Whole Day Workload: Evaluation of a New Outcome Measure in Occupational Therapy for Adults With Type 1 Diabetes

People with Type 1 diabetes (T1D) are often responsible for completing a multitude of diabetes self-management tasks, including self-monitoring of blood glucose, self-administering insulin, and problem-solving issues (e.g., hypoglycemia) as they arise (Beck et al., 2017). One study found that performing all activities recommended by health care providers to manage diabetes would take more than 2 hr per day (Russell et al., 2005). Additionally, in the United States, 34% of individuals with T1D were found to be in the 20-to-39 age range and 31% in the 40-to-59 age range (Menke et al., 2013), meaning that many people with T1D are often also responsible for obligations common to young and middle adulthood. These include engaging in paid employment, caring for children, and receiving a formal education (Oh et al., 2020; Pelletier & Laska, 2012). Given all the obligations that people with T1D may have, they often experience T1D management as being extremely burdensome, which can lead to diabetes distress, or the emotional and behavioral challenges from diabetes and its management (Fisher et al., 2015).

The totality of demands that individuals with T1D experience from diabetes self-management and other responsibilities (e.g., work, caregiving) can lead to a compromised occupational balance (OB), or the extent to which individuals perceive that they have the right variation and amount of engagement in different occupations (Wagman et al., 2012). The total level of demands people experience is one key driver of OB, with other key components including engagement in meaningful activity and successfully meeting demands of valued roles (Hernandez et al., 2020). Lack of OB resulting from excessive demands can lead to a multitude of health complications. For instance, prolonged exposure to excessive daily demands and the resulting cascade of stress hormones can lead to elevated blood sugar or blood pressure levels (McEwen, 2008). Thus, excessive demand exposure can interfere with the diabetes management focus of maintaining blood sugar levels in the target range (Beck et al., 2017). In addition, the overall demands that individuals with T1D experience can significantly affect their ability to manage their condition effectively. As an example, in a qualitative study, workers with diabetes reported that they would postpone diabetes self-management such as measuring their blood sugar to complete job-related tasks (Hansen et al., 2018).

To help capture the totality of demands experienced over the course of a day (i.e., whole day workload), we had previously adapted the NASA Task Load Index (NASA–TLX) for use as a daily diary measure (Hernandez et al., 2022). The NASA–TLX is one of the most widely used workload measures and assesses workload as the sum of six items, each capturing a different type of demand: mental demand, time pressure, effort, frustration level, physical demand, and performance satisfaction (Hart, 2006). Human factors researchers at NASA went through a rigorous validation process to determine the types of demands to measure for the comprehensive assessment of workload (Hart & Staveland, 1988). The NASA–TLX has traditionally been used to assess workload from specific tasks, such as driving a car or completing various types of cognitive tests (Grier, 2015). Evidence from prior research supported the validity of the adapted whole day TLX for capturing day-to-day changes in workload (Hernandez et al., 2022). Use of the whole day TLX is fitting for the T1D population because their diabetes self-management often involves multiple forms of demands. For example, problem solving ways to fix malfunctioning diabetes devices is often cognitively demanding, frustrating, and can involve time pressure. Furthermore, the whole day TLX can also capture the multiple forms of demands that people with T1D experience daily from tasks aside from diabetes self-management.

A current gap in the measurement of whole day workload is the examination of whether the whole day TLX, when administered across multiple days, can serve as a measure of a person’s “typical” workload. Daily repeated measurements can provide two distinct sources of information about a person: (1) how their experiences change from day to day and (2) what they typically experience (i.e., on average across days). These types of information are not the same and require different psychometric tests. For instance, concurrent validity testing for use of a whole day workload measure to assess day-to-day changes in whole day workload levels involves checking for expected associations with day-to-day changes in other variables (e.g., examining whether greater workload on one day is associated with greater stress than usual stress for a person; Hernandez et al., 2022). Validity testing for use of a whole day workload measure to assess typical whole day workload levels has not yet been done, and it involves investigating whether the average whole day workload score from multiple days of ratings has the expected associations with long-term averages of other variables (e.g., examining whether average workload is associated with average stress).

