Reducing bias in trials from reactions to measurement: the MERIT study including developmental work and expert workshop

Untapped Potential of Unobtrusive Observation for Studying Health Behaviors

Improving the environment is an important upstream intervention to promote population health by influencing health behaviors such as physical activity, smoking, and social distancing. Examples of promising environmental interventions include creating high-quality green spaces, building active transport infrastructure, and implementing urban planning regulations. However, there is little robust evidence to inform policy and decision makers about what kinds of environmental interventions are effective and for which populations. In this viewpoint, we make the case that this evidence gap exists partly because health behavior research is dominated by obtrusive methods that focus on studying individual behavior and that are less suitable for understanding environmental influences. In contrast, unobtrusive observation can assess how behavior varies in different environmental contexts. It thereby provides valuable data relating to how environments affect the behavior of populations, which is often useful knowledge for effectively and equitably tackling population health challenges such as obesity and noncommunicable diseases. Yet despite a long history, unobtrusive observation methods are currently underused in health behavior research. We discuss how developing the use of video technology and automated computer vision techniques can offer a scalable solution for assessing health behaviors, facilitating a more thorough investigation of how environments influence health behaviors. We also reflect on the important ethical challenges associated with unobtrusive observation and the use of these emerging video technologies. By increasing the use of unobtrusive observation alongside other methods, we strongly believe this will improve our understanding of the influences of the environment on health behaviors.

Engagement with a nationally-implemented digital behaviour change intervention: Usage patterns over the 9-month duration of the National Health Service Digital Diabetes Prevention Programme

Background

Digital behaviour change interventions may offer a scalable way to promote weight loss by increasing physical activity and improving diet. However, user engagement is necessary for such benefits to be achieved. There is a dearth of research that assesses engagement with nationally implemented digital programmes offered in routine practice. The National Health Service Digital Diabetes Prevention Programme (NHS-DDPP) is a nine-month digital behaviour change intervention delivered by independent providers for adults in England who are at high risk of developing type 2 diabetes. This study reports engagement with the NHS-DDPP for users enrolled onto the programme over the nine-month duration.

Methods

Anonymous usage data was obtained for a cohort of service users (n = 1826) enrolled on the NHS-DDPP with three independent providers, between December 2020 and June 2021. Usage data were obtained for time spent in app, and frequency of use of NHS-DDPP intervention features in the apps including self-monitoring, goal setting, receiving educational content (via articles) and social support (via health coaches and group forums), to allow patterns of usage of these key features to be quantified across the nine-month intervention. Median usage was calculated within nine 30-day engagement periods to allow a longitudinal analysis of the dose of usage for each feature.

Results

App usage declined from a median of 32 min (IQR 191) in month one to 0 min (IQR 14) in month nine. Users self-monitored their behaviours (e.g., physical activity and diet) a median of 117 times (IQR 451) in the apps over the nine-month programme. The open group discussion forums were utilised less regularly (accessed a median of 0 times at all time-points). There was higher engagement with some intervention features (e.g., goal setting) when support from a health coach was linked to those features.

Conclusions

App usage decreased over the nine-month programme, although the rate at which the decrease occurred varied substantially between individuals and providers. Health coach support may promote engagement with specific intervention features. Future research should assess whether engagement with particular features of digital diabetes prevention programmes is associated with outcomes such as reduced bodyweight and HbA1c levels.

