Potential benefits of using ecological momentary assessment to study high-risk polydrug use

A Qualitative Exploration of Attitudes Toward Global Positioning System Tracking and Ecological Momentary Assessment Among Individuals in Substance Use Treatment

BACKGROUND

The use of tracking technology in substance use research can uncover the role of contextual factors, such as social networks and environmental cues, in triggering cravings and precipitating return to use. Few studies have explored the opinions of individuals in substance use treatment related to tracking technology.

METHODS

We conducted 30 semi-structured interviews with individuals in substance use treatment facilities in Connecticut and Georgia. Interviews were not limited to individuals with any specific substance use disorder. Interviewers described a hypothetical study involving ecological momentary assessment and global positioning system tracking to examine place-based predictors of substance use. Participants were invited to share reactions to this description. We used thematic analysis to identify themes in participant perceptions of this hypothetical research study.

RESULTS

Most participants shared positive opinions about study participation and expressed little to no concern about the tracking components. Participant concerns focused on the security of their information and the potential burden of responding to study questions. Participants largely understood the importance of study participation for promoting greater understanding of substance use and identified potential therapeutic effects of study participation on their own recovery.

CONCLUSIONS

Individuals in substance use treatment expressed little concern with research studies or interventions incorporating mobile-tracking elements. Future studies should explore the responsible use of tracking elements in recovery support interventions.

"I Know Myself Again, Which Makes Me Motivated for Life": Feasibility and Acceptability of Using Experience Sampling Methods With Trauma-Exposed Sexual Minority Women

Intensive longitudinal designs (e.g., experience sampling methods [ESMs]) hold promise for examining the dynamic interplay between daily adversity, coping strategies, and behavioral and mental health issues among marginalized populations. However, few studies have used intensive longitudinal designs with sexual minority women (SMW), an understudied and at-risk population. We assessed feasibility and acceptability of using once-daily, interval-contingent ESM with 161 trauma-exposed SMW (Mage = 29.1, SD = 7.57); 20.5% nonbinary; 32.3% queer; 52.2% people of color; 14.3% with annual incomes ≤$9,999; and 30.4% in Southern United States (U.S.). SMW completed one comprehensive online baseline assessment and once-daily brief online assessments for 14 days. Daily surveys assessed past-24-hour stressors, stress responses, and behavioral and mental health symptoms. At the end of the 14-day ESM period, SMW answered three open-ended questions about participating in this study and about research with SMW. Regarding feasibility, 151 participants (94.0%) initiated the post-baseline ESM study portion and 72 (45.0%) completed all 14 daily surveys. An average of 11.70 (median = 13, SD = 3.31) daily surveys (83.5%) were completed by those who initiated the ESM. ESM completion level varied by race/ethnicity and U.S. region. Qualitative acceptability data revealed several themes, namely that SMW (1) enjoyed participating and felt positively about the ESM experience, (2) felt supported to reflect on impacts of early and ongoing stressors, (3) appreciated the chance to self-reflect and challenge existing thought patterns and coping behaviors, (4) recognized their capacity to tolerate trauma-related distress, (5) recommended that researchers focus on SMW's diverse stressors and daily experiences, (6) wanted a rationale for providing sensitive information and more space to narrate their experiences, and (7) recognized the need for affirmative treatment and policies. Findings could inform modifications to ESM protocols to improve their feasibility and acceptability among trauma-exposed SMW and promote ongoing utility of this valuable method.

Feasibility study of using mobile phone-based experience sampling to assess drug checking by opioid street drug users

BACKGROUND

To date, evaluations of take-home fentanyl (and/or benzodiazepine) test strip use - the most common form of drug checking services - and potential effects on overdose risk have relied on retrospective accounts for some preceding time period, usually a week to several months. Such accounts, however, are subject to recall and memory biases. This pilot study assessed the feasibility of using experiential sampling to collect daily information in situ on drug checking and associated overdose risk reduction - the primary outcomes - among a sample of street opioid users and compared the results to retrospective reports.

METHODS

We recruited 12 participants from a Chicago-based syringe services program. Participants were 18 years of age or older, reported using opioids purchased on the street 3 + times per week in the past month, and had an available Android mobile phone. A phone-based app was programmed to collect daily drug checking information and provided to each participant along with a supply of fentanyl and benzodiazepine test strips and instructions for use over 21 days. Comparable retrospective data were collected via follow-up in-person surveys at the conclusion of daily report collection.