The primary aim of this article was to evaluate the psychometric properties of the whole day workload (NASA–TLX) measure by examining its reliability and validity as an indicator of a person’s typical experienced workload. This effort builds on prior research that found evidence supporting the validity of use of the whole day TLX to capture day-to-day changes in workload (Hernandez et al., 2022). We evaluated the psychometric properties of the whole day TLX through three objectives. First, we examined the number of whole day TLX measures needed for reliable measurement of a person’s typical workload level. To limit respondent burden, it would be desirable if a person’s typical workload could be reliably captured with only a few daily assessments. Second, we investigated the factor structure of individual differences in whole day workload. Third, we assessed the convergent and divergent validity of the average whole day TLX of people with T1D. For the convergent validity test, we hypothesized that greater typical whole day workload would be associated with greater average stress and fatigue (Hart, 2006; Hernandez et al., 2022; Hernandez Arellano et al., 2015), lower average ability to manage diabetes (Hansen et al., 2018, 2019), and less time in target blood glucose range (Hansen et al., 2018, 2019). In terms of divergent validity, we hypothesized that typical whole day workload would have low to no associations with components of subjective well-being, including evaluative well-being (e.g., life satisfaction) and experienced well-being (e.g., positive affect, depression; Stone & Mackie, 2013). A prior systematic review found low to no association between work-related workload and subjective well-being variables (Bowling et al., 2015), likely because workload can have a positive or negative association with well-being, depending on whether it is perceived as a positive challenge or an unwelcome burden (Erdogan et al., 2012). Workload is not always detrimental to subjective well-being.

We analyzed data from an intensive longitudinal study investigating the relationship between blood glucose metrics, momentary emotions, and functioning of adults with T1D (full details of the study protocol have been previously published; Pyatak et al., 2021). Recruitment occurred at three outpatient endocrinology sites via mailings, email, and health provider referrals. Inclusion–exclusion criteria included being older than age 18 yr, having a T1D diagnosis for at least 1 yr, having stable diabetes therapy (e.g., no change in insulin dosage and devices used) for >3 mo, and being able and willing to use a study-provided smartphone to carry out study procedures. Consent to participate in the study was provided through the REDCap e-consent framework (Harris et al., 2009). Participants were asked to complete self-report surveys at the beginning (baseline) and end (follow-up) of a 2-wk study period. They also completed 2 wk of ecological momentary assessment (EMA) surveys five to six times per day and wore a blinded continuous glucose monitor (CGM), a device that assesses an individual’s glucose levels every 15 min. If participants had their own personal CGM, during the study period they were requested to also wear the study-provided CGM. Data collection procedures were approved by the institutional review board of the University of Southern California (Proposal No. HS-18-01014).

We assessed whole day workload using a version of the NASA–TLX adapted for use in the whole day repeated measures context (Hernandez et al., 2022). It consisted of six items assessing the following workload dimensions: mental demand, time pressure, effort, frustration level, physical demand, and performance (actual items are presented in Table A.1 in the Supplemental Material, available online with this article at https://research.aota.org/ajot). The combination of all six items, each assessed on a scale from 0 to 100, is referred to as the TLX–6 in this article. Higher scores indicate greater exposure to workload. The subset of items assessing mental demand, time pressure, effort, and frustration were found to load onto a single mental strain factor (Hernandez et al., 2022), which is referred to as the TLX–4. The workload items were assessed with daily diaries at the end of each day over the 2-wk study period. We used the sum scores of workload items in the TLX–6 and TLX–4 to calculate the overall daily workload (Hart, 2006; Hoonakker et al., 2011).

We assessed stress and fatigue with EMA items adopted from prior EMA studies (Dunton et al., 2018; Small et al., 2019). For stress, the item was “How stressed are you right now?” For fatigue, the item was “At this moment, how tired do you feel?” We created measures of average stress and fatigue for each person by averaging daily EMA ratings, then obtaining the latent average of these across all days for each participant. Additionally, stress was also assessed with the Perceived Stress Scale (α = .84 to .86; S. Cohen et al., 1983) at follow-up (after the EMA period).

