Just-in-time adaptive ecological momentary assessment (JITA-EMA)

Interest in just-in-time adaptive interventions (JITAI) has rapidly increased in recent years. One core challenge for JITAI is the efficient and precise measurement of tailoring variables that are used to inform the timing of momentary intervention delivery. Ecological momentary assessment (EMA) is often used for this purpose, even though EMA in its traditional form was not designed specifically to facilitate momentary interventions. In this article, we introduce just-in-time adaptive EMA (JITA-EMA) as a strategy to reduce participant response burden and decrease measurement error when EMA is used as a tailoring variable in JITAI. JITA-EMA builds on computerized adaptive testing methods developed for purposes of classification (computerized classification testing, CCT), and applies them to the classification of momentary states within individuals. The goal of JITA-EMA is to administer a small and informative selection of EMA questions needed to accurately classify an individual's current state at each measurement occasion. After illustrating the basic components of JITA-EMA (adaptively choosing the initial and subsequent items to administer, adaptively stopping item administration, accommodating dynamically tailored classification cutoffs), we present two simulation studies that explored the performance of JITA-EMA, using the example of momentary fatigue states. Compared with conventional EMA item selection methods that administered a fixed set of questions at each moment, JITA-EMA yielded more accurate momentary classification with fewer questions administered. Our results suggest that JITA-EMA has the potential to enhance some approaches to mobile health interventions by facilitating efficient and precise identification of momentary states that may inform intervention tailoring.

Effects of Group-delivered Stress-reduction Guided Imagery on Salivary Cortisol, Salivary Amylase, and Stress Mood in Urban, Predominantly Latino Adolescents

Objectives

To determine acute effects of stress-reduction guided imagery delivered in group format on stress biomarkers salivary cortisol and salivary amylase, and on self-reported stress mood, in healthy, predominantly Latino adolescents.

Study Design

111 adolescent participants (94% Latino), a subset from a large, randomized controlled lifestyle intervention to improve obesity-related health behaviors, received either 4 weekly lifestyle education sessions (Lifestyle group; LS) or the same weekly lifestyle education sessions plus an additional weekly stress-reduction guided imagery session delivered in group format (Guided imagery group; GI). Salivary cortisol, salivary amylase, and self-reported stress moods were assessed before and after sessions on intervention weeks 3 and 4. Statistics: Linear mixed effects models examined within- and between-session and group differences in pre- to post-session changes.

Results

Both groups showed decreases in salivary cortisol, 5% decrease in LS group and 32% in GI group (within-group differences all P < .05), with between-group difference in salivary cortisol of moderate size (P = .05; Cohen’s d = .44). Within the GI group alone, salivary cortisol decrease was similar following either the lifestyle or GI sessions (P = .64). There were no statistically significant amylase changes within or between groups. All 5 individual stress moods declined by 27% to 46% in the GI group (all P < .05), while only 1 of the 5 declined in LS group.

Conclusions

Group stress-reduction guided imagery reduces the stress biomarker salivary cortisol, as well as reducing subjective stress mood states, making it a viable modality for large scale stress-reduction interventions.

The Acute Relationship between Affective States and Stress Biomarkers in Ethnic Minority Youths

Background: Whether affective states acutely predict the hypothalamic–pituitary–adrenal (HPA) axis activities and whether energy balance-related behaviors moderate the affect–HPA axis relationship in obese youths are not well-understood. Methods: 87 mostly obese (94.3% obese) minority adolescents (mean: 16.3 ± 1.2 years old; 56.8% Latino and 43.2% African American) participated in a randomized crossover trial in an observation laboratory, where they received either high-sugar/low-fiber (HSLF) or low-sugar/high-fiber (LSHF) meals first and then crossed over in the next visit 2–4 weeks later. During each visit, they rated five affective states and provided a saliva sample every 30 min for the first 5 h and wore a waist-worn accelerometer. The association between the affect ratings and cortisol levels in the subsequent 30 min and the moderation effect of energy balance-related behavior were examined using multilevel models. Results: Within-person negative affect (β = 0.02, p = 0.0343) and feeling of panic (β = 0.007, p = 0.004) were acutely related to the subsequent cortisol level only during the HSLF condition. The time spent in moderate-to-vigorous physical activity did not moderate the acute relationship between affect and the subsequent cortisol level. Conclusions: Negative affect could be acutely related to heightened HPA axis activities in youths, but only when they were exposed to meals with high sugar and low fiber content. These results suggest that the meals’ sugar and fiber content may modulate HPA axis reactivity to negative affect in youths.

