Rationale and Design of the Women's Health And Daily Experiences Project: Protocol for an Ecological Momentary Assessment Study to Identify Real-Time Predictors of Midlife Women's Physical Activity

Daily social comparisons among women in midlife with elevated risk for cardiovascular disease: A within-person test of the identification/contrast model

Women age 40-60 are disproportionately affected by health problems that increase their risk for cardiovascular disease (CVD; e.g. hypertension). Social comparisons (i.e. self-evaluations relative to others) are known to influence health in this and other groups, but their nature and consequences in daily life are poorly understood. We conducted an ecological momentary assessment study over 10 days (5x/day) with 75 women ages 40-60 who had ≥1 CVD risk conditions (MAge = 51.6 years, MBMI = 34.0 kg/m2). Using a mix of frequentist and Bayesian analytic approaches, we examined characteristics of women's naturally occurring comparisons and tested predictions from the Identification/Contrast Model within-person (e.g. identifying with an upward target results in positive affect, whereas contrasting results in negative affect). Comparisons occurred at 21% of moments, with considerable within-person variability in response. In line with predictions from the Identification/Contrast Model, women were more likely to experience positive affect after upward identification or downward contrast and more likely to experience negative affect after upward contrast or downward identification, though observed nuances warrant additional consideration. Overall, findings support the Identification/Contrast Model to describe women's comparison experiences as they occur in daily life. Future work should determine pathways between the immediate consequences of comparisons and longer-term health outcomes.

Examining reactivity to the measurement of physical activity and sedentary behavior among women in midlife with elevated risk for cardiovascular disease

OBJECTIVES

To estimate the extent of reactivity to measurement of physical activity (PA) and sedentary behavior among women in midlife with elevated risk for cardiovascular disease (CVD).

DESIGN

Secondary analysis of a 10-day observational study of PA and sedentary behavior.

MAIN OUTCOME MEASURES

PA (steps, minutes of light PA, total minutes of moderate-to- vigorous PA [MVPA]) and percent time in sedentary behavior per day were assessed using ActiGraph GT3X tri-axial accelerometers in 75 women in midlife with elevated CVD risk (e.g. hypertension; MAge = 51.61, MBMI = 34.02 kg/m2). Two-level multilevel models were used to test for evidence of reactivity, with the addition of random effects to test for evidence of individual differences in observed trends.

RESULTS

All outcomes showed linear trends across days (ps < 0.001), though this masked what appeared to be meaningful dropoff after Day 1 or Day 2 (with little difference between subsequent days; srs ranging from 0.15 to 0.32). The random effect was significant only for percent time in sedentary behavior (χ2[1] = 10.40, p = 0.02).

CONCLUSIONS

Consistent small to medium effects were found for all PA and sedentary behavior outcomes, underscoring the importance of considering measurement reactivity in populations with elevated CVD risk.

"You get what you need when you need it": A mixed methods examination of the feasibility and acceptability of a tailored digital tool to promote physical activity among women in midlife

During midlife (ages 40-60), women experience myriad changes that elevate their risk for cardiovascular disease (CVD), including decreased physical activity (PA). Women cite lack of social support for PA and lack of active peers who can serve as role models as key barriers. Digital tools such as web applications can provide exposure to these social inputs; they are also accessible in daily life and require modest time investment. However, as few tools have been designed to meet the unique needs of women in midlife with CVD risk, our research team previously built a web application that is tailored for this population. In the present study, we used a convergent mixed methods design to develop a deep understanding of the feasibility, usability, and acceptability of this web application in a sample of identified end users. Participants (N = 27, MAge = 53 years, MBMI = 32.6 kg/m2) used the web application at the start of each day for 7 days and completed a 1-hour qualitative interview at the end of this test period. Integration of findings from two-level multilevel models (quantitative) and thematic analysis (qualitative) indicated support for the feasibility, usability, and acceptability of the new web application among women in midlife with CVD risk conditions and identified critical opportunities for improving the user experience. Findings also speak to the utility of options for content selection that can meet women's needs in daily life and highlight women's desire for PA resources that prioritize their perspectives.