RESULTS

We found a reasonably high rate of daily reporting (63.5%) with participants submitting reports on 160 "person-days" out of 252 possible days. Participants submitted daily reports an average of 13 of 21 days. Reports of test strip use frequency varied between the retrospective and daily reports with a relatively higher percentage of days/time using test strips obtained from the daily reports. We also found higher proportions reporting overdose risk reduction behaviors on the daily reports compared with the retrospective reviews.

CONCLUSIONS

We believe the results support using daily experience sampling to collect information on drug checking behaviors among street drug users. Although resource intensive in comparison to retrospective reports, daily reporting potentially provides more detailed information on test strip use and its association with overdose risk reduction and, ultimately, fewer overdoses. Needed are larger trials and validation studies of daily experience sampling to identify the optimum protocol for collecting accurate information on drug checking and overdose risk reduction behavior.

Short Take: Collecting Data from a Vulnerable Population during the COVID-19 Pandemic

Conducting field research with a vulnerable population is difficult under the most auspicious conditions, and these difficulties only increase during a pandemic. Here, we describe the practical challenges and ethical considerations surrounding a recent data collection effort with a high-risk population during the COVID-19 pandemic. We detail our strategies related to research design, site selection, and ethical review.

Mobile phone and internet use among people who inject drugs: Implications for mobile health interventions

Background: Mobile health (mHealth) interventions have the potential to improve substance use treatment engagement and outcomes, and to reduce risk behaviors among people who inject drugs (PWID). However, there are few studies assessing mobile technology use among PWID and none have investigated continuity of mobile phone use. Methods: We surveyed 494 PWID. We used bivariate (independent-sample t- and chi-square tests) and multivariate (logistic regression) analyses to determine whether mobile phone and/or internet use differed as a function of participant- and/or injection-related characteristics. Results: Most participants (77%) had a mobile phone, with 67% having a phone that was free of charge. Participants with a phone were significantly less likely to be homeless (AOR = 0.28), to have shared syringes (AOR = 0.53), and to have reused syringes (AOR = 0.26) in the past 3 months. We observed high rates of phone and number turnover, with more than half reporting that they got a new phone (57%) and/or number (56%) at least once within the past 3 months. Most participants were familiar with using the internet (80% ever use), though participants who had ever used the internet were younger (AOR = 0.89), were less likely to be homeless (AOR = 0.38), were less likely to have shared syringes (AOR = 0.49), and were more likely to have injected methamphetamine by itself (AOR = 2.49) in the past 3 months. Conclusions: Overall, mobile technology and internet use was high among our sample of PWID. Several factors should be considered in recruiting diverse samples of PWID to minimize bias in mHealth study outcomes, including mobile phone access and protocol type (text- vs internet-based).

Exploring multiple drug use by integrating mobile health and qualitative mapping methods - An individual case study

BACKGROUND

Multiple drug use involves particular pleasures and risks, and is disproportionately practiced by some minority and socially marginalized groups. The unique patterns, intentions, and social contexts of multiple drug use for these groups are poorly understood.

METHODS

Our mixed method integrates geo-enabled smartphone survey data collection with a qualitative mapping interview method. This brief report presents data from one study participant to demonstrate this method's potential contributions to multiple drug use research for priority groups in different settings.

RESULTS

'Jason's' data revealed the interrelated dynamics within his drug use repertoire and links between his substance use to rural life as a transgender person with autism spectrum disorder (ASD). Cigarettes played a role in coping with acute stress from repeatedly being misgendered. Cannabis intoxication helped manage social interactions as a person with ASD, while 'chasing' with cigarettes calibrated cannabis intoxication. Methamphetamine use related to managing body dysmorphia in a rural context with poor access to transgender health services.

CONCLUSION

This mixed method can integrate reliable and ecologically valid assessments of multiple drug use repertoires and combination patterns with the place-embedded experiences, intersecting identities, structural barriers, and intentions related to multiple drug use for different priority groups.