The mediating role of emotional eating in the relationship between perceived stress and dietary intake quality in Hispanic/Latino adolescents

Obesity rates have steadily increased over the past three decades, and large racial/ethnic disparities in childhood obesity rates-specifically for Hispanic/Latino youth-highlight the major need for identifying and examining key mechanisms of obesogenic behaviors for this at-risk population. This study investigates the relationship between stress and dietary quality in Hispanic/Latino adolescents and seeks to determine the mediating role of emotional eating as a behavioral mechanism. Baseline data from 169 adolescents enrolled in the Imagine HEALTH trial were used to investigate these relationships. Perceived stress and emotional eating were assessed with age-validated questionnaires, and dietary quality was measured via 24-hour recall dietary assessments (later calculated as individual Healthy Eating Index-2015 scores). Nonparametric bootstrapping was used to test the primary hypothesis that emotional eating partially or fully mediates the relationship between perceived stress and dietary quality in this sample, and to test the significance of the mediating effect. Results indicate that emotional eating partially mediates the relationship between perceived stress and dietary quality. The total effect of perceived stress scores on dietary quality scores was -0.24 (p = .006); the direct effect of perceived stress scores on dietary quality scores (controlling for emotional eating scores) was -0.16 (p = .107), and the mediating (indirect) effect of emotional eating was -0.09 (p = .001). The proportion of mediation was 0.36 (36%) (p = .008). This study identifies an important mechanism of obesogenic behavior and can be used to inform future obesity prevention and intervention strategies tailored for the Hispanic/Latino adolescent population.

The Effect of Training on Participant Adherence With a Reporting Time Frame for Momentary Subjective Experiences in Ecological Momentary Assessment: Cognitive Interview Study

Background

Ecological momentary assessment (EMA) has the potential to minimize recall bias by having people report on their experiences in the moment (momentary model) or over short periods (coverage model). This potential hinges on the assumption that participants provide their ratings based on the reporting time frame instructions prescribed in the EMA items. However, it is unclear what time frames participants actually use when answering the EMA questions and whether participant training improves participants’ adherence to the reporting instructions.

Objective

This study aims to investigate the reporting time frames participants used when answering EMA questions and whether participant training improves participants’ adherence to the EMA reporting timeframe instructions.

Methods

Telephone-based cognitive interviews were used to investigate the research questions. In a 2×2 factorial design, participants (n=100) were assigned to receive either basic or enhanced EMA training and randomized to rate their experiences using a momentary (at the moment you were called) or a coverage (since the last phone call) model. Participants received five calls over the course of a day to provide ratings; after each rating, participants were immediately interviewed about the time frame they used to answer the EMA questions. A total of 2 raters independently coded the momentary interview responses into time frame categories (Cohen κ=0.64, 95% CI 0.55-0.73).

Results

The results from the momentary conditions showed that most of the calls referred to the period during the call (57/199, 28.6%) or just before the call (98/199, 49.2%) to provide ratings; the remainder were from longer reporting periods. Multinomial logistic regression results indicated a significant training effect (χ²₁=16.6; P<.001) in which the enhanced training condition yielded more reports within the intended reporting time frames for momentary EMA reports. Cognitive interview data from the coverage model did not lend themselves to reliable coding and were not analyzed.

Conclusions

The results of this study provide the first evidence about adherence to EMA instructions to reporting periods and that enhanced participant training improves adherence to the time frame specified in momentary EMA studies.

Evaluating the Effect of Daily Diary Instructional Phrases on Respondents' Recall Time Frames: Survey Experiment

Background

Daily diaries are extensively used for examining participants’ daily experience in behavioral and medical science. However, little attention is paid to whether participants recall their experiences within the time frames prescribed by the task.

Objective

This study aimed to describe survey respondents’ self-reported recall time frames and to evaluate the impact of different daily diary items on respondents’ reported affective states.

Methods

In this study, 577 participants completed a mood survey with one of the following 4 time frame instructions: (1) today, (2) since waking up today, (3) during the last 24 hours, or (4) in the last day. They were also asked to indicate the periods they considered when answering these items and to recall the instructional phrases associated with the items.