Pain experiences among women in midlife with existing health conditions: changes across pre-COVID-19, stay-at-home orders, and initial reopening

OBJECTIVE

To examine the pain experiences of women in midlife with existing health conditions, including changes from prior to the COVID-19 pandemic through the first 6 months of the crisis.

DESIGN

Women ages 40-60 with health conditions (e.g., hypertension; N = 35, MBMI = 32.2 kg/m2) were prompted to complete 5 surveys per day for 5 days at 3 time points: pre-COVID-19, during stay-at-home orders, and at initial reopening.

MAIN OUTCOME MEASURES

Pain occurrence (yes/no), number of locations, and intensity.

RESULTS

Women reported pain at 35% of surveys, particularly after waking and before bed compared to the middle of the day. The occurrence of pain decreased over time, whereas pain intensity decreased between pre-COVID-19 and stay-at-home orders but then remained stable. The number of pain locations decreased between stay-at-home orders and reopening, and pain was more variable during the pandemic than prior to its onset (srs = 0.24-0.32).

CONCLUSION

Women experienced decreased pain frequency and intensity from prior to during the COVID-19 pandemic, though pain was less predictable during (vs. prior to) the pandemic. This information may be useful for informing care in this at-risk group, to prevent the development of chronic pain.

Rationale and Design of an Ecological Momentary Assessment Study Examining Predictors of Binge Eating Among Sexual Minority and Heterosexual Young Women: Protocol for the Health and Experiences in Real Life (HER Life) Study

BACKGROUND

Previous research has identified health disparities between sexual minority and heterosexual women, including increased rates of obesity and binge eating in sexual minority women. Established predictors of binge eating behavior include negative emotions and sociocultural processes; however, these studies are generally conducted in samples of young women where sexual identity is not known or reported. There is a dearth of research evaluating how sexual minority-specific factors (eg, minority stress and connectedness to the lesbian, gay, bisexual, transgender, and queer community) may affect binge eating in sexual minority women. In addition, no studies have examined these processes in racially diverse samples or considered how intersecting minority identities (eg, Black and sexual minority) may affect eating behaviors.

OBJECTIVE

The Health and Experiences in Real Life (HER Life) Project aims to clarify real-world predictors of binge eating in young heterosexual and sexual minority women using ecological momentary assessment. The role of affective, social, and health behavior factors in binge eating will be examined for all women (aim 1), and sexual minority-specific predictors will also be considered for sexual minority women participants (aim 2). Person-level moderators of race, body- and eating-related factors, and sexual minority-specific factors will also be examined to better understand how real-world binge eating predictors may differ for various demographic groups (aim 3).

METHODS

Researchers aim to recruit 150 sexual minority and 150 heterosexual women from across the United States, including at least 50 Black women for each group, using web-based recruitment methods. The eligibility criteria include identifying as a woman, being aged between 18 and 30 years, and having had at least two binge eating episodes in the last 2 weeks. Participants must endorse being only or mostly attracted to men (considered heterosexual) or only or mostly attracted to women or having a current or most recent female partner (considered sexual minority). Eligible participants complete an initial web-based baseline survey and then 14 days of ecological momentary assessment involving the completion of a morning and before-bed survey and 5 prompted surveys per day as well as a user-initiated survey after binge eating episodes. The data will be analyzed using a series of multilevel models.

RESULTS

Data collection started in February 2021. We have currently enrolled 129 sexual minority women and 146 heterosexual women. Data collection is expected to conclude in fall 2022.

CONCLUSIONS

The Health and Experiences in Real Life Project aims to elucidate potential differences between sexual minority and heterosexual women in within-person factors predicting binge eating and inform eating disorder interventions for sexual minority women. The challenges in recruiting sexual minority women, including the determination of eligibility criteria and considerations for remote data collection, are discussed.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41199.

