A smartphone ecological momentary assessment/intervention "app" for collecting real-time data and promoting self-awareness

Active recall strategies associated with academic achievement in young adults: A systematic review

BACKGROUND

Effective learning strategies are crucial to the development of academic skills and information retention, especially in post secondary education where increasingly complex subjects are explored. Active recall-based strategies have been identified as particularly effective for long-term learning. This systematic review investigates the effectiveness of various active recall-based learning strategies for improving academic performance and self-efficacy in higher education students.

METHODS

A systematic review of peer-reviewed articles was conducted with a priori criteria by searching PubMed, ScienceDirect, JSTOR, PsycInfo, and Web of Science databases. Search results were screened/extracted and reconciled by two independent authors with the use of a piloted screening tool. Included studies were assessed for quality and risk of bias using the GRADE Quality Assessment Tool for Quantitative Studies. Three overarching study strategies were extracted for further investigation including flashcards, practice testing or retrieval practice, and concept mapping. Within each category, three additional unique search strings were searched, screened, and extracted. A qualitative analysis of the studies was provided.

RESULTS

Among the appraised articles, flashcards were found to be popular and correlated with higher GPA and test scores. Self-testing, retrieval practice, and concept mapping were also effective but under-utilized. Concept mapping was found to boost student confidence.

CONCLUSION

Active recall strategies exhibit promise for effective learning and additional research in these developing field can support academic pursuits.

Benefits of the combination of digital and analogic tools as a strategy to control possible awake bruxism: A randomised clinical trial

BACKGROUND

Awake Bruxism (AB) management includes cognitive and behavioural changes. Digital and analogic tools can be used to remind the individual to control/avoid AB behaviours. However, no study addressed both tools together.

OBJECTIVE

To compare the efficacy of the combination of digital (smartphone application) and analogic (adhesive reminders) tools versus digital tool alone for AB management.

METHODS

Seventy-two individuals diagnosed with probable AB were divided into 3 groups: Group 1 (n = 24), used both digital and analogic tools during 30 days; Group 2 (n = 24), used only a digital tool during 30 days and Group 3 (n = 24), used only a digital tool for the first 15 days and then added the analogic tool for 15 days. The AB frequency was measured in real-time with a smartphone app, which sent alerts asking the individuals if they were doing any AB behaviours (bracing, teeth contact, clenching or grinding). Groups were compared using one-way ANOVA and before-after adding an analogic tool (group 3) by paired t-test, considering α = 0.05.

RESULTS

All groups showed a decrease in AB behaviours at the end of the evaluation period. Group 1 (digital and analogic tools) showed the lowest average of AB behaviours among all groups; however, statistically significant differences were found only for the comparison between groups 1 and 2. In group 3, a significantly greater reduction in AB behaviours was found after combining both approaches.

CONCLUSION

The combination of digital and analogic tools showed the greatest reduction of AB frequency and can be recommended for AB control.

Daily Time-Use Patterns and Quality of Life in Parents: Protocol for a Pilot Quasi-Experimental, Nonrandomized Controlled Trial Using Ecological Momentary Assessment

BACKGROUND

The gender gap in time use and its impact on health and well-being are still prevalent. Women work longer hours than men when considering both paid and unpaid (eg, childcare and chores) work, and this gender disparity is particularly visible among parents. Less is known about factors that could potentially mediate or moderate this relationship (eg, work-family conflict and gender role beliefs). Ecological momentary assessment (EMA) allows for the documentation of changes in momentary internal states, such as time use, stress, or mood. It has shown particular validity to measure shorter-term activities (eg, unpaid work) and is thus useful to address gender differences.

OBJECTIVE

The feasibility of the daily EMA surveys in a parent sample will be examined. The associations between time use, well-being, and stress will be examined, along with potential moderating and mediating factors such as gender, gender role beliefs, and work-family conflict. Finally, the act of monitoring one's own time use, well-being, and stress will be examined in relation to, for example, the quality of life.

METHODS

We conducted a quasi-experimental, nonrandomized controlled trial with 3 data collection methods, namely, online questionnaires, EMA surveys, and qualitative interviews. The intervention group (n=64) will participate in the online questionnaires and EMA surveys, and a subsample of the intervention group (n=6-17) will also be invited to participate in qualitative interviews. Over a period of 1 week, participants in the intervention group will answer daily EMA surveys (4 times per day). In contrast, the control group (n=17) will only participate in the online questionnaires at baseline and after 1 week. The following constructs were surveyed: sociodemographic background (eg, age, gender, and household composition; baseline questionnaire); mediators and moderators (eg, gender role beliefs and work-family conflict; baseline and follow-up questionnaires); well-being, quality of life, and trait mindfulness (baseline and follow-up questionnaires); momentary activity and well-being, as well as state mindfulness (EMA); and feasibility (baseline and follow-up questionnaires as well as interviews). We anticipate that participants will regard the daily EMA as feasible. Particular daily time-use patterns (eg, high paid and unpaid workload) are expected to be related to lower well-being, higher stress, and health-related quality of life. These associations are expected to be moderated and mediated by factors such as gender, gender role beliefs, work-family conflict, and social support. Participants in the intervention group are expected to show higher values of mindfulness, well-being, health-related quality of life, and lower stress.

RESULTS

Patient recruitment started in November 2023 and ended in mid April 2024. Data analysis commenced in mid April 2024.

CONCLUSIONS

This study aims to provide valuable insights into the feasibility of using EMAs and the potential benefits of activity tracking in various aspects of daily life.

TRIAL REGISTRATION

Open Science Framework 8qj3d; https://osf.io/8qj3d.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54728.

Effects of a brief online emotion word learning task on negative emotion differentiation, emotional self-efficacy, and prospective distress: Preliminary findings

BACKGROUND

Disruptions in emotion processing are common across psychological disorders. Research suggests that emotion differentiation (ED; specificity in language used to characterize one's emotional experience) and emotional self-efficacy (ESE; perceived ability to understand and manage one's emotions) are important transdiagnostic factors associated with various psychological benefits. Whether ED and ESE can be improved in adults remains largely unclear.

METHODS

Using a longitudinal prospective design, we tested a brief online training targeting emotion word knowledge (vs. a control condition) to see if it improved negative ED (NED) and ESE in a college sample. Moreover, we tested if changes in NED or ESE mediated the effects of the training on levels of psychological distress one week and two-months post-intervention.

RESULTS

Findings provided partial support for our hypotheses. Individuals whose ESE increased post-intervention reported lower levels of distress two months later. Moreover, exploratory analyses revealed those who demonstrated greater training engagement experienced increases in NED that in turn predicted lower distress one-week post-intervention. However, there were no direct effects of intervention group on NED or ESE and distress.

CONCLUSIONS

These findings highlight the potential of a remotely-administered emotion-language intervention to influence key dimensions of emotion processing and suggest avenues for further refinement. Both NED and ESE may be malleable for some, and that enhancements in ESE may produce long-term psychological benefits.

The Effects of a Relationship-Focused Professional Development Intervention on Infant and Toddler Teachers' Mindfulness-Based Strategies for Coping

Teaching is a demanding profession with teachers of very young children reporting high rates of stress and exhaustion. We tested the effects of a relationship-focused professional development intervention designed to enhance teachers' use of mindfulness-based strategies to support coping on trajectories of teachers' stress, exhaustion (emotional, physical, and mental), and coping. Infant and toddler teachers (N = 81) from Early Head Start (EHS) or EHS childcare partnerships (CCP) were randomized to the intervention or usual care control condition. Using ecological momentary assessment, teachers completed twice-weekly reports of stress, exhaustion, coping, and coping strategy effectiveness via smartphones for 40 weeks. Multilevel linear regression modeling, accounting for within-person repeated measures, showed no intervention effects on stress and exhaustion trajectories. Teachers in the intervention reported increased use of mindfulness-based strategies for coping over time as compared to the control group, although frequency of use peaked and then declined. While perceptions of stress and exhaustion did not change, teachers' increased use of mindfulness-based strategies suggests improvements in how teachers managed stress and exhaustion; however, the decline in use of coping suggests the need for ongoing support within the workplace.

