy compliance. [23] These device trainers can be well-informed MS nurses and can provide support to pwMS to help them cope with their needle-related fears. While pwMS can be trained on the self-injection technique, routines and rituals are mostly self-discovered by the pwMS, and when these are anchored with timely guidance and continual educational support, they may help pwMS gain more con dence regarding the self-injection process.…”

“…While pwMS can be trained on the self-injection technique, routines and rituals are mostly self-discovered by the pwMS, and when these are anchored with timely guidance and continual educational support, they may help pwMS gain more con dence regarding the self-injection process. [23] Since MS nurses typically have more frequent clinical contact with pwMS than physicians, they can play a crucial role in educating pwMS about the disease and treatment they are receiving. This survey allowed us to understand the MS nurses' perspective on the key features of the RebiSmart 3.0 device that pwMS should be given additional information about that may potentially facilitate a smooth transition to it from their existing device or to start it as their rst device.…”