A scoping review of behavior change techniques used to promote physical activity among women in midlife

Women in midlife experience health risks that could be mitigated by regular physical activity and reduced sedentary time, but this population rarely achieves physical activity levels that would protect their health. As a result, many behavioral interventions are designed to promote physical activity in this population, which are purportedly guided by theoretical models of health behavior (change) and activate an associated set of behavior change techniques (BCTs). The efficacy and effectiveness of these interventions appear to be limited, however, raising questions about their design and adaptation for women in midlife. Several aspects of these interventions are currently unclear. Specifically, which women they target (i.e., how "midlife" and "sedentary" or "inactive" are defined), which theoretical models or behavior BCTs are used, and how BCTs are activated in such interventions. A synthesis of this information would be useful as an initial step toward improving physical activity interventions for this at-risk group, and thus, represented the goal of the present scoping review. Eligibility required publication in a peer-reviewed journal in English between 2000 and 2021, inclusion of only women in midlife who did not have any medical or other restrictions on their physical activity (e.g., cancer diagnosis), and free-living physical activity or sedentary behavior as the target outcome (with associated assessment). Of the 4,410 initial results, 51 articles met inclusion criteria, and these described 36 unique interventions. More than half of the articles (59%) named an underlying theoretical model and interventions included an average of 3.76 identifiable BCTs (range 1-11). However, descriptions of many interventions were limited and did not provide enough detail to determine whether or how specific BCTs were activated. Interventions also used a wide range of inclusion criteria for age range and starting activity level, which has implications for targeting/tailoring and effectiveness, and many interventions focused on marginalized populations (e.g., women from racial/ethnic minority backgrounds, those un- or under-insured). The present review identifies some strengths and highlights important limitations of existing literature, as well as key opportunities for advancing the design and potential utility of physical activity interventions for women in midlife.

Systematic review registration

https://osf.io/g8tuc.

Changes in Life Circumstances and Mental Health Symptoms during the COVID-19 Pandemic among Midlife Women with Elevated Risk for Cardiovascular Disease

Cardiovascular disease (CVD) remains the leading cause of death among women. During midlife (ages 40-60), universal aging processes, sex-specific factors such as menopause, psychological distress, and conditions such as hypertension substantially increase women's risk for CVD. The onset of the COVID-19 pandemic has impacted employment, social interactions, caregiving responsibilities, and overall well-being worldwide; however, little research has investigated how COVID-19 has affected women in midlife. The present study was designed to determine how COVID-19 has affected women in midlife with elevated risk for CVD, by examining changes in their mental health symptoms and life domains across three time points: prior to COVID-19 (2019), during stay-at-home orders (April-June 2020), and during initial reopening (August 2020). Women in midlife with one or more CVD risk conditions (e.g., hypertension; n = 35) responded to questions related to COVID-19, changes in life circumstances, and mental health symptoms at each time point. Findings showed meaningful changes in caregiving, medical visits, and employment status, as well as significant changes in depression and sleep quality scores across time. However, the findings also showed that women were distressed prior to COVID-19 and did not exhibit changes in perceived stress, body dissatisfaction, or anxiety symptoms over time. Findings from this study highlight the impact of the COVID-19 pandemic on an at-risk group of women, which may be used to help guide future health promotion efforts specifically tailored to this population.

Ecological Momentary Assessment of Associations Between Social Interactions and Physical Activity Outcomes Among Women in Midlife With CVD Risk Conditions

BACKGROUND

Risk for cardiovascular disease is particularly high among women in midlife (ages 40-60). Moderate-to-vigorous-intensity physical activity (PA) can protect against risk during this time, and research is needed to understand contributors to PA motivation and behavior in daily life.

PURPOSE

This study used ecological momentary assessment to examine: (a) within-person associations between social interactions (both quantity and quality) and PA outcomes (motivation and behavior) among women in midlife, and (b) variability in within-person associations across days.