Results

Almost all participants in the today (141/146, 96.6%) and since waking up today (136/145, 93.8%) conditions reported using periods consistent with our expectations, whereas a lower proportion was observed in the during the last 24 hours (100/145, 69.0%) condition. A diverse range of responses was observed in the in the last day condition. Furthermore, the instructions influenced the levels of some self-reported affects, although exploratory analyses were not able to identify the mechanism underlying this finding.

Conclusions

Overall, these results indicate that today and since waking up today are the most effective instructional phrases for inquiring about daily experience and that investigators should use caution when using the other 2 instructional phrases.

Compliance with ecological momentary assessment protocols in substance users: a meta-analysis

BACKGROUND AND AIMS

While there are considerable benefits to Ecological Momentary Assessment (EMA), poor compliance with assessment protocols has been identified as a limitation, particularly in substance users. Our aim was to identify the pooled compliance rate of EMA studies in substance users and examine variables that may influence compliance with EMA protocols, such as the length and frequency of assessments.

DESIGN

A meta-analysis and meta-regression of all possible studies (randomized controlled trials and longitudinal) which incorporated EMA protocols, examining substance use.

SETTING

Studies took place from 1998 to 2017, in numerous countries world-wide.

PARTICIPANTS

One hundred and twenty-six studies were identified, contributing a total of 19 431 participants (52.32% male, mean age = 28.86).

MEASUREMENTS

Compliance data, the proportion of responses to the study protocol, were extracted from each study alongside prompt frequency, total length of assessment period, substance use population and device used to administer EMA prompts.

FINDINGS

The pooled compliance rate across all studies was 75.06% [95% confidence interval (CI) = 72.37%, 77.65%]. There was no evidence that compliance rates were significantly associated with prompt frequency [Q(3) = 7.35, P = 0.061], length of assessment period [Q(2) = 2.40, P = 0.301], substance type [Q(3) = 6.30, P = 0.098] or device administration [Q(4) = 4.28, P = 0.369]. However, dependent samples (69.80%) had lower compliance rates than non-dependent samples [76.02%; Q(1) = 4.13, P = 0.042].

CONCLUSIONS

The pooled compliance rate for Ecological Momentary Assessment studies in substance-using populations from 1998 to 2017 was lower than the recommended rate of 80%, and was not associated with frequency or duration of assessments.

Relationships among affective states, physical activity, and sedentary behavior in children: Moderation by perceived stress

OBJECTIVE

We examined the acute bidirectional relationships between affective states and moderate-to-vigorous physical activity (MVPA) or sedentary behavior (SB) in children, and whether perceived stress moderates these associations.

METHOD

A total of 180 children (mean age = 9.6 years, 51.7% female, 53.9% Hispanic) completed a 7-day ecological momentary assessment (EMA) study, where they received 3-7 random prompts per day asking about their current affective states. MVPA and SB during this period were measured by waist-worn accelerometers. Children's and mothers' perceived stress were measured by paper questionnaires. Multilevel models tested the within-person (WP) and between-person (BP) associations of (a) MVPA and SB 30 and 60 min before an EMA prompt with subsequent affective states at the prompt, and (b) affective states at the prompt with MVPA and SB in the subsequent 30 and 60 min after the prompt. Interaction terms were used to assess whether children's and mothers' perceived stress moderated these associations.

RESULTS

Children reported a higher positive affect after engaging in more MVPA than usual (WP; β = 0.04, SE = 0.02, p < .05) and a lower positive affect after spending more SB than usual (WP; β = -0.02, SE = 0.01, p < .05) in the previous 30 min. Children's affective states were unrelated to time in MVPA and SB within the subsequent 30 min. Parent's perceived stress level attenuated the relationship between children's time spent in MVPA 60 min before a prompt and self-reported positive affect at that prompt (β = -0.01, SE = 0.01, p < .05).

CONCLUSIONS

MVPA and SB acutely impacted children's psychological well-being, with the benefits of MVPA on positive affect across longer intervals attenuated among children whose mothers had higher perceived stress. (PsycINFO Database Record