Psychological and Behavioural Within-participant Predictors of Adherence to Oral HIV Pre-Exposure Prophylaxis (PrEP)

Oral PrEP's effectiveness relies on adequate adherence during periods of substantial HIV risk. Since most PrEP users will miss doses, understanding predictors within participants can help to explain adherence. We used a cross-sectional, within-participant design with 67 gay, bisexual, and other men who have sex with men taking PrEP daily. Using a questionnaire, informed by the Information Motivation Behavioral Skills Model, participants were asked about an adherent and a non-adherent episode. PrEP non-adherence was associated with non-normality of the day (p < .001), being out of the home (p < .001), weekend days (p = .01), having company (p = .02), using substances (p = 0.02), not using reminders (p = .03), lower PrEP information (p = .04), lower behavioural skills (p < .001) and less positive affect (p = .002). PrEP adherence assessment could focus on situational variations, supporting the construction of alternative strategies to facilitate adherence in these situations.

A Trauma-Informed, Geospatially Aware, Just-in-Time Adaptive mHealth Intervention to Support Effective Coping Skills Among People Living With HIV in New Orleans: Development and Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

In 2020, Greater New Orleans, Louisiana, was home to 7048 people living with HIV-1083 per 100,000 residents, 2.85 times the US national rate. With Louisiana routinely ranked last in indexes of health equity, violent crime rates in Orleans Parish quintupling national averages, and in-care New Orleans people living with HIV surviving twice the US average of adverse childhood experiences, accessible, trauma-focused, evidence-based interventions (EBIs) for violence-affected people living with HIV are urgently needed.

OBJECTIVE

To meet this need, we adapted Living in the Face of Trauma, a well-established EBI tailored for people living with HIV, into NOLA GEM, a just-in-time adaptive mobile health (mHealth) intervention. This study aimed to culturally tailor and refine the NOLA GEM app and assess its acceptability; feasibility; and preliminary efficacy on care engagement, medication adherence, viral suppression, and mental well-being among in-care people living with HIV in Greater New Orleans.

METHODS

The development of NOLA GEM entailed identifying real-time tailoring variables via a geographic ecological momentary assessment (GEMA) study (n=49; aim 1) and place-based and user-centered tailoring, responsive to the unique cultural contexts of HIV survivorship in New Orleans, via formative interviews (n=12; aim 2). The iOS- and Android-enabled NOLA GEM app leverages twice-daily GEMA prompts to offer just-in-time, in-app recommendations for effective coping skills practice and app-delivered Living in the Face of Trauma session content. For aim 3, the pilot trial will enroll an analytic sample of 60 New Orleans people living with HIV individually randomized to parallel NOLA GEM (intervention) or GEMA-alone (control) arms at a 1:1 allocation for a 21-day period. Acceptability and feasibility will be assessed via enrollment, attrition, active daily use through paradata metrics, and prevalidated usability measures. At the postassessment time point, primary end points will be assessed via a range of well-validated, domain-specific scales. Care engagement and viral suppression will be assessed via past missed appointments and self-reported viral load at 30 and 90 days, respectively, and through well-demonstrated adherence self-efficacy measures.

RESULTS

Aims 1 and 2 have been achieved, NOLA GEM is in Beta, and all aim-3 methods have been reviewed and approved by the institutional review board of Tulane University. Recruitment was launched in July 2023, with a target date for follow-up assessment completion in December 2023.

CONCLUSIONS

By leveraging user-centered development and embracing principles that elevate the lived expertise of New Orleans people living with HIV, mHealth-adapted EBIs can reflect community wisdom on posttraumatic resilience. Sustainable adoption of the NOLA GEM app and a promising early efficacy profile will support the feasibility of a future fully powered clinical trial and potential translation to new underserved settings in service of holistic survivorship and well-being of people living with HIV.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05784714; https://clinicaltrials.gov/ct2/show/NCT05784714.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47151.

Remote Symptom Monitoring With Ecological Momentary Computerized Adaptive Testing: Pilot Cohort Study of a Platform for Frequent, Low-Burden, and Personalized Patient-Reported Outcome Measures

BACKGROUND

Remote patient-reported outcome measure (PROM) data capture can provide useful insights into research and clinical practice and deeper insights can be gained by administering assessments more frequently, for example, in ecological momentary assessment. However, frequent data collection can be limited by the burden of multiple, lengthy questionnaires. This burden can be reduced with computerized adaptive testing (CAT) algorithms that select only the most relevant items from a PROM for an individual respondent. In this paper, we propose "ecological momentary computerized adaptive testing" (EMCAT): the use of CAT algorithms to reduce PROM response burden and facilitate high-frequency data capture via a smartphone app. We develop and pilot a smartphone app for performing EMCAT using a popular hand surgery PROM.

OBJECTIVE

The aim of this study is to determine the feasibility of EMCAT as a system for remote PROM administration.

METHODS

We built the EMCAT web app using Concerto, an open-source CAT platform maintained by the Psychometrics Centre, University of Cambridge, and hosted it on an Amazon Web Service cloud server. The platform is compatible with any questionnaire that has been parameterized with item response theory or Rasch measurement theory. For this study, the PROM we chose was the patient evaluation measure, which is commonly used in hand surgery. CAT algorithms were built using item response theory models derived from UK Hand Registry data. In the pilot study, we enrolled 40 patients with hand trauma or thumb-base arthritis, across 2 sites, between July 13, 2022, and September 14, 2022. We monitored their symptoms with the patient evaluation measure, via EMCAT, over a 12-week period. Patients were assessed thrice weekly, once daily, or thrice daily. We additionally administered full-length PROM assessments at 0, 6, and 12 weeks, and the User Engagement Scale at 12 weeks.

RESULTS

The use of EMCAT significantly reduced the length of the PROM (median 2 vs 11 items) and the time taken to complete it (median 8.8 seconds vs 1 minute 14 seconds). Very similar scores were obtained when EMCAT was administered concurrently with the full-length PROM, with a mean error of <0.01 on a logit (z score) scale. The median response rate in the daily assessment group was 93%. The median perceived usability score of the User Engagement Scale was 4.0 (maximum possible score 5.0).

CONCLUSIONS

EMCAT reduces the burden of PROM assessments, enabling acceptable high-frequency, remote PROM data capture. This has potential applications in both research and clinical practice. In research, EMCAT could be used to study temporal variations in symptom severity, for example, recovery trajectories after surgery. In clinical practice, EMCAT could be used to monitor patients remotely, prompting early intervention if a patient's symptom trajectory causes clinical concern.

TRIAL REGISTRATION

ISRCTN 19841416; https://www.isrctn.com/ISRCTN19841416.

Evaluating spatial and temporal patterns of tick exposure in the United States using community science data submitted through a smartphone application

Research initiatives that engage the public (i.e., community science or citizen science) increasingly provide insights into tick exposures in the United States. However, these data have important caveats, particularly with respect to reported travel history and tick identification. Here, we assessed whether a smartphone application, The Tick App, provides reliable and novel insights into tick exposures across three domains - travel history, broad spatial and temporal patterns of species-specific encounters, and tick identification. During 2019-2021, we received 11,424 tick encounter submissions from across the United States, with nearly all generated in the Midwest and Northeast regions. Encounters were predominantly with human hosts (71%); although one-fourth of ticks were found on animals. Half of the encounters (51%) consisted of self-reported peri‑domestic exposures, while 37% consisted of self-reported recreational exposures. Using phone-based location services, we detected differences in travel history outside of the users' county of residence along an urbanicity gradient. Approximately 75% of users from large metropolitan and rural counties had travel out-of-county in the four days prior to tick detection, whereas an estimated 50-60% of users from smaller metropolitan areas did. Furthermore, we generated tick encounter maps for Dermacentor variabilis and Ixodes scapularis that partially accounted for travel history and overall mirrored previously published species distributions. Finally, we evaluated whether a streamlined three-question sequence (on tick size, feeding status, and color) would inform a simple algorithm to optimize image-based tick identification. Visual aides of tick coloration and size engaged and guided users towards species and life stage classification moderately well, with 56% of one-time submitters correctly selecting photos of D. variabilis adults and 76% of frequent-submitters correctly selecting photos of D. variabilis adults. Together, these results indicate the importance of bolstering the use of smartphone applications to engage community scientists and complement other active and passive tick surveillance systems.

Use of Electronic Ecological Momentary Assessment Methodologies in Physical Activity, Sedentary Behavior, and Sleep Research in Young Adults: Systematic Review

BACKGROUND

Recent technological advances allow for the repeated sampling of real-time data in natural settings using electronic ecological momentary assessment (eEMA). These advances are particularly meaningful for investigating physical activity, sedentary behavior, and sleep in young adults who are in a critical life stage for the development of healthy lifestyle behaviors.

OBJECTIVE

This study aims to describe the use of eEMA methodologies in physical activity, sedentary behavior, and sleep research in young adults.