Practical problems and positive experiences with ecological momentary assessment: reflections from people who use drugs

Background: Ecological momentary assessment (EMA) is an increasingly popular and feasible form of data collection, but it can be intensive and intrusive. Especially for at-risk, vulnerable populations like people who use drugs (PWUD), poor experiences with EMA may exacerbate existing chronic struggles while decreasing response rates. However, little research queries participants' experiences with EMA studies.Objectives: We explore participants' positive and negative experiences with EMA, identifying what they liked about the study, the problems they experienced, and suggested solutions to these problems.Methods: Results come from semi-structured interviews from 26 PWUD (6 women; 20 men) in Nebraska who participated in a two-week EMA pilot study on drug use with a study-provided smartphone. Participant responses were recorded by interviewers into open-text fields in Qualtrics. Data were analyzed with an iterative open coding procedure.Results: We found that many participants enjoyed the study and seamlessly incorporated the phone into their daily lives. There were a number of negative study aspects identified, however, as many participants experienced functional issues (e.g., running out of high-speed data, trouble keeping the phone charged, not able to answer questions within the two-hour timeframe) that detracted from their experience, especially if they were homeless.Conclusion: Our findings provide methodological considerations for studies with EMA components among at-risk, vulnerable populations, like PWUD. These suggestions are targeted toward the continued ethical collection of high-quality data in clinical and non-clinical settings.

Perceived Confidentiality Risks of Mobile Technology-Based Ecologic Momentary Assessment to Assess High-Risk Behaviors Among Rural Men Who Have Sex with Men

Although men who have sex with men (MSM) within rural communities are disproportionately impacted by HIV, limited HIV research and programmatic resources are directed to these communities within the U.S. There is a need for improved behavioral data collection methods to obtain more detailed information on the relationship between rural environments, sexual behavior, and substance use. Utilization of mobile health (mHealth) technologies, such as ecologic momentary assessment (EMA), has been advocated for; however, limited research has evaluated its utility among rural MSM. Forty MSM residing in rural Oklahoma were recruited to complete in-depth interviews related to participating online/mobile-based HIV prevention research. Men described a willingness to participate in HIV and substance use studies that use EMA methodologies for data collection; however, they raised various research-related concerns. In particular, participants indicated potential privacy and confidentiality concerns related to the use of the mobile technology-based EMA in public and the storage of data by researchers. Given the varying degree of sexual orientation and substance use disclosure by participants, rural MSM were largely concerned with being inadvertently "outed" within their communities. Men described the various strategies they could employ to protect private information and methods to minimize research risk. Study findings suggest that EMA is an acceptable research methodology for use among rural MSM in the context of HIV and sexual health information, when privacy and confidentiality concerns are adequately addressed. Input from community members and stakeholders is necessary to identify potential areas of concerns for participants prior to data collection.

Ecological momentary assessment of daily drug use and harm reduction service utilization among people who inject drugs in non-urban areas: A concurrent mixed-method feasibility study

BACKGROUND

Ecological momentary assessments (EMA) can improve data accuracy and be useful for understanding the real-time co-occurrence of drug use and harm reduction service utilization among people who inject drugs (PWID); however, feasibility and acceptability of EMA in this population is unknown.

METHODS

We conducted qualitative interviews (n = 45) and EMA surveys (n = 38) with PWID in cities and towns outside of Massachusetts' and Rhode Island's capital cities to 1) assess EMA feasibility and acceptability and 2) examine day-level correlations between drug use and harm reduction service utilization.

RESULTS

Qualitative and quantitative data demonstrated that a 14-day EMA study was both feasible and acceptable. Interviews identified housing instability and related disruptions in cellphone access as challenges to consistent EMA participation. In the 14-day EMA study, EMA completion was high (mean = 10.1 days,SD = 5.3). High completion was associated with higher education (p = 0.005), receiving EMA via SMS text (vs. email, p = 0.017), and not having injected crack in the past month (p = 0.026). Of those who responded (n = 29), 100 % reported willingness to participate in a similar future study. Past 24 -h use of harm reduction services was positively associated with past 24 -h injection drug use (p = 0.013), but not past 24 -h syringe sharing (p = 0.197).

CONCLUSION

Findings support the acceptability, feasibility, and potential utility of EMA for understanding daily experiences of PWID. Future studies should explore strategies to overcome structural barriers to maximize EMA participation, and assess how injection practices, syringe sharing, and use of harm reduction services interact to impact health risks in larger and diverse samples of PWID.

A Systematic Review of Recent Methodological Approaches for Using Ecological Momentary Assessment to Examine Outcomes in U.S. Based HIV Research

PURPOSE OF REVIEW

In recent years, researchers have been adopting and using ecological momentary assessment (EMA) methods via technology devices for real-time measurement of exposures and outcomes in HIV research. To assess and critically evaluate how EMA methods are currently being used in HIV research, we systematically reviewed recent published literature (October 2017-October 2019) and searched select conference databases for 2018 and 2019.