The measures of diabetes self-management used were the Diabetes Self-Management Questionnaire (α = .84; Schmitt et al., 2013) and the Adapted Illness Intrusiveness Rating Scale (α = .78 to 0.97; Devins, 2010). We administered the Diabetes Self-Management Questionnaire at baseline (before the EMA period) and the Adapted Illness Intrusiveness Rating Scale at follow-up (Pyatak et al., 2021).

We measured blood glucose with a CGM (Abbott FreeStyle Libre Pro Flash Glucose Monitoring System; Abbott, Abbott Park, IL). The device records interstitial glucose every 15 min, to which an algorithm is applied to estimate blood glucose. The CGMs with participant data were reprocessed with an algorithm equivalent to the FreeStyle Libre 2 system by the Abbott Diabetes Clinical Research group. Momentary values of blood glucose between 70 and 180 mg/dL are considered to be in the target range (Beck et al., 2019). For convergent validity testing, we calculated the percentage of time people were in the target blood glucose range, or blood glucose time in range, over the 2-wk study period.

We assessed subjective well-being at baseline, follow-up, or as EMA measures. The Satisfaction With Life Scale (α = .79 to 0.89; Pavot & Diener, 2008) was used at follow-up to assess life satisfaction, one aspect of the evaluative well-being component of subjective well-being (Stone & Mackie, 2013). All other measures captured aspects of the subjective well-being component of experienced well-being (Stone & Mackie, 2013), specifically positive affect, negative affect, depression, and diabetes distress. We assessed positive and negative affect with EMA items from Scott et al.’s (2018) stress and working memory study. We calculated average positive and negative affect for each person by computing a day-level average for each and then finding the latent average of these across all days for each individual. In addition, we assessed positive and negative affect at follow-up with the same stress and working memory study items but using a 2-wk recall, and in this sample, both were found to have a Cronbach’s alpha of .86. Depression was assessed with the Patient Health Questionnaire at baseline (α = .86 to .89; Kroenke et al., 2009). Diabetes distress was measured at follow-up with the Problem Areas in Diabetes Scale (α = .83 to .86; McGuire et al., 2010).

We computed the between-person reliability of the average of the whole day TLX with the Spearman–Brown prediction formula: Var(BP)/(Var(BP) + Var(WP)/n (Raykov & Marcoulides, 2006), where Var(BP) is the between-person variance in the average of scores across measurement occasions, Var(WP) is the variance of scores across measurement occasions within a person, and n is the number of measurement occasions. According to the formula, reliability of the average of repeated whole day workload measures is greater with a larger number of assessment occasions and with less variation in whole day workload within a person.

We computed reliability separately for the following groups: whole sample, workers only, nonworkers only, workdays for workers, and nonworkdays for workers. We chose these groups because they were anticipated to differ in the extent to which their whole day workload levels fluctuated on a day-to-day basis, thereby affecting reliability estimates. For instance, workers likely had more fluctuation in whole day workload as compared with nonworkers because they had workdays and nonworkdays, with nonworkdays typically associated with much lower demands compared with workdays (Fritz et al., 2010). When we considered all days of the week, we therefore expected workers to require a greater number of daily assessments as compared with nonworkers to reliably capture their typical workload level. Workers were all participants who reported working full-time or part-time, and all other participants (e.g., students, retirees) were considered nonworkers. We used this grouping because the worker–nonworker distinction had been commonly used and was the most feasible given the composition of the sample. That is, the sample size was not large enough to assess reliability of more granular groupings of participants such as full-time versus part-time workers, and we noted this as a limitation.