METHODS

The PubMed, CINAHL, PsycINFO, Embase, and Web of Science electronic databases were searched through August 2022. Inclusion criteria were use of eEMA; sample of young adults aged 18 to 25 years; at least 1 measurement of physical activity, sedentary behavior, or sleep; English language; and a peer-reviewed report of original research. Study reports were excluded if they were abstracts, protocols, or reviews. The risk of bias assessment was conducted using the National Heart, Lung, and Blood Institute's Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Screening, data extraction, and risk of bias assessments were conducted by independent authors, with discrepancies resolved by consensus. Descriptive statistics and narrative synthesis were used to identify overarching patterns within the following categories guided by the Checklist for Reporting Ecological Momentary Assessments Studies: study characteristics, outcomes and measures, eEMA procedures, and compliance.

RESULTS

The search resulted in 1221 citations with a final sample of 37 reports describing 35 unique studies. Most reports (28/37, 76%) were published in the last 5 years (2017-2022), used observational designs (35/37, 95%), consisted of samples of college students or apprentices (28/35, 80%), and were conducted in the United States (22/37, 60%). The sample sizes ranged from 14 to 1584 young adults. Physical activity was measured more frequently (28/37, 76%) than sleep (16/37, 43%) or sedentary behavior (4/37, 11%). Of the 37 studies, 11 (30%) reports included 2 movement behaviors and no reports included 3 movement behaviors. eEMA was frequently used to measure potential correlates of movement behaviors, such as emotional states or feelings (25/37, 68%), cognitive processes (7/37, 19%), and contextual factors (9/37, 24%). There was wide variability in the implementation and reporting of eEMA procedures, measures, missing data, analysis, and compliance.

CONCLUSIONS

The use of eEMA methodologies in physical activity, sedentary behavior, and sleep research in young adults has greatly increased in recent years; however, reports continue to lack standardized reporting of features unique to the eEMA methodology. Additional areas in need of future research include the use of eEMA with more diverse populations and the incorporation of all 3 movement behaviors within a 24-hour period. The findings are intended to assist investigators in the design, implementation, and reporting of physical activity, sedentary behavior, and sleep research using eEMA in young adults.

TRIAL REGISTRATION

PROSPERO CRD42021279156; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021279156.

Ecological Momentary Assessment of Awake Bruxism Behaviors: A Scoping Review of Findings from Smartphone-Based Studies in Healthy Young Adults

BACKGROUND

The recent introduction of ecological momentary assessment (EMA) smartphone-based strategies has allowed achieving some interesting data on the frequency of different awake bruxism (AB) behaviors reported by an individual in the natural environment.

OBJECTIVE

The present paper aims to review the literature on the reported frequency of AB based on data gathered via smartphone EMA technology.

METHODS

On September 2022, a systematic search in the Pubmed, Scopus and Google Scholar databases was performed to identify all peer-reviewed English-language studies assessing awake bruxism behaviors using a smartphone-based Ecological Momentary Assessment. The selected articles were assessed independently by two authors according to a structured reading of the articles' format (PICO).

RESULTS

A literature search, for which the search terms "Awake Bruxism" and "Ecological Momentary Assessment" were used, identified 15 articles. Of them, eight fulfilled the inclusion criteria. The results of seven studies using the same smartphone-based app reported a frequency of AB behaviors in the range between 28.3 and 40% over one week, while another investigation adopted a different smartphone-based EMA approach via WhatsApp using a web-based survey program and reported an AB frequency of 58.6%. Most included studies were based on convenience samples with limited age range, highlighting the need for more studies on other population samples.

CONCLUSIONS

Despite the methodological limits, the results of the reviewed studies provide a standpoint for comparison for future studies on the epidemiology of awake bruxism behaviors.

Associations of Momentary Mindfulness With Affect and Cannabis Desire in a Trial of Cannabis Use Interventions With and Without Momentary Assessment

PURPOSE

Mindfulness, awareness resulting from attending to the present without judgment, has been associated with improved health. When considered as a time-varying momentary state, mindfulness is associated with other momentary states such as affect. We examined whether momentary mindfulness, specifically mindful attention and awareness (MAA), changed after counseling interventions to reduce cannabis use that included ecological momentary assessment (EMA) and explored associations with negative affect, positive affect, and cannabis desire.

METHODS

Outpatients 15-24 years using cannabis ≥3x/week were randomized to one of the three interventions, each including two motivational enhancement therapy (MET) sessions. For two interventions, MET was followed by 2 weeks of EMA (with/without messaging). Momentary MAA, negative affect, positive affect, and cannabis desire were assessed over 1 week of EMA at baseline and 3-month follow-up (N = 1,971 reports, 68 participants). We examined changes in momentary MAA from baseline to follow-up overall and by group (MET + EMA, MET-only) using generalized linear mixed effects models. We tested associations of momentary MAA with momentary affect and cannabis desire using generalized estimating equations.

RESULTS

Momentary MAA increased from baseline to follow-up after MET counseling plus EMA (β = 0.237), but did not change with MET counseling alone. Higher momentary MAA was associated with lower negative affect (β = -0.526) and cannabis desire (β = -0.521), but not with positive affect.

DISCUSSION

Among youth using cannabis frequently, momentary MAA was increased 3 months after interventions with EMA after counseling and was inversely associated with momentary negative affect and momentary cannabis desire. Mindfulness may be a useful target for momentary intervention.

Stress Intensity and Exhaustion Among Infant and Toddler Teachers: Descriptive Analysis and Associations with Sources of Stress and Coping Strategy Use

This study described infant/toddler teachers' (N = 106) perceptions of stress intensity and exhaustion (emotional, physical, mental) intensity. We examined the associations between stress and exhaustion and teachers' reports of stress sources and coping strategy use. Using ecological momentary assessment (EMA), teachers from Early Head Start (EHS), EHS childcare-partnerships, or independent childcare programs (midwestern U.S.) completed twice-weekly reports of: stress and exhaustion intensity; stress sources (workload, children's behaviors, personal life); and, coping strategies (support from colleagues, distraction, mindfulness techniques, reframing).

Research Findings

Stress and exhaustion reports were similar to studies of preschool teachers. Workload and personal life stressors were associated with stress and all exhaustion types. Teachers used fewer than two different coping strategies/per reporting day. Only reframing was negatively associated with stress and emotional exhaustion. Teachers reported greater stress at end-of-week than beginning-of-week. Older teachers reported greater stress and emotional exhaustion. Although one-third of teachers reported ≥4 ACEs, early adversity was not associated with stress or exhaustion.

Practice or Policy

We discuss the results relative to the sparse literature on infant/toddler teachers' well-being and suggest areas for professional development supports while underscoring the need for EHS federal policy makers and program administrators to consider how to reduce/streamline workload.

Workplace Intervention for Reducing Sitting Time in Sedentary Workers: Protocol for a Pilot Study Using the Behavior Change Wheel

The workplace is a major contributor to excessive sitting in office workers. There are a wide array of adverse effects of high volumes of sitting time, including an increased risk of type 2 diabetes and depression. Active workstations can be used in effective interventions to decrease workplace sitting. However, there are a lack of interventions that have been developed using a systematic process that is informed by participant needs and a framework for identifying the most appropriate content for the intervention. Applying these methods could increase adherence and potential effectiveness of the intervention. Therefore, the purpose of this pilot study is to examine the feasibility, acceptability, and efficacy of a tailored workplace intervention to reduce and break up sitting in office workers that has been developed using the Behavior Change Wheel and the APEASE (Acceptability, Practicability, Effectiveness/cost-effectiveness, Affordability, Safety/side-effects, Equity) criteria. This article reports the protocol for this study that is currently ongoing. Participants will be cluster-randomized (by offices) to control and intervention groups. The evaluation of the intervention includes determining feasibility by assessing participant recruitment, retention and data completion rates. Adherence to the intervention will be assessed based on daily sitting and standing time relative to guidelines provided to participants as part of the intervention. Outcome measures also include productivity measured using Ecological Momentary Assessment, absenteeism, presenteeism, cardiometabolic risk markers, and wellbeing. The findings of this study will inform the effective design and implementation of interventions for reducing and breaking up sitting in office workers.