METHODS

Women ages 40-60 with one or more cardiovascular disease risk conditions (e.g., hypertension; n = 75; MAge = 51.6 years, MBMI = 34.0 kg/m2) wore waistband accelerometers and completed five surveys per day for 10 days.

RESULTS

Controlling for social interactions overall, at times when women reported a higher number of positive interactions, they reported higher PA motivation; this association was negative for both the number and valence of negative interactions. At times when women experienced a higher number of interactions overall, they engaged in fewer subsequent minutes of moderate-to-vigorous-intensity PA, though reports of positive and negative interactions were not associated with moderate-to-vigorous-intensity PA behavior. Importantly, the direction of these within-person associations differed between days of observation (positive associations on ~50% of days and negative associations on ~50% of days).

CONCLUSIONS

Findings show that social interactions influence PA motivation and behavior among women in midlife but that these influences are inconsistent, suggesting the need for careful consideration of how to engage social interactions to promote PA in this group.

Development and Initial Testing of a Personalized, Adaptive, and Socially Focused Web Tool to Support Physical Activity Among Women in Midlife: Multidisciplinary and User-Centered Design Approach

BACKGROUND

Women in midlife are vulnerable to developing cardiovascular disease, particularly those who have conditions such as hypertension. Physical activity (PA) can reduce risk, but efforts to promote PA in this population have been only modestly effective. More attention to social influences on PA behavior may be useful, particularly social support and social comparison processes. Activating these processes with digital tools can provide easy access that is flexible to the needs of women in midlife.

OBJECTIVE

This paper describes the user-centered design processes of developing and conducting initial evaluation of a personalized and adaptive web application, tailored to the social needs of women in midlife. The goal was to gather feedback from the population of interest, before and during the design process.

METHODS

This study was conducted in 4 stages. The first and second authors (DA and AFL) developed technical specifications, informed by their experience with the population of interest. We collected feedback on potential content for the web application with women in midlife using both interviews (5/10, 50%; mean age 47.4, SD 6.66 years; mean BMI 35.3, SD 9.55 kg/m2) and surveys (5/10, 50%; mean age 51, SD 6.60 years; mean BMI 32.7, SD 8.39 kg/m2). We used their feedback to inform support messages and peer profiles (ie, sources of social comparison information). Nine members of the behavioral science team and 3 testers unfamiliar with the web application completed internal testing. We conducted naturalistic functionality testing with a different group of women in midlife (n=5; mean age 50, SD 6.26 years; mean BMI 30.1, SD 5.83 kg/m2), who used the web application as intended for 4 days and provided feedback at the end of this period.

RESULTS

Iterative storyboard development resulted in programming specifications for a prototype of the web application. We used content feedback to select and refine the support messages and peer profiles to be added. The following 2 rounds of internal testing identified bugs and other problems regarding the web application's functioning and full data collection procedure. Problems were addressed or logged for future consideration. Naturalistic functionality testing revealed minimal further problems; findings showed preliminary acceptability of the web application and suggested that women may select different social content across days.

CONCLUSIONS

A multidisciplinary and user-centered design approach led to a personalized and adaptive web application, tailored to the social needs of women in midlife. Findings from testing with this population demonstrated the feasibility and acceptability of the new application and supported further development toward its use in daily life. We describe several potential uses of the web application and next steps for its development. We also discuss the lessons learned and offer recommendations for future collaborations between behavioral and computer scientists to develop similar tools.

