Synthesis of evidence on the use of ecological momentary assessments to monitor health outcomes after traumatic injury: rapid systematic review

An Ecological Momentary Assessment and Intervention Tool for Memory in Chronic Traumatic Brain Injury: Development and Usability of Memory Ecological Momentary Intervention

Background

Memory and learning deficits are among the most impactful and longest-lasting symptoms experienced by people with chronic traumatic brain injury (TBI). Despite the persistence of post-TBI memory deficits and their implications for community reintegration, memory rehabilitation is restricted to short-term care within structured therapy sessions. Technology shows promise to extend memory rehabilitation into daily life and to increase the number and contextual diversity of learning opportunities. Ecological momentary assessment and intervention frameworks leverage mobile phone technology to assess and support individuals' behaviors across contexts and have shown benefits in other chronic conditions. However, few studies have used regular outreach via text messaging for adults with chronic TBI, and none have done so to assess and support memory.

Objective

This study aimed to develop and test the usability of memory ecological momentary intervention (MEMI), a text message-based assessment and intervention tool for memory in daily life. MEMI is designed to introduce new information, cue retrieval of the information, and assess learning across time and contexts. We tested MEMI via an iterative, user-centered design process to ready it for a future trial.

Methods

We developed MEMI by leveraging automated text messages for prompts using a REDCap (Research Electronic Data Capture)/Twilio interface linking to the Gorilla web-based behavioral experimental platform. We recruited 14 adults with chronic, moderate-severe TBI from the Vanderbilt Brain Injury Patient Registry to participate in 3 rounds of usability testing: one round of ThinkAloud sessions using the platform and providing real-time feedback to an experimenter (n=4) and 2 rounds of real-world usability testing in which participants used MEMI in their daily lives for a week and provided feedback (n=5/round). We analyzed engagement and quantitative and qualitative user feedback to assess MEMI's usability and acceptability.

Results

Participants were highly engaged with MEMI, completing an average of 11.8 out of 12 (98%) possible sessions. They rated MEMI as highly usable, with scores on the System Usability Scale across all rounds equivalent to an A+ on a standardized scale. In semistructured interviews, they stated that MEMI was simple and easy to use, that daily retrieval sessions were not burdensome, and that they perceived MEMI as helpful for memory. We identified a few small issues (eg, instruction wording) and made improvements between usability testing rounds.

Conclusions

Testing MEMI with adults with chronic TBI revealed that this technology is highly usable and favorably rated for this population. We incorporated feedback regarding users' preferences and plan to test the efficacy of this tool in a future clinical trial.

Moderation Effects of Daily Behavior on Associations Between Symptoms and Social Participation Outcomes After Burn Injury: A 6-Month Digital Phenotyping Study

OBJECTIVE

To examine the moderation effects of daily behavior on the associations between symptoms and social participation outcomes after burn injury.

DESIGN

A 6-month prospective cohort study.

SETTING

Community.

PARTICIPANTS

Twenty-four adult burn survivors.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Symptoms and social participation outcomes were assessed weekly using smartphone surveys, including symptoms of pain (Patient-Reported Outcomes Measurement Information System [PROMIS] Pain Intensity and Pain Interference), anxiety (PROMIS Anxiety), and depression (Patient Health Questionnaire), as well as outcomes of social interactions and social activities (Life Impact Burn Recovery Evaluation [LIBRE] Social Interactions and Social Activities). Daily behaviors were automatically recorded by a smartphone application and smartphone logs, including physical activity (steps, travel miles, and activity minutes), sleep (sleep hours), and social contact (number of phone calls and message contacts).

RESULTS

Multilevel models controlling for demographic and burn injury variables examined the associations between symptoms and social participation outcomes and the moderation effects of daily behaviors. Lower (worse) LIBRE Social Interactions and LIBRE Social Activities scores were significantly associated with higher (worse) PROMIS Pain Intensity, PROMIS Pain Interference, PROMIS Anxiety, and Patient Health Questionnaire-8 scores (P<.05). Additionally, daily steps and activity minutes were associated with LIBRE Social Interactions and LIBRE Social Activities (P<.05), and significantly moderated the association between PROMIS Anxiety and LIBRE Social Activities (P<.001).

CONCLUSIONS

Social participation outcomes are associated with pain, anxiety, and depression symptoms after burn injury, and are buffered by daily physical activity. Future intervention studies should examine physical activity promotion to improve social recovery after burns.

Feasibility of a novel blended-care intervention for fatigue after acquired brain injury: a pilot study of the Tied by Tiredness intervention

PURPOSE

Evidence-based treatments for fatigue after brain injury are scarce and often not personalized. An approach to foster personalization is Experience Sampling Methodology (ESM), consisting of repeated daily measurements of fatigue and related factors in daily life. We investigated the feasibility and usability of a novel six-week ESM-based intervention for fatigue after brain injury.

MATERIALS AND METHODS

Ten individuals with acquired brain injury (six men; four women) aged between 36-70 years (M = 53.3, SD = 12.9) used a mHealth application for three days each week during six-weeks; seven completed the intervention. Momentary fatigue, activities, mood, worrying, and social context were assessed with ESM and participants received weekly personalized feedback by a therapist..

RESULTS

56% of ESM-questionnaires (568/1008) were completed, providing detailed insights into individual fatigue patterns. No statistically significant decrease in response rate was found over the course of treatment. Qualitative feedback from participants revealed increased insight into factors underlying fatigue, and no problems with treatment duration or difficulties using the app. Five participants showed a decline in fatigue level during treatment.

