Mobile Intervention to Address Cannabis Use Disorder Among Black Adults: Protocol for a Randomized Controlled Trial

BACKGROUND

African American or Black (hereafter referred to as Black) adults who use cannabis use it more frequently and are more likely to meet criteria for cannabis use disorder (CUD) than both White and Hispanic or Latin individuals. Black adults may be more apt to use cannabis to cope with distress, which constitutes a false safety behavior (FSB; a behavior designed to reduce psychological distress in the short term). Although FSB engagement can perpetuate the cycle of high rates of CUD among Black individuals, limited work has applied an FSB elimination treatment approach to Black adults with CUD, and no previous work has evaluated FSB reduction or elimination in the context of a culturally tailored and highly accessible treatment developed for Black individuals.

OBJECTIVE

This study aims to develop and pilot-test a culturally tailored adaptive intervention that integrates FSB reduction or elimination skills for cannabis reduction or cessation among Black adults with probable CUD (Culturally Tailored-Mobile Integrated Cannabis and Anxiety Reduction Treatment [CT-MICART]).

METHODS

Black adults with probable CUD (N=50) will complete a web-based screener, enrollment call, baseline assessment, 3 daily ecological momentary assessments (EMAs) for 6 weeks, and a follow-up self-report assessment and qualitative interview at 6 weeks after randomization. Participants will be randomized into 1 out of the 2 conditions after baseline assessment: (1) CT-MICART+EMAs for 6 weeks or (2) EMAs only for 6 weeks.

RESULTS

The enrollment started in June 2023 and ended in November 2023. Data analysis will be completed in March 2024.

CONCLUSIONS

No culturally tailored, evidence-based treatment currently caters to the specific needs of Black individuals with CUD. This study will lay the foundation for a new approach to CUD treatment among Black adults that is easily accessible and has the potential to overcome barriers to treatment and reduce practitioner burden in order to support Black individuals who use cannabis with probable CUD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05566730; https://clinicaltrials.gov/study/NCT05566730.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52776.

Mixed amphetamine salts-extended release (MAS-ER) as a behavioral treatment augmentation strategy for cocaine use disorder: A randomized clinical trial

Psychosocial interventions remain the primary strategy for addressing cocaine use disorder (CUD), although many individuals do not benefit from these approaches. Amphetamine-based interventions have shown significant promise and may improve outcomes among individuals continuing to use cocaine in the context of behavioral interventions. One hundred forty-five adults (122 males) who used cocaine a minimum of 4 days in the prior month and met the criteria for a CUD enrolled in a two-stage intervention. All participants received a computer-delivered skills intervention and contingency management for reinforcing abstinence for a 1-month period. Participants demonstrating less than 3 weeks of abstinence in the first month were randomized to receive mixed amphetamine salts-extended release (MAS-ER) or placebo (80 mg/day) for 10 weeks under double-blind conditions. All participants continued with the behavioral intervention. The primary outcome was the proportion of individuals who achieved 3 consecutive weeks of abstinence as measured by urine toxicology confirmed self-report at the study end. The proportion of participants demonstrating 3 consecutive weeks of abstinence at study end did not differ between the medication groups: MAS-ER = 15.6% (7/45) and placebo = 12.2% (5/41). Participants who received MAS-ER reported greater reductions in the magnitude of wanting cocaine, although no group differences were noted in either the perceived improvement or the frequency of wanting cocaine. Retention rates were greater for both medication groups compared to behavioral responders. Overall, augmenting a behavioral intervention with MAS-ER did not significantly increase the abstinence rate among individuals continuing to use cocaine following a month of behavioral therapy alone. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Increasing Physical Activity in Persons With Spinal Cord Injury With an eHealth-Based Adaptive Exercise Intervention: Protocol for a Sequential Multiple Assignment Randomized Trial

BACKGROUND

Participating in an adequate amount of physical activity to acquire health benefits is challenging for people with spinal cord injury (SCI) due to personal and logistic barriers. Barriers in the built and social environments may include lack of transportation, lack of accessible facilities or programs, and lack of training among fitness personnel. Low self-efficacy, lack of self-regulation skills, and improper outcome expectations are examples of personal barriers. Current approaches to investigating physical activity programs in people with SCI have been limited to traditional "one-size-fits-all" design, which has yielded low adherence rates, high dropout rates, and participants not maintaining physical activity levels at follow-up.

OBJECTIVE

The primary aim of this study is to test the feasibility of a tele-exercise program that applies an adaptive intervention design for 30 adults with SCI, targeting increases in adherence to the exercise program and physical activity participation.

METHODS

The Sequential Multiple Assignment Randomized Trial for Home-based Exercise and Lifestyle Tele-Health (SMART-HEALTH) is a 12-week, home-based, movement-to-music (M2M) program. The goal of a SMART-designed study is to develop an adaptive intervention that modifies support provisions based on response levels. In SMART-HEALTH, 2 groups of participants will undergo 3-week and 6-week asynchronous M2M interventions in the first phase. Participants who did not achieve the desired adherence rate (≥95% of video watch minutes) will be rerandomized into M2M Live (switch) or individualized behavioral coaching (augmented with the asynchronous M2M program). The study will primarily assess rates of recruitment or enrollment, adherence and retention, timing to identify nonresponders, and scientific outcomes (eg, physical activity and exercise self-efficacy). The study will qualitatively evaluate the acceptability of the study using semistructured interviews among participants who complete the 12-week intervention.