We used multilevel confirmatory factor analysis to test whether the factor structures of the TLX–4 and TLX–6 were consistent with prior research on day-to-day changes in average whole day workload, which found that four of the six whole day TLX items loaded onto a single factor of “mental strain” and that a unidimensional model was not appropriate for all six items (Hernandez et al., 2022). In the present analyses, the TLX items were specified to load onto a single factor not only at the within-person level but also at the between-person level. With this setup, we could examine whether the study’s averages of the TLX items (represented at the between-person level) loaded onto a single factor of typical whole day workload, which would suggest that the items measure the same construct. The single factor MCFA was expected to fit the TLX–4 well but not the TLX–6. Criteria for good model fit were root-mean-square error of approximation of at least <0.08, comparative fit index and Tucker–Lewis Index of at least >0.90, and standardized root mean square residual (SRMR) of <0.08 (Hu & Bentler, 1999). We also examined the extent to which each item loaded on the underlying latent factor. One guideline is that weak associations with the latent variable are indicated by factor loadings less than 0.40 (Cabrera-Nguyen, 2010).

We tested convergent and divergent validity with correlation coefficients estimated from multilevel models, where daily EMA metrics were nested in people. Effect sizes (correlations) of .10, .30, and .50 were interpreted as small, medium, and large effects, respectively (J. Cohen, 1988). The TLX and the daily average of EMA measures (i.e., stress, fatigue, positive affect, and negative affect) had both within- and between-person variance, so they were specified at both Level 1 (within-person level) and Level 2 (between-person level). Time in optimal blood glucose range (calculated from blood glucose recorded over the whole study) and the cross-sectional measures (administered at baseline or follow-up) had only between-person variance, so they were specified at Level 2 only. We estimated correlations between the variables specified at Level 1 and between variables at Level 2. All analyses were conducted with Mplus (Version 8.10; Muthén & Muthén, 1998) via the R package MplusAutomation (Hallquist & Wiley, 2018).

We analyzed data from 164 of 196 participants with whole day workload ratings for at least 75% of the 2-wk study period to avoid potential biases that can result from including participants who opt to complete ratings only on particular (e.g., low workload) days. Demographic information is presented in Table A.2 in the Supplemental Material. The average age of the sample was 40.1 yr (SD = 14.6 yr), and 55% of participants were female. Of the sample, the largest ethnicity categories were Latino (n = 69, 42%), White (n = 49, 30%), and Black (n = 21, 13%). For education, the largest categories were some college (n = 58, 35%), bachelor’s degree (n = 46, 28%), and high school graduate or less (n = 38; 23%). With regard to diabetes-specific metrics, the average percentage of time in target blood glucose range during the study period was 54.8% (SD = 21.7%); 24% (n = 40) of participants had an automated insulin delivery system (AID) at baseline, 38% (n = 63) had a CGM without an AID, and 37% (n = 61) had no CGM. Over the 2-wk study, the median EMA completion rate of the sample was 93%, and the median completion rate for end-of-day surveys (where the TLX was completed) was 88%.

The 2-wk averages of the TLX–4 (M = 46.4, SD = 14.5) and TLX–6 (M = 45.0, SD = 11.1) were approximately normally distributed. The TLX–4 averages had a minimum of 11.7, maximum of 89.2, 25th percentile of 36.4, 50th percentile (median) of 46.8, and 75th percentile of 55.6. The TLX–6 averages had a minimum of 16.9, maximum of 76.12, 25th percentile of 36.5, 50th percentile (median) of 44.8, and 75th percentile of 51.9.

For all groupings examined for reliability testing (whole sample, workers only, nonworkers only, workdays for workers, and nonworkdays for workers), the average of the whole day TLX had at least 0.70 reliability when six or more daily measurements were aggregated (i.e., averaged; Table A.3 of the Supplemental Material). In the sample with both workers and nonworkers, the average of three whole day workload measurements had an acceptable (>0.7; Downing, 2004) between-person reliability of 0.73 for the TLX–6 and 0.74 for the TLX–4. The average of two measurements for the nonworkers group had a reliability of 0.74 for the TLX–6 and 0.76 for the TLX–4. When considering the worker group inclusive of work and nonwork days, the average of five TLX–6 measures had a reliability of 0.72, whereas the average of six TLX–4 measures had a reliability of 0.73.