CONCLUSIONS

This pilot study provides initial support for the feasibility and usability of this novel blended-care intervention, aimed at alleviating fatigue through personalized feedback and treatment strategies.

The Promise of Ecological Momentary Assessment to Improve Depression Management for Older Adults in Primary Care

Among older adults, depression is a common, morbid, and costly disorder. Older adults with depression are overwhelmingly treated by primary care providers with poor rates of remission and treatment response, despite attempts to improve care delivery through behavioral health integration and care management models. Given one in 10 older adults in primary care settings meet criteria for depression, there is a pressing need to improve the efficacy of depression treatment among affected individuals. Measurement-based care (i.e., the incorporation of systematic measurement of patient outcomes into treatment) for depressed older adults in primary care has had poor uptake, which at least partly underlies the limited efficacy of depression treatments. In this perspective, we discuss the proposal that ecological momentary assessment (EMA) may increase uptake of measurement-based care for depression in primary care, enhance the quality of clinical depression data, and lead to improvements in treatment efficacy without adding to providers' burden. We describe key issues related to EMA implementation and application in routine settings for depressed older adults, along with potential pitfalls and future research directions.

Feasibility of Using Research Electronic Data Capture (REDCap) to Collect Daily Experiences of Parent-Child Dyads: Ecological Momentary Assessment Study

BACKGROUND

Intensive longitudinal data collection, including ecological momentary assessment (EMA), has the potential to reduce recall biases, collect more ecologically valid data, and increase our understanding of dynamic associations between variables. EMA is typically administered using an application that is downloaded on participants' devices, which presents cost and privacy concerns that may limit its use. Research Electronic Data Capture (REDCap), a web-based survey application freely available to nonprofit organizations, may allow researchers to overcome these barriers; however, at present, little guidance is available to researchers regarding the setup of EMA in REDCap, especially for those who are new to using REDCap or lack advanced programming expertise.

OBJECTIVE

We provide an example of a simplified EMA setup in REDCap. This study aims to demonstrate the feasibility of this approach. We provide information on survey completion and user behavior in a sample of parents and children recruited across Canada.

METHODS

We recruited 66 parents and their children (aged 9-13 years old) from an existing longitudinal cohort study to participate in a study on risk and protective factors for children's mental health. Parents received survey prompts (morning and evening) by email or SMS text message for 14 days, twice daily. Each survey prompt contained 2 sections, one for parents and one for children to complete.

RESULTS

The completion rates were good (mean 82%, SD 8%) and significantly higher on weekdays than weekends and in dyads with girls than dyads with boys. Children were available to respond to their own survey questions most of the time (in 1134/1498, 75.7% of surveys submitted). The number of assessments submitted was significantly higher, and response times were significantly faster among participants who selected SMS text message survey notifications compared to email survey notifications. The average response time was 47.0 minutes after the initial survey notification, and the use of reminder messages increased survey completion.

CONCLUSIONS

Our results support the feasibility of using REDCap for EMA studies with parents and children. REDCap also has features that can accommodate EMA studies by recruiting participants across multiple time zones and providing different survey delivery methods. Offering the option of SMS text message survey notifications and reminders may be an important way to increase completion rates and the timeliness of responses. REDCap is a potentially useful tool for researchers wishing to implement EMA in settings in which cost or privacy are current barriers. Researchers should weigh these benefits with the potential limitations of REDCap and this design, including staff time to set up, monitor, and clean the data outputs of the project.

Traditional surveys versus ecological momentary assessments: Digital citizen science approaches to improve ethical physical activity surveillance among youth

The role of physical activity (PA) in minimizing non-communicable diseases is well established. Measurement bias can be reduced via ecological momentary assessments (EMAs) deployed via citizen-owned smartphones. This study aims to engage citizen scientists to understand how PA reported digitally by retrospective and prospective measures varies within the same cohort. This study used the digital citizen science approach to collaborate with citizen scientists, aged 13-21 years over eight consecutive days via a custom-built app. Citizen scientists were recruited through schools in Regina, Saskatchewan, Canada in 2018 (August 31-December 31). Retrospective PA was assessed through a survey, which was adapted from three validated PA surveys to suit smartphone-based data collection, and prospective PA was assessed through time-triggered EMAs deployed consecutively every day, from day 1 to day 8, including weekdays and weekends. Data analyses included paired t-tests to understand the difference in PA reported retrospectively and prospectively, and linear regressions to assess contextual and demographic factors associated with PA reported retrospectively and prospectively. Findings showed a significant difference between PA reported retrospectively and prospectively (p = 0.001). Ethnicity (visible minorities: β = - 0.911, 95% C.I. = -1.677, -0.146), parental education (university: β = 0.978, 95% C.I. = 0.308, 1.649), and strength training (at least one day: β = 0.932, 95% C.I. = 0.108, 1.755) were associated with PA reported prospectively. In contrast, the number of active friends (at least one friend: β = 0.741, 95% C.I. = 0.026, 1.458) was associated with retrospective PA. Physical inactivity is the fourth leading cause of mortality globally, which requires accurate monitoring to inform population health interventions. In this digital age, where ubiquitous devices provide real-time engagement capabilities, digital citizen science can transform how we measure behaviours using citizen-owned ubiquitous digital tools to support prevention and treatment of non-communicable diseases.