Real-world feasibility and acceptability of real-time suicide risk monitoring via smartphones: A 6-month follow-up cohort

Active and passive Ecological Momentary Assessment of suicide risk is crucial for suicide prevention. We aimed to assess the feasibility and acceptability of active and passive smartphone-based EMA in real-world conditions in patients at high risk for suicide. We followed 393 patients at high risk for suicide for six months using two mobile health applications: the MEmind (active) and the eB2 (passive). Retention with active EMA was 79.3% after 1 month and 22.6% after 6 months. Retention with passive EMA was 87.8% after 1 month and 46.6% after 6 months. Satisfaction with the MEmind app, uninstalling the eB2 app and diagnosis of eating disorders were independently associated with stopping active EMA. Satisfaction with the eB2 app and uninstalling the MEmind app were independently associated with stopping passive EMA. Smartphone-based active and passive EMA are feasible and may increase accessibility to mental healthcare.

Remote learning during Covid-19 lockdown: A study on anatomy and histology education for pharmacy students in Jordan

The Covid-19 pandemic has changed almost all aspects of education. The anatomy and histology courses for pharmacy students focus heavily on the face-to-face communication of theory and practical knowledge, and due to the pandemic, only theory content was delivered in an online format. This brought up many concerns about pharmacy student preparedness. This work explores the effectiveness and student perspective of remote teaching of the theoretical anatomy and histology course in Jordanian universities from the perspective of pharmacy students. The objectives are to determine the strengths, challenges, and the effectiveness of remote delivery on student learning. An online-based validated questionnaire was distributed to students majoring in Pharmacy and enrolled in the course during the second semester of 2019-2020 at 11 universities in Jordan. A total of 442 students participated in the study. Results showed that there were significant differences in perceptions of the social media platforms used in distance learning and remote delivery of the course. Most participants had positive perceptions of the educational process and studying via distance learning. There were many strengths noted including time flexibility and several challenges such as the lack of face-to-face interaction with instructors, inadequate internet connectivity, and technical issues. In conclusion, online-taught anatomy and histology course during the Covid-19 lockdown in Jordan was a success as perceived by students, but the course still possessed challenges need to be overcome in the future.

An Ecological Momentary Intervention Study of Emotional Responses to Smartphone-Prompted CBT Skills Practice and the Relationship to Clinical Outcomes

The practice of therapeutic skills outside of sessions in which they are learned is one presumed key component of cognitive behavioral therapy (CBT). Yet, our understanding of how skills practice relates to clinical outcomes remains limited. Here, we explored patients' emotional responses to CBT skills practice in a pilot study pairing smartphone-app-delivered skills reminders and guided practice (ecological momentary intervention [EMI]) using ecological momentary assessment (EMA). Participants (n = 25) were adults recently hospitalized for a suicide attempt or severe suicidal thinking. They received brief inpatient CBT (1 to 3 sessions covering core CBT skills from the Unified Protocol), followed by 1 month of EMI and EMA after discharge. On average, participants reported modest reductions in negative affect after skills use (i.e., immediate responses; median time elapsed = 4.30 minutes). Additionally, participants tended to report less negative affect when the timepoint preceding the current assessment included EMI skills practice, rather than EMA alone (i.e., delayed responses; median time elapsed between prompts = 2.17 hours). Immediate effects were unrelated to longer-term clinical outcomes, whereas greater delayed effects were associated with lower symptom severity at follow-up. Future studies should further examine how CBT skills use in daily life may alleviate symptoms.

Military Injuries-Understanding Posttraumatic Epilepsy, Health, and Quality-of-Life Effects of Caregiving: Protocol for a Longitudinal Mixed Methods Observational Study

BACKGROUND

Veterans with posttraumatic epilepsy (PTE), particularly those with comorbidities associated with epilepsy or traumatic brain injury (TBI), have poorer health status and higher symptom burden than their peers without PTE. One area that has been particularly poorly studied is that of the role of caregivers in the health of veterans with PTE and the impact caring for someone with PTE has on the caregivers themselves.

OBJECTIVE

In this study, we aim to address the following: describe and compare the health and quality of life of veterans and caregivers of veterans with and without PTE; evaluate the change in available supports and unmet needs for services among caregivers of post-9/11 veterans with PTE over a 2-year period and to compare support and unmet needs with those without PTE; and identify veteran and caregiver characteristics associated with the 2-year health trajectories of caregivers and veterans with PTE compared with veterans without PTE.

METHODS

We conducted a prospective cohort study of the health and quality of life among 4 groups of veterans and their caregivers: veterans with PTE, nontraumatic epilepsy, TBI only, and neither epilepsy nor TBI. We will recruit participants from previous related studies and collect information about both the veterans and their primary informal caregivers on health, quality of life, unmet needs for care, PTE and TBI symptoms and treatment, relationship, and caregiver experience. Data sources will include existing data supplemented with primary data, such as survey data collected at baseline, intermittent brief reporting using ecological momentary assessment, and qualitative interviews. We will make both cross-sectional and longitudinal comparisons, using veteran-caregiver dyads, along with qualitative findings to better understand risk and promotive factors for quality of life and health among veterans and caregivers, as well as the bidirectional impact of caregivers and care recipients on one another.

RESULTS

This study was approved by the institutional review boards of the University of Utah and Salt Lake City Veterans Affairs and is under review by the Human Research Protection Office of the United States Army Medical Research and Development Command. The Service Member, Veteran, and Caregiver Community Stakeholders Group has been formed and the study questionnaire will be finalized once the panel reviews it. We anticipate the start of recruitment and primary data collection by January 2022.

CONCLUSIONS

New national initiatives aim to incorporate the caregiver into the veteran's treatment plan; however, we know little about the impact of caregiving-both positive and negative-on the caregivers themselves and on the veterans for whom they provide care. We will identify specific needs in this understudied population, which will inform clinicians, patients, families, and policy makers about the specific impact and needs to equip caregivers in caring for veterans at home.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/30975.

Attitudes About COVID-19 and Health (ATTACH): Online Survey and Mixed Methods Study

BACKGROUND

Behavioral mitigation strategies to slow the spread of COVID-19 have resulted in sweeping lifestyle changes, with short- and long-term psychological, well-being, and quality of life implications. The Attitudes About COVID-19 and Health (ATTACH) study focuses on understanding attitudes and beliefs while considering the impact on mental and physical health and the influence of broader demographic and geographic factors on attitudes, beliefs, and mental health burden.

OBJECTIVE

In this assessment of our first wave of data collection, we provide baseline cohort description of the ATTACH study participants in the United Kingdom, the United States, and Mexico. Additionally, we assess responses to daily poll questions related to COVID-19 and conduct a cross-sectional analysis of baseline assessments collected in the UK between June 26 and October 31, 2020.

METHODS

The ATTACH study uses smartphone app technology and online survey data collection. Participants completed poll questions related to COVID-19 2 times daily and a monthly survey assessing mental health, social isolation, physical health, and quality of life. Poll question responses were graphed using 95% Clopper-Pearson (exact) tests with 95% CIs. Pearson correlations, hierarchical linear regression analyses, and generalized linear models assessed relationships, predictors of self-reported outcomes, and group differences, respectively.

RESULTS

By October 31, 2020, 1405, 80, and 90 participants had consented to participate in the UK, United States, and Mexico, respectively. Descriptive data for the UK daily poll questions indicated that participants generally followed social distancing measures, but worry and negative impacts on families increased as the pandemic progressed. Although participants generally reported feeling that the reasons for current measures had been made clear, there was low trust that the government was doing everything in its power to meet public needs. In the UK, 1282 participants also completed a monthly survey (94.99% [1326/1396] White, 72.22% [1014/1404] female, and 20.12% [277/1377] key or essential workers); 18.88% (242/1282) of UK participants reported a preexisting mental health disorder, 31.36% (402/1282) reported a preexisting chronic medical illness, and 35.11% (493/1404) were aged over 65; 57.72% (740/1282) of participants reported being more sedentary since the pandemic began, and 41.89% (537/1282) reported reduced access to medical care. Those with poorer mental health outcomes lived in more deprived neighborhoods, in larger households (Ps<.05), had more preexisting mental health disorders and medical conditions, and were younger than 65 years (all Ps<.001).

CONCLUSIONS

Communities who have been exposed to additional harm during the COVID-19 pandemic were experiencing worse mental outcomes. Factors including having a medical condition, or living in a deprived neighborhood or larger household were associated with heightened risk. Future longitudinal studies should investigate the link between COVID-19 exposure, mental health, and sociodemographic and residential characteristics.

A Scoping Review of Methods Used to Assess Medication Adherence in Patients with Chronic Conditions

BACKGROUND

Medication nonadherence of patients with chronic conditions is a complex phenomenon contributing to increased economic burden and decreased quality of life. Intervention development relies on accurately assessing adherence but no "gold standard" method currently exists.