Advances and Controversies in Diet and Physical Activity Measurement in Youth

Technological advancements in the past decades have improved dietary intake and physical activity measurements. This report reviews current developments in dietary intake and physical activity assessment in youth. Dietary intake assessment has relied predominantly on self-report or image-based methods to measure key aspects of dietary intake (e.g., food types, portion size, eating occasion), which are prone to notable methodologic (e.g., recall bias) and logistic (e.g., participant and researcher burden) challenges. Although there have been improvements in automatic eating detection, artificial intelligence, and sensor-based technologies, participant input is often needed to verify food categories and portions. Current physical activity assessment methods, including self-report, direct observation, and wearable devices, provide researchers with reliable estimations for energy expenditure and bodily movement. Recent developments in algorithms that incorporate signals from multiple sensors and technology-augmented self-reporting methods have shown preliminary efficacy in measuring specific types of activity patterns and relevant contextual information. However, challenges in detecting resistance (e.g., in resistance training, weight lifting), prolonged physical activity monitoring, and algorithm (non)equivalence remain to be addressed. In summary, although dietary intake assessment methods have yet to achieve the same validity and reliability as physical activity measurement, recent developments in wearable technologies in both arenas have the potential to improve current assessment methods.

THEME INFORMATION

This article is part of a theme issue entitled Innovative Tools for Assessing Diet and Physical Activity for Health Promotion, which is sponsored by the North American branch of the International Life Sciences Institute.

Protocol for the Imagine HEALTH Study: Guided imagery lifestyle intervention to improve obesity-related behaviors and salivary cortisol patterns in predominantly Latino adolescents

Innovative lifestyle interventions are needed to reduce type 2 diabetes risk in adolescents. This report describes the protocol of the Imagine HEALTH cluster randomized control trial, that tests an intervention based in Self-Determination Theory (SDT) and uses lifestyle education combined with the mind-body, complementary health modality of guided imagery (GI), to address obesity prevention and treatment in predominantly Latino adolescents. The primary aim is to determine the unique effects of each of the three major components of the 12-week lifestyle intervention (lifestyle education, stress reduction guided imagery, and lifestyle behavior guided imagery) compared to control on primary outcomes of physical activity (accelerometry), dietary intake (3-day recall), and stress biomarker levels (salivary cortisol). Secondary aims assess changes compared to controls in psychosocial outcomes (stress, well-being, depression), diabetes-related metabolic outcomes (adiposity, insulin resistance), maintenance of outcome changes for one year post-intervention, and SDT-based mediation of intervention effects. The development and rationale for each of the intervention components, study design, and outcome measurement processes are described. Adolescent participants recruited from four urban schools are cluster randomized by school into one of four arms of the 12-week (3-month) intervention, followed by 6 months of maintenance and 6 months of no contact. Outcome measures are assessed at the end of each period (3-, 9-, and 15-months). Results to date show successful recruitment of 97% of the target study population. Future results will demonstrate the effects of this integrative intervention on primary and secondary outcome measures in adolescents at risk for lifestyle-related metabolic disease.

Life-Threatening Allergies: Using a Patient-Engaged Approach

BACKGROUND

Adolescents at risk for anaphylaxis are a growing concern. Novel training methods are needed to better prepare individuals to manage anaphylaxis in the community.

INTRODUCTION

Didactic training as the sole method of anaphylaxis education has been shown to be ineffective. We developed a smartphone-based interactive teaching tool with decision support and epinephrine auto-injector (EAI) training to provide education accessible beyond the clinic.

METHODS

This study consisted of two parts: (1) Use of food allergy scenarios to assess the decision support's ability to improve allergic reaction management knowledge. (2) An assessment of our EAI training module on participant's ability to correctly demonstrate the use of an EAI by comparing it to label instructions.

RESULTS

Twenty-two adolescents were recruited. The median (range) baseline number of correct answers on the scenarios before the intervention was 9 (3-11). All subjects improved with decision support, increasing to 11 (9-12) (p < .001). The median (range) demonstration score was 6 (5-6) for the video training module group and 4.5 (3-6) for the label group (p < 0.001).

DISCUSSION

Results suggest that the use of this novel m-health application can improve anaphylaxis symptom recognition and increase the likelihood of choosing the appropriate treatment. In addition, performing EAI steps in conjunction with the video training resulted in more accurate medication delivery with fewer missed steps compared to the use of written instructions alone.

CONCLUSION

The results suggest that mobile health decision support technology for anaphylaxis emergency preparedness may support traditional methods of training by providing improved access to anaphylaxis training in the community setting.

Compliance With Mobile Ecological Momentary Assessment Protocols in Children and Adolescents: A Systematic Review and Meta-Analysis

BACKGROUND

Mobile device-based ecological momentary assessment (mobile-EMA) is increasingly used to collect participants' data in real-time and in context. Although EMA offers methodological advantages, these advantages can be diminished by participant noncompliance. However, evidence on how well participants comply with mobile-EMA protocols and how study design factors associated with participant compliance is limited, especially in the youth literature.