Within-person examination of the exercise intention-behavior gap among women in midlife with elevated cardiovascular disease risk

Engaging in moderate-to-vigorous intensity physical activity (MVPA) is important for protecting cardiovascular health among women in midlife (i.e., ages 40-60), particularly if they have already developed conditions that increase their risk for cardiovascular disease (e.g., hypertension). Although the gap between MVPA intentions and behavior is well documented in other populations, little is known about the intention-behavior gap in this at-risk group - particularly as it plays a role in daily life. The present study employed an ecological momentary assessment design to examine the relation between women's MVPA intentions and behavior in the subsequent 3 hours, as well as momentary moderators of this relation (i.e., affective states and body satisfaction). Surveys sent to women's smartphones 5 times per day for 10 days while they wore ActiGraph GT3X waistband accelerometers. Women achieved their exercise intentions at only 13% of occasions on which they set intentions. Although the most common intended exercise was walking, women engaged in more minutes of MVPA after setting intentions to do yoga or Pilates than any other type of exercise (sr = 0.25). Multilevel models showed a modest within-person relation between minutes of intended MVPA and observed MVPA in the next 3 hours (sr = 0.20). This relation was moderated within-person by the reported extent of positive affect (particularly contentment) and body satisfaction (srs = 0.35 and 0.28, respectively). Findings extend knowledge about the physical activity intention-behavior gap to an at-risk population of women and identify positive affect and body satisfaction as potential contextual influences for this group, which could inform improvements to existing interventions (e.g., delivering intervention content at times with lower-than-usual body satisfaction).

Relations between social comparisons and physical activity among women in midlife with elevated risk for cardiovascular disease: an ecological momentary assessment study

Women in midlife (ages 40–60) show decreases in physical activity (PA) that exacerbate risk for cardiovascular disease. Social comparisons (i.e., self-evaluations relative to others) are known to influence PA in other groups, but their association in this population is unknown. The present study used ecological momentary assessment to examine this relation among women in midlife with hypertension or another CVD risk condition (N = 75, M_BMI = 34.0 kg/m²). Participants completed 5 surveys per day and wore tri-axial accelerometers for 10 days. PA engagement was lower after women reported more comparisons than were typical for them (7–14% reductions in PA for each additional comparison). These relations varied across days of observation and relations were positive on 34–58% of days. Findings call for careful consideration of how best to harness any potential benefits of social comparison for promoting PA in this and other groups.

A multi-study approach to refining ecological momentary assessment measures for use among midlife women with elevated risk for cardiovascular disease

BACKGROUND

Ample evidence indicates that everyday perceptions of the social environment can affect health behaviors; these include social comparisons (i.e., self-evaluations compared to others) and positive versus negative social interactions. However, relations between social perceptions and healthy behaviors have received little attention among specific medical populations for whom an improved understanding of behavioral determinants could inform updates to tailored interventions. Research methods that capture and differentiate between stable, person-level differences and dynamic, within-person variability in these relations would be particularly useful, both for identifying their nature in daily life and informing improvements to tailored interventions.

METHODS

We conducted a series of three formative research studies to adapt and test the measures and instructions for an ecological momentary assessment (EMA) protocol with midlife women who had elevated risk for cardiovascular disease (CVD; e.g., current diagnosis of hypertension, type 2 diabetes). Study 1 involved a pilot test of initial EMA items, sent to participants' smartphones 5 times per day for 7 days (N=13; M_Age =47, M_BMI =33.7 kg/m²), as well as brief exit interviews to identify points of confusion and suggestions for improvement. Study 2 used 1-hour, individual qualitative interviews with a new sample to elicit women's perceptions of revised items and identify additional opportunities for refinement (N=10, M_Age =52, M_BMI =29.8 kg/m²). In Study 3, a new sample of participants completed 7 days of EMA with revised items and instructions (5 times per day; N=13, M_Age =50, M_BMI =33.4 kg/m²).

RESULTS

Item performance in Study 3, including the frequencies of reporting social comparisons and interactions, was compared to that in Study 1 using multilevel modeling; these tests showed meaningful improvement in reporting patterns between Studies 1 and 3 (e.g., changes of d=0.33-0.75 where appropriate).

CONCLUSIONS

Together, findings from this series of studies demonstrate the utility of a multi-study approach to refining EMA methods for use with midlife women who have elevated CVD risk, which may generalize to other populations of interest.