PURPOSE

The present scoping review aimed to: (a) review and describe current methods of assessing medication adherence (MA) in patients with chronic conditions with the highest nonadherence rates (asthma, cancer, diabetes, epilepsy, HIV/AIDS, hypertension), (b) outline and compare the evidence on the quality indicators between assessment methods (e.g., sensitivity), and (c) provide evidence-based recommendations.

METHODS

PubMed, PsycINFO and Scopus databases were screened, resulting in 62,592 studies of which 71 met criteria and were included.

RESULTS

Twenty-seven self-report and 10 nonself-report measures were identified. The Medication Adherence Report Scale (MARS-5) was found to be the most accurate self-report, whereas electronic monitoring devices such as Medication Event Monitoring System (MEMS) corresponded to the most accurate nonself-report. Higher MA rates were reported when assessed using self-reports compared to nonself-reports, except from pill counts.

CONCLUSIONS

Professionals are advised to use a combination of self-report (like MARS-5) and nonself-report measures (like MEMS) as these were found to be the most accurate and reliable measures. This is the first review examining self and nonself-report methods for MA, across chronic conditions with the highest nonadherence rates and provides evidence-based recommendations. It highlights that MA assessment methods are understudied in certain conditions, like epilepsy. Before selecting a MA measure, professionals are advised to inspect its quality indicators. Feasibility of measures should be explored in future studies as there is presently a lack of evidence.

Using Paradata to Evaluate Youth Participation in a Digital Diary Study

We analyze recruitment, access and longitudinal response paradata from a year-long intensive longitudinal study (mDiary) that used a mobile-optimized web app to administer 25 bi-weekly diaries to youth recruited from a birth cohort study. Analyses investigate which aspects of teen recruitment experiences are associated with enrollment and longitudinal response patterns; whether compliance behavior of teens who require multiple invitations to enroll differs from that of teens who enroll on the first invitation; and what personal and social circumstances are associated with different longitudinal compliance patterns. Latent Class Analysis (LCA) is used to derive longitudinal compliance classes. mDiary's person-survey response rate of 70 percent is noteworthy considering reports that response rates for smartphone studies trail those administered via telephone or personal computers. Conditional on agreeing to participate, teens with texting capability were over six times as likely to enroll as their peers lacking access, and they also completed 6-7 more diaries. Youth who required multiple prods to register not only were less likely to enroll than their peers who registered at the first invitation, but also tended to attrite early. Compared with teens who completed all 25 surveys, those who attrited early had less access to texting capability, home Internet service, and had low-education mothers. Consistent with studies of adults, nonparticipants were disproportionately black males from socioeconomically disadvantaged backgrounds.

The Clinical Impacts of Mobile Mood-Monitoring in Young People With Mental Health Problems: The MeMO Study

Background: Limited evidence suggests that mobile mood-monitoring can improve mental health outcomes and therapeutic engagement in young people. The aim of this mixed methods study was to explore the clinical impacts of mobile mood-monitoring in youth with mental health problems, using a publicly accessible app. Methods: Twenty-three patients with mental health problems and 24 young people without mental health problems participated in the quantitative study. Participants monitored their mood using a mood-monitoring app twice a day for 3 weeks, which was preceded by a 3-week baseline period. Outcome measures included momentary and retrospective assessments of affect regulation (all participants) and therapeutic engagement (patients only). Following the quantitative study, patients (n = 7) and their clinicians (n = 6) participated in individual interviews. Interview data was analysed using thematic analysis. Results: Use of the mood-monitoring app significantly reduced momentary negative mood (p < 0.001) and retrospectively assessed impulsivity across all 47 participants (p = 0.001). All other outcomes showed no significant difference. Qualitative feedback similarly indicated the potential of apps to improve problems with impulsivity in patients. Furthermore, apps may aid communication, promote empowerment, and ameliorate memory difficulties in clinical appointments. Conclusions: This mixed methods study demonstrated the potential utility of apps for clinical practice. Apps may potentially be an interventional tool, or at a minimum, an adjunct to existing treatments. Data was collected from a small sample size over a short study duration, limiting the generalisability of findings and inferences regarding long-term effects. Potential sources of bias in the qualitative study (e.g., researcher bias) should also be considered.

Women's Usage Behavior and Perceived Usefulness with Using a Mobile Health Application for Gestational Diabetes Mellitus: Mixed-Methods Study

The prevalence of gestational diabetes mellitus (GDM) is increasing, and only a few mobile health (mHealth) applications are specifically designed to manage GDM. In this mixed-methods study, a follow-up study of a randomized controlled trial (RCT) analyzed a largely automated mHealth application-based lifestyle coaching program to (a) measure the application's usage behavior and (b) explore users' perceptions of its usefulness in GDM management. Quantitative data were collected from the 170 application users who had participated in the intervention arm of the RCT. Semi-structured interviews (n = 14) captured users' experiences when using the application. Data were collected from June 2019 to January 2020. Quantitative data were analyzed descriptively, and interviews were analyzed thematically. Only 57/170 users (34%) logged at least one meal, and only 35 meals on average were logged for eight weeks because of the incorrectly worded food items and limited food database. On the contrary, an average of 1.85 (SD = 1.60) weight values were logged per week since the weight tracking component was easy to use. Many users (6/14 (43%)) mentioned that the automatic coach messages created an immediate sense of self-awareness in food choices and motivated behavior. The findings suggest that for GDM management, a largely automated mHealth application has the potential to promote self-awareness of healthy lifestyle choices, reducing the need for intensive human resources. Additionally, several gaps in the application's design were identified which need to be addressed in future works.

Using a Mobile Phone App to Analyze the Relationship Between Planned and Performed Physical Activity in University Students: Observational Study

BACKGROUND

The relationship between intention and behavior has been well researched, but most studies fail to capture dynamic, time-varying contextual factors. Ecological momentary assessment through mobile phone technology is an innovative method for collecting data in real time, including time-use data. However, only a limited number of studies have examined day-level plans to be physically active and subsequent physical activity behavior using real-time time-use data to better understand this relationship.

OBJECTIVE

This study aims to examine whether plans to be physically active (recorded in advance on an electronic calendar) were associated with objectively assessed physical activity (accelerometry), to identify activities that replaced planned periods of physical activity by using the mobile app Life in a Day (LIAD), and to test the feasibility and acceptability of LIAD for collecting real-time time-use data.

METHODS

The study included 48 university students who were randomly assigned to 1 of 3 protocols, which were defined by 1, 3, or 5 days of data collection. Participants were asked to record their planned activities on a Google Calendar and were provided with mobile phones with LIAD to complete time-use entries in real time for a set of categories (eg, exercise or sports, eating or cooking, school, or personal care). Participants were instructed to wear an accelerometer on their nondominant wrist during the protocol period. A total of 144 days of protocol data were collected from the 48 participants.

RESULTS

Protocol data for 123 days were eligible for analysis. A Fisher exact test showed a statistically significant association between plans and physical activity behavior (P=.02). The congruence between plans and behavior was fair (Cohen κ=0.220; 95% CI 0.028-0.411). Most participants did not plan to be active, which occurred on 75.6% (93/123) of days. Of these 93 days, no physical activity occurred on 76 (81.7%) days, whereas some physical activity occurred on 17 (18.3%) days. On the remaining 24.4% (30/123) of days, some physical activity was planned. Of these 30 days, no physical activity occurred on 18 (60%) days, whereas some physical activity occurred on 12 (40%) days. LIAD data indicated that activities related to screen time most often replaced planned physical activity, whereas unplanned physical activity was often related to active transport. Feasibility analyses indicated little difficulty in using LIAD, and there were no significant differences in feasibility by protocol length.

CONCLUSIONS

Consistent with previous literature, physical activity plans and physical activity behaviors were linked, but not strongly linked. LIAD offers insight into the relationship between plans and behavior, highlighting the importance of active transport for physical activity and the influence of screen-related behaviors on insufficient physical activity. LIAD is a feasible and practical method for collecting time-use data in real time.