A cross-level invariant single-factor model was found to fit the TLX–4 well in MCFA, but not a model with loadings allowed to vary across levels (Table A.4 in the Supplemental Material). Both single-factor models with and without cross-level invariance fit the TLX–6 poorly (Table A.4). For cross-level invariant MCFA applied to the TLX–4, all the fit metrics were acceptable according to traditional cutoffs with the exception of SRMR at the between-person level, which was 0.089, greater than 0.08 but still satisfactory given the sample size. With a sample size of 250, an SRMR cutoff of 0.10 was found to be optimal (Sivo et al., 2006). The SRMR value of 0.089 with the sample size here of 164 may therefore be indicative of acceptable fit, because it was below the more stringent cutoff of 0.10 meant for a larger sample size of 250. The following items had standardized loadings less than 0.40 (in the cross-level invariant models), indicating a weak association with the latent workload variable: frustration and performance for the TLX–6 at both the between-person level (loadings of 0.259 and 0.311 for frustration and performance, respectively) and within-person level (loadings of 0.220 and 0.248 for frustration and performance, respectively), and frustration for the TLX–4 at both the between-person level (loading of 0.324) and within-person level (loading of 0.288; Table A.5 in the of the Supplemental Material).

Overall, tests of convergent and discriminant validity showed correlations consistent with our hypotheses (Table 1). For the TLX–6, higher typical workload was associated with more fatigue (r = .32, p < .001), stress (r = .63, p < .001), illness intrusiveness (r = .29, p < .001), and less time in a healthy blood glucose range (r = −.25, p = .002). In addition, no significant associations were found between typical workload and both life satisfaction (r = −.03, p = .698) and positive affect (r = .11, p = .125), and a small association was found with depression (r = .16, p = .032). Contrary to expectation, no significant association was found between the diabetes self-management questionnaire and typical whole day workload (r = −.04, p = .593). Moreover, medium to large positive associations were observed between whole day workload and both negative affect (both the EMA average, r = .58, p < .001, and follow-up versions, r = .46, p < .001) and diabetes distress (r = .33, p < .001), although null or small associations were hypothesized. Correlations with the TLX–4 were very similar to correlations with the TLX–6.

Overall, the study results suggested that the averages of whole day TLX measures were reliable and valid indicators of typical whole day workload. For instance, greater whole day workload was significantly associated with lower time in target blood glucose range. Some findings from convergent and divergent validity testing were contrary to expectations, such as the findings that whole day workload was not significantly associated with diabetes self-management behaviors and was associated with negative affect.

Study results suggested that the averages of whole day TLX measures (from both the TLX–6 and TLX–4) were reliable typical workload indicators of people with T1Ds, even when aggregating only a few measurement days. More days were needed for reliable measurement of whole day workload for workers, especially if assessing workload across both workdays and nonworkdays.

Overall, this study’s results supported the validities of the average of whole day TLX measures. According to results from MCFA, typical whole day workload as assessed by the TLX–4 appeared to capture a single factor of “mental strain relevant whole day workload,” whereas the TLX–6 represents a mixture of factors contributing to whole day workload, which is consistent with prior research (Hart, 2006; Hernandez et al., 2022). The TLX–6 differed from the TLX–4 only in that it included items addressing physical demands and satisfaction with performance. Thus, the TLX–6 may be more useful for researchers working with populations or addressing research questions for which physical demands and satisfaction with performance are relevant. When physical demands and performance satisfaction are less relevant for the research questions of interest, the TLX–4 may be best for assessing whole day workload.

Contrary to expectations, typical whole day workload was not significantly associated with engagement in diabetes self-management behaviors, but it was associated with less time in target blood glucose range. This may have been due to two situations resulting in opposite associations between the measures that canceled out each other. In Situation A, individuals may invest much effort in their diabetes management, leading to both high ratings of diabetes self-management and high average workload (Adu et al., 2019). In Situation B, individuals may be busy with a multitude of responsibilities (high average workload), leading to a neglect of diabetes management behaviors (Hansen et al., 2018). The occurrence of scenarios in which typically high whole day workload was associated with both high and low engagement in diabetes self-management may have led to no relationship between the two. If typical whole day workload was not significantly associated with self-management behaviors on average, then perhaps workload influenced blood glucose via stress (Kusnanto et al., 2020), which was found to be highly correlated with workload. Past research has suggested that whole day workload is a significant precursor to stress (Hernandez et al., 2024). Prior research has also found that perceived stress, as measured by the Perceived Stress Scale, was significantly correlated with higher average blood glucose levels (Grau-Del Valle et al., 2023). Consistent with this finding, in follow-up analysis using data from this study, we found that greater stress as measured by the Perceived Stress Scale was significantly associated with lower time in target blood glucose range (r = −.28, p = .001).