A systematic review and meta-analysis of studies of reactivity to digital in-the-moment measurement of health behaviour

Self-report measures of health behaviour have several limitations including measurement reactivity, i.e., changes in people's behaviour, cognitions or emotions due to taking part in research. This systematic review investigates whether digital in-the-moment measures induce reactivity to a similar extent and why it occurs. Four databases were searched in December 2020. All observational or experimental studies investigating reactivity to digital in-the-moment measurement of a range of health behaviours were included if they were published in English in 2008 or later. Of the 11,723 records initially screened, 30 publications reporting on 31 studies were included in the qualitative synthesis/ 7 studies in the quantitative synthesis. Eighty-one percent of studies focused on reactivity to the measurement of physical activity indicators; small but meaningful pooled effects were found (Cohen's ds: 0.27-0.30). Only a small number of studies included other behaviours, yielding mixed results. Digital in-the-moment measurement of behaviour thus may be as prone to reactivity as self-reports in questionnaires. Measurement reactivity may be amplified by (1) ease of changing the behaviour (2) awareness of being measured and social desirability, and (3) resolving discrepancies between actual and desired behaviour through self-regulation.

A digital approach to asthma self-management in adults: Protocol for a pragmatic randomized controlled trial

Asthma self-management can improve symptom control, but adherence to established self-management behaviors is often poor. With adult asthma uncontrolled in over 60% of U.S. cases, there is a need for scalable, cost-effective tools to improve asthma outcomes. Here we describe a protocol for the Asthma Digital Study, a 24-month, decentralized, pragmatic, open-label, randomized controlled trial investigating the impact of a digital asthma self-management (DASM) program on asthma outcomes in adults. The program leverages consumer-grade devices with a smartphone app to provide "smart nudges," symptom logging, trigger tracking, and other features. Participants are recruited (target N = 900) from throughout the U.S., and randomized to a DASM or control arm (1:1). Co-primary outcomes at one year are a) asthma-associated costs for acute care and b) change from baseline in Asthma Control Test™ scores. Findings may inform decisions around adoption of digital tools for asthma self-management. Trial registration:clinicaltrials.gov identifier: NCT04609644. Registered: Oct 30, 2020.

Bias in Self-Reports: An Initial Elevation Phenomenon

Researchers have long worried about a phenomenon where study participants give higher ratings on self-report scales the first time they take a survey compared to subsequent times, particularly for negative subjective experiences. Recent experimental evidence, using samples of U.S. college students, suggests that this initial elevation phenomenon is due to an upward bias in people’s initial responses. Such bias potentially undermines the validity of many research findings. However, more recent studies have found little evidence in support of the phenomenon. To investigate the robustness of the initial elevation phenomenon, we conducted the largest experiments to date in diverse online samples ( N = 5,285 across three studies, from Prolific.co). We observed an initial elevation on self-reports of negative subjective experiences such as mood and mental and physical health symptoms. Our findings show that the threats to validity posed by the phenomenon are real and need to be reckoned with.

Effects of Using a Text Message Intervention on Psychological Constructs and the Association Between Changes to Psychological Constructs and Medication Adherence in People With Type 2 Diabetes: Results From a Randomized Controlled Feasibility Study

BACKGROUND

Poor adherence to oral medications is common in people with type 2 diabetes and can lead to an increased chance of health complications. Text messages may provide an effective delivery method for an intervention; however, thus far, the majority of these interventions do not specify either a theoretical basis or propose specific mechanisms of action. This makes it hard to determine how and whether an intervention is having an effect. The text messages included in the current intervention have been developed to deliver specific behavior change techniques. These techniques are the "active ingredients" of the intervention and were selected to target psychological constructs identified as predictors of medication adherence.

OBJECTIVE

There are 2 aims of this study: (1) to assess whether a text message intervention with specified behavior change techniques can change the constructs that predict medication adherence behaviors in people with type 2 diabetes and (2) to assess whether changes to psychological constructs are associated with changes in self-reported medication adherence.

METHODS

We conducted a randomized controlled, 6-month feasibility trial. Adults prescribed oral medication for type 2 diabetes (N=209) were recruited from general practice and randomized to either receive a text message-based intervention or care as usual. Data were analyzed with repeated measures analysis of covariance and Spearman rho correlation coefficients.