Awake Bruxism-Single-Point Self-Report versus Ecological Momentary Assessment

Assessment of awake bruxism (AB) is problematic due to the inability to use continuous recordings during daytime activities. Recently, a new semi-instrumental approach was suggested, namely, ecological momentary assessment (EMA), via the use of a smartphone application. With the application, subjects are requested to report, at least 12 times per day, the status of their masticatory muscle activity (relaxed muscles, muscle bracing without tooth contact, teeth contact, teeth clenching, or teeth grinding). The aim of the present study was to test the association between a single observation point self-report and EMA assessment of AB. The most frequent condition recorded by the EMA was relaxed muscles (ca. 60%) and the least frequent was teeth grinding (less than 1%). The relaxed muscle condition also showed the lowest coefficient of variance over a seven-day period of report. Additionally, only the relaxed muscles and the muscle bracing conditions presented an acceptable ability to assess AB-positive and AB-negative subjects, as defined by single-point self-report questions. The combination between self-report and EMA may have the potential to promote our ability to assess AB. We suggest to re-consider the conditions of teeth contact and teeth grinding while using EMA to evaluate AB.

Perceived Impacts, Acceptability, and Recommendations for Ecological Momentary Assessment Among Youth Experiencing Homelessness: Qualitative Study

BACKGROUND

The use of ecological momentary assessment (EMA) to study youth experiencing homelessness (YEH) behaviors is an emerging area of research. Despite high rates of participation and potential clinical utility, few studies have investigated the acceptability and recommendations for EMA from the YEH perspective.

OBJECTIVE

This study aimed to describe the perceived benefits, usability, acceptability, and barriers to the use of EMA from the homeless youth perspective.

METHODS

YEH were recruited from a larger EMA study. Semistructured exit interviews were performed using an interview guide that focused on the YEH experience with the EMA app, and included perceived barriers and recommendations for future studies. Data analyses used an inductive approach with thematic analysis to identify major themes and subthemes.

RESULTS

A total of 18 YEH aged 19-24 years participated in individual and group exit interviews. The EMA was highly acceptable to YEH and they found the app and EMA surveys easy to navigate. Perceived benefits included increased behavioral and emotional awareness with some YEH reporting a decrease in their high-risk behaviors as a result of participation. Another significant perceived benefit was the ability to use the phones for social support and make connections to family, friends, and potential employers. Barriers were primarily survey and technology related. Survey-related barriers included the redundancy of questions, the lack of customizable responses, and the timing of survey prompts. Technology-related barriers included the "freezing" of the app, battery charge, and connectivity issues. Recommendations for future studies included the need to provide real-time mental health support for symptomatic youth, to create individually customized questions, and to test the use of personalized motivational messages that respond to the EMA data in real time.

CONCLUSIONS

YEH are highly receptive to the use of EMA in studies. Further studies are warranted to understand the impact of EMA on YEH behaviors. Incorporating the YEH perspective into the design and implementation of EMA studies may help minimize barriers, increase acceptability, and improve participation rates in this hard-to-reach, disconnected population.

Use of mHealth Technology for Patient-Reported Outcomes in Community-Dwelling Adults with Acquired Brain Injuries: A Scoping Review

The purpose of our scoping review was to describe the current use of mHealth technology for long-term assessment of patient-reported outcomes in community-dwelling individuals with acquired brain injury (ABI). Following PRISMA guidelines, we conducted a scoping review of literature meeting these criteria: (1) civilians or military veterans, all ages; (2) self-reported or caregiver-reported outcomes assessed via mobile device in the community (not exclusively clinic/hospital); (3) published in English; (4) published in 2015-2019. We searched Ovid MEDLINE(R) < 1946 to 16 August 2019, MEDLINE InProcess, EPub, Embase, and PsycINFO databases for articles. Thirteen manuscripts representing 12 distinct studies were organized by type of ABI [traumatic brain injury (TBI) and stroke] to extract outcomes, mHealth technology used, design, and inclusion of ecological momentary assessment (EMA). Outcomes included post-concussive, depressive, and affective symptoms, fatigue, daily activities, stroke risk factors, and cognitive exertion. Overall, collecting patient-reported outcomes via mHealth was feasible and acceptable in the chronic ABI population. Studies consistently showed advantage for using EMA despite variability in EMA timing/schedules. To ensure best clinical measurement, research on post-ABI outcomes should consider EMA designs (versus single time-point assessments) that provide the best timing schedules for their respective aims and outcomes and that leverage mHealth for data collection.

Geographically-explicit Ecological Momentary Assessment (GEMA) Architecture and Components: Lessons Learned from PMOMS

Geographically explicit Ecological Momentary Assessment (GEMA), an extension of Ecological Momentary Assessment (EMA), allows to record time-stamped geographic location information for behavioral data in the every-day environments of study participants. Considering that GEMA studies are continually gaining the attention of researchers and currently there is no single approach in collecting GEMA data, in this paper, we propose and present a GEMA architecture that can be used to conduct any GEMA study based on our experience developing and maintaining the Postpartum Mothers Mobile Study (PMOMS). Our GEMA client-server architecture can be customized to meet the specific requirements of each GEMA study. Key features of our proposed GEMA architecture include: utilization of widely used smartphones to make GEMA studies practical; alleviation of the burden of activities on participants by designing clients (mobile applications) that are very lightweight and servers that are heavyweight in terms of functionality; utilization of at least one positioning sensor to determine EMA contexts marked with locations; and communication through the Internet. We believe that our proposed GEMA architecture, with the illustrated foundation for GEMA studies in our exemplar study (PMOMS), will help researchers from any field conduct GEMA studies efficiently and effectively.

A pilot study on ecological momentary assessment in asylum-seeking children and adolescents resettled to Germany: Investigating compliance, post-migration factors, and the relation between daily mood, sleep patterns, and mental health

Background

Asylum-seeking children and adolescents (ASCs) resettled to western countries show elevated levels of psychological distress. While research on the mental health of ASCs is increasing, less is known about their day-to-day living experiences such as their daily mood, sleep patterns, and post-migration factors. Moreover, no examination in situ, using smartphone-assisted ecological momentary assessment (EMA), has been conducted up to now among ASCs. Furthermore, we do not know if screening measures succeed in reflecting the daily mood of ASCs experienced in everyday life.

Methods

We undertook a smartphone-assisted EMA study over a two-week period with 3 measurements a day. Participants were N = 40 ASCs from 10 different countries who had resettled to Germany. They completed standardized questionnaires screening for history of trauma and clinical symptoms (post-traumatic stress symptoms, depression, and anxiety) that were carried out in interview-like settings, and they participated in the subsequent EMA where they rated mood, sleep parameters, and post-migration factors on a daily basis. Multilevel models of clinical symptoms, daily mood, and sleep parameters were computed based on a total of 680 measurements.

Results

The multiply traumatized and highly distressed participants reported different levels of discrimination, and various social activities and contacts in the EMA. The overall compliance rate was shown to be 40.5%. Higher PTSS and anxiety scores were associated with lower levels of daily mood and poorer outcomes of some sleep parameters. Depression scores were not associated with any of the variables assessed in the EMA.

Conclusions

Smartphone-assisted EMA among ASCs resettled to Germany proved to be implementable despite a rather low compliance rate. Not only do ASCs show high symptom levels, they are also affected by these symptoms in their daily lives. The results emphasize the need for concise screenings and psychological treatment for this high-risk population. Limitations include the convenient nature of the sample and the lack of a comparison group.

A Randomized Controlled Trial to Evaluate the Effects of a Smartphone Application-Based Lifestyle Coaching Program on Gestational Weight Gain, Glycemic Control, and Maternal and Neonatal Outcomes in Women With Gestational Diabetes Mellitus: The SMART-GDM Study

OBJECTIVE

SMART-GDM examined whether Habits-GDM, a smartphone application (app) coaching program, can prevent excessive gestational weight gain (EGWG) and improve glycemic control and maternal and neonatal outcomes in gestational diabetes mellitus (GDM).

RESEARCH DESIGN AND METHODS

In this randomized controlled trial, women diagnosed with GDM between 12 and 30 weeks were randomly assigned to usual care (control) or to additional support from Habits-GDM that integrated dietary, physical activity, weight, and glucose monitoring (intervention). The primary outcome was the proportion of participants with EGWG. Secondary outcomes included absolute gestational weight gain (GWG), glycemic control, and maternal, delivery, and neonatal outcomes.

RESULTS

In total, 340 women were randomized (170 intervention, 170 control; mean ± SD age 32.0 ± 4.2 years; mean BMI 25.6 ± 5.6 kg/m²). There were no statistically significant differences in the proportions of women with EGWG, absolute GWG, or maternal and delivery outcomes between experimental groups. Average glucose readings were lower in the intervention group (mean difference -0.15 mmol/L [95% CI -0.26; -0.03], P = 0.011) as were the proportions of glucose above targets (premeal: 17.9% vs. 23.3%, odds ratio 0.68 [95% CI 0.53; 0.87], P = 0.003; 2-h postmeal: 19.9% vs. 50%, 0.54 [0.42; 0.70], P < 0.001). When regarded as a composite (although not prespecified), the overall neonatal complications (including birth trauma, neonatal hypoglycemia, hyperbilirubinemia, respiratory distress, neonatal intensive care unit admission, and perinatal death) were significantly lower in the intervention group (38.1% vs. 53.7%, 0.53 [0.34; 0.84], P = 0.006).