OBJECTIVE

To systematically and meta-analytically examine youth's compliance to mobile-EMA protocols and moderators of participant compliance in clinical and nonclinical settings.

METHODS

Studies using mobile devices to collect EMA data among youth (age ≤18 years old) were identified. A systematic review was conducted to describe the characteristics of mobile-EMA protocols and author-reported factors associated with compliance. Random effects meta-analyses were conducted to estimate the overall compliance across studies and to explore factors associated with differences in youths' compliance.

RESULTS

This review included 42 unique studies that assessed behaviors, subjective experiences, and contextual information. Mobile phones were used as the primary mode of EMA data collection in 48% (20/42) of the reviewed studies. In total, 12% (5/42) of the studies used wearable devices in addition to the EMA data collection platforms. About half of the studies (62%, 24/42) recruited youth from nonclinical settings. Most (98%, 41/42) studies used a time-based sampling protocol. Among these studies, most (95%, 39/41) prompted youth 2-9 times daily, for a study length ranging from 2-42 days. Sampling frequency and study length did not differ between studies with participants from clinical versus nonclinical settings. Most (88%, 36/41) studies with a time-based sampling protocol defined compliance as the proportion of prompts to which participants responded. In these studies, the weighted average compliance rate was 78.3%. The average compliance rates were not different between studies with clinical (76.9%) and nonclinical (79.2%; P=.29) and studies that used only a mobile-EMA platform (77.4%) and mobile platform plus additional wearable devices (73.0%, P=.36). Among clinical studies, the mean compliance rate was significantly lower in studies that prompted participants 2-3 times (73.5%) or 4-5 times (66.9%) compared with studies with a higher sampling frequency (6+ times: 89.3%). Among nonclinical studies, a higher average compliance rate was observed in studies that prompted participants 2-3 times daily (91.7%) compared with those that prompted participants more frequently (4-5 times: 77.4%; 6+ times: 75.0%). The reported compliance rates did not differ by duration of EMA period among studies from either clinical or nonclinical settings.

CONCLUSIONS

The compliance rate among mobile-EMA studies in youth is moderate but suboptimal. Study design may affect protocol compliance differently between clinical and nonclinical participants; including additional wearable devices did not affect participant compliance. A more consistent compliance-related result reporting practices can facilitate understanding and improvement of participant compliance with EMA data collection among youth.

The Role of Assimilating to the US Culture and the Relationship Between Neighborhood Ethnic Composition and Dietary Intake Among Hispanic Youth

BACKGROUND

Dietary fiber and sugar intake have been shown to affect metabolic health in overweight Hispanic youth. Evidence on the influence of culture on fiber and sugar intake in Hispanic youth is limited.

METHODS

The associations among score for levels of assimilation, neighborhood ethnic characteristics, and daily total and added dietary sugar and dietary fiber intake were assessed using regression analyses.

RESULTS

One hundred twenty-four Hispanic youth (age = 13.6 ± 3.0, 106 female) were included. The proportion of Hispanic population in the neighborhood was positively associated with fiber intake (standardized β = 0.205, p < 0.01) and inversely associated with added (standardized β = -0.234, p < 0.01) and total sugar intake (standardized β = -0.229, p < 0.01). Youth's self-identified levels of assimilation inversely moderated (standardized β = -0.465, p = 0.036) the association between %HP and dietary fiber intake.

CONCLUSIONS

Hispanic youth residing in areas of that are predominantly populated with Hispanics may be protected from conforming to unhealthy dietary behaviors. This protective effect is weaker among Hispanic youth with higher level of assimilation.

Innovations in the Use of Interactive Technology to Support Weight Management

New and emerging mobile technologies are providing unprecedented possibilities for understanding and intervening on obesity-related behaviors in real time. However, the mobile health (mHealth) field has yet to catch up with the fast-paced development of technology. Current mHealth efforts in weight management still tend to focus mainly on short message systems (SMS) interventions, rather than taking advantage of real-time sensing to develop just-in-time adaptive interventions (JITAIs). This paper will give an overview of the current technology landscape for sensing and intervening on three behaviors that are central to weight management: diet, physical activity, and sleep. Then five studies that really dig into the possibilities that these new technologies afford will be showcased. We conclude with a discussion of hurdles that mHealth obesity research has yet to overcome and a future-facing discussion.