RESULTS

For 8 of the 14 constructs that were measured, a significant time-by-condition interaction was found: necessity beliefs, intention, maintenance self-efficacy, recovery self-efficacy, action control, prompts and cues, social support, and satisfaction with experienced consequences all increased in the intervention group compared to the control group. Changes in action self-efficacy, intention, automaticity, maintenance self-efficacy, and satisfaction with experienced consequences were positively associated with changes in self-reported medication adherence.

CONCLUSIONS

A relatively low-cost, scalable, text message-only intervention targeting medication adherence using behavior change techniques can influence psychological constructs that predict adherence. Not only do these constructs predict self-reported medication adherence, but changes in these constructs are correlated with changes in self-reported medication adherence. These findings support the promise of text message-based interventions for medication adherence in this population and suggest likely mechanisms of action.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN13404264; https://www.isrctn.com/ISRCTN13404264.

Reducing bias in trials due to reactions to measurement: experts produced recommendations informed by evidence

OBJECTIVE

This study (MEasurement Reactions In Trials) aimed to produce recommendations on how best to minimize bias from measurement reactivity (MR) in randomized controlled trials of interventions to improve health.

STUDY DESIGN AND SETTING

The MERIT study consisted of: (1) an updated systematic review that examined whether measuring participants had effects on participants' health-related behaviors, relative to no-measurement controls, and three rapid reviews to identify: (i) existing guidance on MR; (ii) existing systematic reviews of studies that have quantified the effects of measurement on behavioral or affective outcomes; and (iii) studies that have investigated the effects of objective measurements of behavior on health-related behavior; (2) a Delphi study to identify the scope of the recommendations; and (3) an expert workshop in October 2018 to discuss potential recommendations in groups.

RESULTS

Fourteen recommendations were produced by the expert group to: (1) identify whether bias is likely to be a problem for a trial; (2) decide whether to collect data about whether bias is likely to be a problem; (3) design trials to minimize the likelihood of this bias.

CONCLUSION

These recommendations raise awareness of how and where taking measurements can produce bias in trials, and are thus helpful for trial design.

Clinical efficacy of COMPASS, a digital cognitive-behavioural therapy programme for treating anxiety and depression in patients with long-term physical health conditions: a protocol for randomised controlled trial

INTRODUCTION

Approximately 30% of people with long-term physical health conditions (LTCs) experience mental health problems, with negative consequences and costs for individuals and healthcare services. Access to psychological treatment is scarce and, when available, often focuses on treating primary mental health problems rather than illness-related anxiety/depression. The aim of this study is to evaluate the clinical efficacy of a newly developed, therapist-supported, digital cognitive-behavioural treatment (COMPASS) for reducing LTC-related psychological distress (anxiety/depression), compared with standard charity support (SCS).

METHODS AND ANALYSIS

A two-arm, parallel-group randomised controlled trial (1:1 ratio) with nested qualitative study will be conducted. Two-hundred adults with LTC-related anxiety and depression will be recruited through national LTC charities. They will be randomly allocated to receive COMPASS or SCS only. An independent administrator will use Qualtrics randomiser for treatment allocation, to ensure allocation concealment. Participants will access treatment from home over 10 weeks. The COMPASS group will have access to the digital programme and six therapist contacts: one welcome message and five fortnightly phone calls. Data will be collected online at baseline, 6 weeks and 12 weeks post-randomisation for primary outcome (Patient Health Questionnaire Anxiety and Depression Scale) and secondary outcomes (anxiety, depression, daily functioning, COVID-19-related distress, illness-related distress, quality of life, knowledge and confidence for illness self-management, symptom severity and improvement). Analyses will be conducted following the intention-to-treat principle by a data analyst blinded to treatment allocation. A purposively sampled group of COMPASS participants and therapists will be interviewed. Interviews will be thematically analysed.

ETHICS AND DISSEMINATION

The study is approved by King's College London's Psychiatry, Nursing and Midwifery Research Ethics Subcommittee (reference: LRS-19/20-20347). All participants will provide informed consent to take part if eligible. Findings will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT04535778.