Unexpectedly, both negative affect and diabetes distress had moderate associations with whole day workload. The moderate associations between typical whole day workload and both negative affect and diabetes distress may have been seen because these constructs may have been measured in ways that overlapped with stress. For instance, one negative affect item asked the extent to which participants felt “tense,” which may be closely related to feelings of stress. Given the conceptual overlap between stress, negative affect, and diabetes distress and the differential findings among these constructs and whole day workload, further work is needed in this area.

The results of this study have the following implications for occupational therapy practice:

• ▪ Occupational therapists who work with clients with chronic conditions (e.g., in practice areas such as lifestyle management, chronic condition care, home health, and mental health) may find that the whole day TLX can be a useful assessment tool for tracking progress while implementing strategies to reduce whole day workload exposure. Examining the relative levels of different types of demands captured by the whole day TLX may provide insights regarding which sources of demands are especially problematic for a client.

• ▪ Occupational therapists are especially well-suited to help clients reduce their levels of whole day workload given their expertise in areas such as occupational balance, activity analysis, task adaptation, habit change, time management, and energy conservation.

• ▪ While traditional health promotion interventions for individuals with chronic conditions might focus on the practice of specific health behaviors, such as medication management (Hansen et al., 2018; Kvarnström et al., 2021), occupational therapists can take a broader approach by considering how the characteristics of daily activity patterns (e.g., occupational balance and typical whole day workload) can influence overall wellness and the performance of health behaviors (Pyatak et al., 2022).

Data collection was completed during various stages of the COVID-19 pandemic and primarily in urban areas, which can affect the generalizability of study results. For instance, typical workload levels may have been different compared with the amount experienced during non-COVID periods, which could have affected the observed associations between workload and other constructs. In addition, workload and types of work in urban areas may differ from those in more suburban or rural communities, which may also have affected observed associations with workload.

Participants with very high levels of typical whole day workload may have been less likely to be willing to participate in a 2-wk study compared with those with lower workload levels; thus, participants with higher workload may be underrepresented. This could have attenuated the relationships seen between whole day workload and other measures. Prior research has suggested that person selection bias could be present in ecological momentary assessment studies (Stone et al., 2023).

We examined reliability only for the very general grouping of workers versus nonworkers, because the sample size was not sufficient for more granular groupings. Further research is needed to investigate the minimum number of daily measures required for reliable assessment of typical whole day workload in more specific clusters such as full-time workers, part-time workers, and retirees.

Overall, this study found evidence supporting the validity and reliability of the average of whole day TLX measures as a measure of typical whole day workload among individuals with T1D. Given the large amount of diabetes self-management tasks that individuals with T1D must complete daily in addition to their other responsibilities, whole day workload is very relevant to their health and well-being. Further research is needed to examine the validity of whole day workload measures among populations with other chronic conditions, such as Type 2 diabetes, cardiovascular diseases, or arthritis. For instance, whether whole day workload is associated with other measures specific to chronic conditions (e.g., blood pressure for individuals with hypertension) needs to be investigated. Occupational therapists’ expertise in areas such as task adaptation and occupational balance makes them especially qualified to intervene on clients’ whole day workload, and the whole day TLX may serve as an assessment tool for such intervention efforts.

This work was supported by the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (NIH/NIDDK 1R01DK121298-01) and a grant from Abbott Laboratories (donated devices received from Abbott Diabetes Care). The Southern California Clinical and Translation Science Institute supported the use of REDCap in this study (NIH/NCATS UL1TR001855 and UL1TR000130). Additional support was provided by the New York Regional Center for Diabetes Translation Research (NIH/NIDDK P30 DK111022).