RECENT FINDINGS

Our searches identified 8 published articles that used EMA via smartphone app, a handheld Personal Digital Assistant, and web-based survey programs for real-time measurement of HIV-related exposures and outcomes in behavioral research. Overall trends include use of EMA and technology devices to address substance use, HIV primary prevention (e.g., condom use and preexposure prophylaxis), and HIV treatment (medication adherence). This review supports the use of EMA methods in HIV research and recommends that researchers use EMA methods to measure psychosocial factors and social contexts and with Black and Latinx samples of gay and bisexual men, transgender women, and cisgendered women to reflect current HIV disparities in the U.S.A.

Bridging the Digital Divide Among Racial and Ethnic Minority Men Who Have Sex With Men to Reduce Substance Use and HIV Risk: Mixed Methods Feasibility Study

BACKGROUND

Ecological momentary assessment (EMA) is a promising data collection tool for mobile health interventions targeting episodic health behaviors. For substance-using men who have sex with men (SUMSM), EMA is becoming more widely utilized in efforts to characterize substance use and sexual risk factors for HIV transmission. However, recent literature demonstrates emerging concerns over compliance and lower EMA engagement and data concordance among racial and ethnic minority SUMSM.

OBJECTIVE

This study aimed to provide a qualitative evaluation of the barriers and facilitators of EMA as a data collection tool among racial and ethnic minority SUMSM.

METHODS

Between October and November 2017, 45 racial and ethnic minority SUMSM were recruited from a list of prior research participants at the San Francisco Department of Public Health to participate in daily EMA surveys on their substance use and sexual health behaviors for 1 week, followed by in-person focus groups (FGs). A total of 4 FGs explored the participants' experiences with the surveys, issues regarding privacy and confidentiality, and suggestions for improvement. Qualitative analysis was performed using content analysis. Descriptive statistics and Fisher exact tests were used to assess the associations between demographics or substance use behaviors and EMA completion.

RESULTS

Overall, 93.9% (295/314) of all delivered surveys were initiated, and of those, 98.0% (289/295) were completed. Neither participant demographics, including race (P=.65) or age (P=.43), nor substance use behaviors, including the frequency of alcohol (P=.40) or methamphetamine (P=.91) use or any cocaine (P=.28), crack (P=.99), or polysubstance use (P=.24), were found to be associated with survey completion. Overall, participants were receptive to the text message-based EMA surveys. Facilitators included survey timing, user-friendly survey design, survey-stimulated self-reflection, coding of sensitive phrases, and other privacy benefits of a mobile survey. Barriers included an inability to correct texting errors and participants' perception of judgment or stigmatization related to questions about condomless sex. To improve EMA compliance and uptake, participants suggested adding response confirmations, clarifying survey language, and continuing to diversify the study audience.

CONCLUSIONS

EMA appears to be feasible and acceptable among this sample of racial and ethnic minority SUMSM. Close attention to EMA study design and the development of nonjudgmental, contextualized questions regarding stigmatized health behaviors may be critical to further improve EMA compliance.

The risk-benefit ratio of studying psychiatric symptoms via daily diary methods

Ethics committee members and researchers have deliberated about the risk-benefit ratio of researching sensitive issues such as psychiatric symptoms. Although research has suggested that inquiring about psychiatric symptoms in research generally does not cause harm, these findings have primarily arisen from cross-sectional studies. We examined whether this generalized to repeated, daily assessments of psychiatric symptoms. We collected daily survey data on psychiatric symptoms over 90 days from a sample of 206 college students. A subset of the sample (n = 80) provided reactions to study participation administered on the 90^th day. Individuals who did not complete the 90^th day survey reported higher levels of suicidal ideation and hopelessness than those who did. For individuals who completed the 90^th, final assessment, reactions primarily fell within the neutral to positive range, with variation depending on their baseline levels of psychiatric symptoms and identification as religious. This study adds to past work by demonstrating that individuals who remained in the study had neutral to positive experiences. However, participants with greater suicidal ideation and hopelessness were likely to attrit, warranting caution in assuming a low risk-benefit ratio of these studies. Management of risks involved in repeated assessment studies may be informed by this work.