CONCLUSIONS

When added to usual care, Habits-GDM resulted in better maternal glycemic control and composite neonatal outcomes (nonprespecified) but did not reduce EGWG among women with GDM.

Possibilities, Problems, and Perspectives of Data Collection by Mobile Apps in Longitudinal Epidemiological Studies: Scoping Review

Background

The broad availability of smartphones and the number of health apps in app stores have risen in recent years. Health apps have benefits for individuals (eg, the ability to monitor one’s health) as well as for researchers (eg, the ability to collect data in population-based, clinical, and observational studies). Although the number of health apps on the global app market is huge and the associated potential seems to be great, app-based questionnaires for collecting patient-related data have not played an important role in epidemiological studies so far.

Objective

This study aims to provide an overview of studies that have collected patient data using an app-based approach, with a particular focus on longitudinal studies. This literature review describes the current extent to which smartphones have been used for collecting (patient) data for research purposes, and the potential benefits and challenges associated with this approach.

Methods

We conducted a scoping review of studies that used data collection via apps. PubMed was used to identify studies describing the use of smartphone app questionnaires for collecting data over time. Overall, 17 articles were included in the summary.

Results

Based on the results of this scoping review, there are only a few studies that integrate smartphone apps into data-collection approaches. Studies dealing with the collection of health-related data via smartphone apps have mainly been developed with regard to psychosomatic, neurodegenerative, respiratory, and cardiovascular diseases, as well as malign neoplasm. Among the identified studies, the duration of data collection ranged from 4 weeks to 12 months, and the participants’ mean ages ranged from 7 to 69 years. Potential can be seen for real-time information transfer, fast data synchronization (which saves time and increases effectivity), and the possibility of tracking responses longitudinally. Furthermore, smartphone-based data-collection techniques might prevent biases, such as reminder bias or mistakes occurring during manual data transfers. In chronic diseases, real-time communication with physicians and early detection of symptoms enables rapid modifications in disease management.

Conclusions

The results indicate that using mobile technologies can help to overcome challenges linked with data collection in epidemiological research. However, further feasibility studies need to be conducted in the near future to test the applicability and acceptance of these mobile apps for epidemiological research in various subpopulations.

Paradigm Shift Toward Digital Neuropsychology and High-Dimensional Neuropsychological Assessments: Review

Neuropsychologists in the digital age have increasing access to emerging technologies. The National Institutes of Health (NIH) initiatives for behavioral and social sciences have emphasized these developing scientific and technological potentials (eg, novel sensors) for augmented characterization of neurocognitive, behavioral, affective, and social processes. Perhaps these innovative technologies will lead to a paradigm shift from disintegrated and data-poor behavioral science to cohesive and data-rich science that permits improved translation from bench to bedside. The 4 main advances influencing the scientific priorities of a recent NIH Office of Behavioral and Social Sciences Research strategic plan include the following: integration of neuroscience into behavioral and social sciences, transformational advances in measurement science, digital intervention platforms, and large-scale population cohorts and data integration. This paper reviews these opportunities for novel brain-behavior characterizations. Emphasis is placed on the increasing concern of neuropsychology with these topics and the need for development in these areas to maintain relevance as a scientific discipline and advance scientific developments. Furthermore, the effects of such advancements necessitate discussion and modification of training as well as ethical and legal mandates for neuropsychological research and praxes.

Using Mobile Devices for Educational Purposes in Compulsory Secondary Education to Improve Student’s Learning Achievements

The number of mobiles surpassed the population of the planet in 2018. Without a doubt, they have become the tool of reference in our social life, as well as in our work and leisure, but in educational centers, they continue to be used inefficiently or are declared off limits to some classrooms. This study aims to establish the relationship that the use of mobile phones in secondary education schools may have in regard to the student’s academic performance. For this purpose, we will carry out a secondary exploitation of the Ministry of Education database for 2017 with the data of 1,887,027 students from 7381 compulsory secondary education schools in Spain. As a method of analysis, a multilevel correlation study is carried out. The results show a strong correlation between centers and territories that allow the usage of mobile devices in education and academic performance. Although the methodology that accompanies the use of the smartphone as an educational tool is very important, the data obtained leads us to think that using mobile phones in schools is a proposal that somehow influences the achievement of better academic results, with almost any methodology used.

Context-Aware Delivery of Ecological Momentary Assessment

Ecological Momentary Assessment (EMA) is an in-the-moment data collection method which avoids retrospective biases and maximizes ecological validity. A challenge in designing EMA systems is finding a time to ask EMA questions that increases participant engagement and improves the quality of data collection. In this work, we introduce SEP-EMA, a machine learning-based method for providing transition-based context-aware EMA prompt timings. We compare our proposed technique with traditional time-based prompting for 19 individuals living in smart homes. Results reveal that SEP-EMA increased participant response rate by 7.19% compared to time-based prompting. Our findings suggest that prompting during activity transitions makes the EMA process more usable and effective by increasing EMA response rates and mitigating loss of data due to low response rates.

A simple location-tracking app for psychological research

Location data gathered from a variety of sources are particularly valuable when it comes to understanding individuals and groups. However, much of this work has relied on participants’ active engagement in regularly reporting their location. More recently, smartphones have been used to assist with this process, but although commercial smartphone applications are available, these are often expensive and are not designed with researchers in mind. To overcome these and other related issues, we have developed a freely available Android application that logs location accurately, stores the data securely, and ensures that participants can provide consent or withdraw from a study at any time. Further recommendations and R code are provided in order to assist with subsequent data analysis.

Usability and Feasibility of a Smartphone App to Assess Human Behavioral Factors Associated with Tick Exposure (The Tick App): Quantitative and Qualitative Study

BACKGROUND

Mobile health (mHealth) technology takes advantage of smartphone features to turn them into research tools, with the potential to reach a larger section of the population in a cost-effective manner, compared with traditional epidemiological methods. Although mHealth apps have been widely implemented in chronic diseases and psychology, their potential use in the research of vector-borne diseases has not yet been fully exploited.

OBJECTIVE

This study aimed to assess the usability and feasibility of The Tick App, the first tick research-focused app in the United States.

METHODS

The Tick App was designed as a survey tool to collect data on human behaviors and movements associated with tick exposure while engaging users in tick identification and reporting. It consists of an enrollment survey to identify general risk factors, daily surveys to collect data on human activities and tick encounters (Tick Diaries), a survey to enter the details of tick encounters coupled with tick identification services provided by the research team (Report a Tick), and educational material. Using quantitative and qualitative methods, we evaluated the enrollment strategy (passive vs active), the user profile, location, longitudinal use of its features, and users' feedback.

RESULTS

Between May and September 2018, 1468 adult users enrolled in the app. The Tick App users were equally represented across genders and evenly distributed across age groups. Most users owned a pet (65.94%, 962/1459; P<.001), did frequent outdoor activities (recreational or peridomestic; 75.24%, 1094/1454; P<.001 and 64.58%, 941/1457; P<.001, respectively), and lived in the Midwest (56.55%, 824/1457) and Northeast (33.0%, 481/1457) regions in the United States, more specifically in Wisconsin, southern New York, and New Jersey. Users lived more frequently in high-incidence counties for Lyme disease (incidence rate ratio [IRR] 3.5, 95% CI 1.8-7.2; P<.001) and in counties with cases recently increasing (IRR 1.8, 95% CI 1.1-3.2; P=.03). Recurring users (49.25%, 723/1468) had a similar demographic profile to all users but participated in outdoor activities more frequently (80.5%, 575/714; P<.01). The number of Tick Diaries submitted per user (median 2, interquartile range [IQR] 1-11) was higher for older age groups (aged >55 years; IRR 3.4, 95% CI 1.5-7.6; P<.001) and lower in the Northeast (IRR[NE] 0.4, 95% CI 0.3-0.7; P<.001), whereas the number of tick reports (median 1, IQR 1-2) increased with the frequency of outdoor activities (IRR 1.5, 95% CI 1.3-1.8; P<.001).

CONCLUSIONS

This assessment allowed us to identify what fraction of the population used The Tick App and how it was used during a pilot phase. This information will be used to improve future iterations of The Tick App and tailor potential tick prevention interventions to the users' characteristics.

Measuring the Psychobiological Correlates of Daily Experience in Adolescents

Mapping the psychobiological correlates of social contexts, experiences, and emotional responses of adolescents in their daily lives provides insight into how adolescent well-being shapes, and is shaped by, experience. Measures of these psychobiological correlates are enabled by devices and technologies that must be precise and suitable for adolescent participants. The present report reviews the most often used research measures, and suggests strategies for best practice, drawn from practical experience. The rapid advances in technological methods to collect attuned measures of psychological processes, social context, and biological function indicate the promise for multimodal measures in ecological settings. Attaining these methodological goals will support research to secure comprehensive, quality data, and advance the understanding of psychobiological function in ambulatory settings.

Valence and Motivation as Predictors of Student Time Use in Everyday Life: An Experience Sampling Study

Popular descriptions of studying frequency show remarkable discrepancies: students complain about their workload, and alumni describe freedom and pleasure. Unfortunately, empirical evidence on student time use is sparse. To investigate time use and reveal contributing psychological factors, we conducted an e-diary study. One hundred fifty-four students reported their time use and valence hourly over 7 days, both at the start of the semester and during their examination period. Motivational problems, social support and self-control were assessed once via questionnaires. Whereas the mean academic time use was in the expected range, the between-subject differences were substantial. We used multilevel modeling to separately analyze the within- and between-subject associations of valence as within factor and time use and social support, self-control, and motivation as between factors and time use. The analyses revealed the importance of affective factors on a within-subject level. Before studying, valence was already low, and it deteriorated further during studying. As expected at the between-subject level, motivational problems were related to less time studying, whereas surprisingly, self-control had no effect. The findings at the start of the semester were replicated in the examination period.

Use of Ecological Momentary Assessment and Intervention in Treatment With Adults

This article reviews the use of ecological momentary assessment (EMA) and ecological momentary intervention (EMI) in clinical research applications. EMA refers to a method of data collection that attempts to capture respondents' activities, emotions, and thoughts in the moment, in their natural environment. It typically uses prompts administered through a personal electronic device, such as a smartphone or tablet. EMI extends this technique and includes the use of microlevel interventions administered through personal electronic devices. These technological developments hold promise for enhancing psychological treatments by prompting the patient outside of therapy sessions in his or her day-to-day environment. Research suggests that EMI may be beneficial to participants and that this effect is amplified when EMI is delivered in the context of ongoing psychotherapy. EMI may reflect a cost-effective mechanism to enhance therapeutic outcomes.

Ecological Momentary Assessment of Factors Associated with Water Intake among Adolescents with Kidney Stone Disease

PURPOSE

Maintaining high water intake decreases kidney stone recurrence but is difficult to do. Strategies to reduce stone recurrence among adolescents are lacking. We conducted an ecological momentary assessment study to identify factors associated with water intake in adolescents with nephrolithiasis.

MATERIALS AND METHODS

The study population consisted of 15 female and 10 male patients 12 to 18 years old with at least 1 prior kidney stone. For 7 days participants used "smart" bottles to self-monitor water intake and received questionnaires randomly 4 times daily, which were completed in real time on mobile devices. The questionnaires ascertained awareness of water intake volume, awareness of water intake goals, perceived need to drink, access to water, alternative beverage consumption and attitudes toward bathrooms. Linear mixed effects models were fit to estimate the association between momentary responses and daily water intake.

RESULTS

During 175 person-days 595 assessments (85%) were completed. Median daily water intake was 1,304 ml (IQR 848-1,832) and 20% of participants met their intake goal for 4 days or more. Unawareness of water intake volume was associated with drinking 690 ml less water per day (p = 0.04). A strong self-perceived need to drink more was associated with drinking 1,954 ml less water each day compared to no self-perceived need to drink more (p <0.01). Unawareness of intake goals was weakly associated with drinking 1,129 ml less water each day (p = 0.1). Access to water, alternative beverage consumption and bathroom aversion were not associated with water intake.

CONCLUSIONS

Unawareness of water volume consumed and low responsiveness to perceived need to drink more were associated with low water intake. Interventions that help adolescents recognize when and identify how to increase water intake may be effective in decreasing stone recurrence.

A Smartphone App to Assess Alcohol Consumption Behavior: Development, Compliance, and Reactivity

BACKGROUND

There are disadvantages-largely related to cost, participant burden, and missing data-associated with traditional electronic methods of assessing drinking behavior in real time. This potentially diminishes some of the advantages-namely, enhanced sample size and diversity-typically attributed to these methods. Download of smartphone apps to participants' own phones might preserve these advantages. However, to date, few researchers have detailed the process involved in developing custom-built apps for use in the experimental arena or explored methodological concerns regarding compliance and reactivity.

OBJECTIVE

The aim of this study was to describe the process used to guide the development of a custom-built smartphone app designed to capture alcohol intake behavior in the healthy population. Methodological issues related to compliance with and reactivity to app study protocols were examined. Specifically, we sought to investigate whether hazard and nonhazard drinkers would be equally compliant. We also explored whether reactivity in the form of a decrease in drinking or reduced responding ("yes") to drinking behavior would emerge as a function of hazard or nonhazard group status.

METHODS

An iterative development process that included elements typical of agile software design guided the creation of the CNLab-A app. Healthy individuals used the app to record alcohol consumption behavior each day for 21 days. Submissions were either event- or notification-contingent. We considered the size and diversity of the sample, and assessed the data for evidence of app protocol compliance and reactivity as a function of hazard and nonhazard drinker status.

RESULTS

CNLab-A yielded a large and diverse sample (N=671, mean age 23.12). On average, participants submitted data on 20.27 (SD 1.88) out of 21 days (96.5%, 20.27/21). Both hazard and nonhazard drinkers were highly compliant with app protocols. There were no differences between groups in terms of number of days of app use (P=.49) or average number of app responses (P=.54). Linear growth analyses revealed hazardous drinkers decreased their alcohol intake by 0.80 standard drinks over the 21-day experimental period. There was no change to the drinking of nonhazard individuals. Both hazard and nonhazard drinkers showed a slight decrease in responding ("yes") to drinking behavior over the same period.

CONCLUSIONS

Smartphone apps participants download to their own phones are effective and methodologically sound means of obtaining alcohol consumption information for research purposes. Although further investigation is required, such apps might, in future, allow for a more thorough examination of the antecedents and consequences of drinking behavior.

Ecological Momentary Assessment and Intervention Principles for the Study of Awake Bruxism Behaviors, Part 1: General Principles and Preliminary Data on Healthy Young Italian Adults

Background: Awake bruxism (AB) is an oral condition that has some uncertainties concerning the epidemiology, also due to the different diagnostic strategies that have been adopted to address it in the research setting. The recent new definition of AB suggests that an ecological momentary assessment (EMA), which enables real-time reporting of the condition under study, can implement knowledge on the topic. Objectives: This article will discuss the general principles of EMA and EMI (Ecological Momentary Intervention) and comment on a preliminary dataset gathered with a smartphone application in a population of Italian young adults. Materials and Methods: A dedicated smartphone application has been used (BruxApp®) on a sample of 30 University students (mean age 24 ± 3.5 years) to record real time report on five specific oral conditions (relaxed jaw muscles, tooth contact, teeth clenching, teeth grinding, mandible bracing) that are related with the spectrum of AB activities. Data were recorded over a 7-day period for two times, with a 1-month interval between the two observation periods. The purpose of collecting data over a second week, 1-month later, was to monitor AB behaviors over time, and test for potential "EMI" effects. Results: Over the first 7 days (T1), the average frequency of relaxed jaw muscles reports at the population level was 62%. Teeth contact (20%) and mandible bracing (14%) were the most frequent AB behaviors. No significant gender differences were detected. One month later, during the second week of data collection (T2), the frequency of the conditions was as follows: relaxed jaw muscles 74%, teeth contact 11% and mandible bracing 13%. Conclusions: These data recorded do not allow any generalization due the unrepresentativeness of the study population. On the other hand, they can be used as templates for future comparisons to get deeper into the study of natural fluctuations of AB behaviors as well as into the potential biofeedback effect of an ecological momentary assessment/intervention. It is important to recognize that the use of smartphone technology may help to set range of values for AB frequency in otherwise healthy individuals, in order to stand as comparisons for selected populations with risk or associated factors.