RESULTS

Recruitment procedures started in June 2022. All data are expected to be collected by September 2023. Full trial results are expected to be published by March 2024. Secondary analyses of data will be subsequently published. Results will include exercise adherence rates; changes in self-reported physical activity levels and blood pressure; and changes in secondary conditions including pain, sleep, and fatigue. Thematic analysis of semistructured interviews will include results on participant enjoyment and acceptability of SMART-HEALTH and inform modifications for future delivery of the program.

CONCLUSIONS

This study will strengthen our understanding of the potential benefits of the tele-exercise intervention for people with SCI and build upon adaptive intervention design and its delivery strategies that aim to increase adoption and sustainable exercise behavior. This pilot trial will inform future SMART-designed studies and provide new and innovative strategies for investigating intervention effects on physical activity behavior in the SCI population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04726891; https://classic.clinicaltrials.gov/ct2/show/NCT04726891.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47665.

How Notifications Affect Engagement With a Behavior Change App: Results From a Micro-Randomized Trial

BACKGROUND

Drink Less is a behavior change app to help higher-risk drinkers in the United Kingdom reduce their alcohol consumption. The app includes a daily notification asking users to "Please complete your drinks and mood diary," yet we did not understand the causal effect of the notification on engagement nor how to improve this component of Drink Less. We developed a new bank of 30 new messages to increase users' reflective motivation to engage with Drink Less. This study aimed to determine how standard and new notifications affect engagement.

OBJECTIVE

Our objective was to estimate the causal effect of the notification on near-term engagement, to explore whether this effect changed over time, and to create an evidence base to further inform the optimization of the notification policy.

METHODS

We conducted a micro-randomized trial (MRT) with 2 additional parallel arms. Inclusion criteria were Drink Less users who consented to participate in the trial, self-reported a baseline Alcohol Use Disorders Identification Test score of ≥8, resided in the United Kingdom, were aged ≥18 years, and reported interest in drinking less alcohol. Our MRT randomized 350 new users to test whether receiving a notification, compared with receiving no notification, increased the probability of opening the app in the subsequent hour, over the first 30 days since downloading Drink Less. Each day at 8 PM, users were randomized with a 30% probability of receiving the standard message, a 30% probability of receiving a new message, or a 40% probability of receiving no message. We additionally explored time to disengagement, with the allocation of 60% of eligible users randomized to the MRT (n=350) and 40% of eligible users randomized in equal number to the 2 parallel arms, either receiving the no notification policy (n=98) or the standard notification policy (n=121). Ancillary analyses explored effect moderation by recent states of habituation and engagement.

RESULTS

Receiving a notification, compared with not receiving a notification, increased the probability of opening the app in the next hour by 3.5-fold (95% CI 2.91-4.25). Both types of messages were similarly effective. The effect of the notification did not change significantly over time. A user being in a state of already engaged lowered the new notification effect by 0.80 (95% CI 0.55-1.16), although not significantly. Across the 3 arms, time to disengagement was not significantly different.

CONCLUSIONS

We found a strong near-term effect of engagement on the notification, but no overall difference in time to disengagement between users receiving the standard fixed notification, no notification at all, or the random sequence of notifications within the MRT. The strong near-term effect of the notification presents an opportunity to target notifications to increase "in-the-moment" engagement. Further optimization is required to improve the long-term engagement.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/18690.

Adaptive interventions for opioid prescription management and consumption monitoring

OBJECTIVES

While opioid addiction, treatment, and recovery are receiving attention, not much has been done on adaptive interventions to prevent opioid use disorder (OUD). To address this, we identify opioid prescription and opioid consumption as promising targets for adaptive interventions and present a design framework.

MATERIALS AND METHODS

Using the framework, we designed Smart Prescription Management (SPM) and Smart Consumption Monitoring (SCM) interventions. The interventions are evaluated using analytical modeling and secondary data on doctor shopping, opioid overdose, prescription quality, and cost components.

RESULTS

SPM was most effective (30-90% improvement, for example, prescriptions reduced from 18 to 1.8 per patient) for extensive doctor shopping and reduced overdose events and mortality. Opioid adherence was improved and the likelihood of addiction declined (10-30%) as the response rate to SCM was increased. There is the potential for significant incentives ($2267-$3237) to be offered for addressing severe OUD.

DISCUSSION

The framework and designed interventions adapt to changing needs and conditions of the patients to become an important part of global efforts in preventing OUD. To the best of our knowledge, this is the first paper on adaptive interventions for preventing OUD by addressing both prescription and consumption.

CONCLUSION

SPM and SCM improved opioid prescription and consumption while reducing the risk of opioid addiction. These interventions will assist in better prescription decisions and in managing opioid consumption leading to desirable outcomes. The interventions can be extended to other substance use disorders and to study complex scenarios of prescription and nonprescription opioids in clinical studies.

The Independent Walking for Brain Health Intervention for Older Adults: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Extensive research suggests that physical activity (PA) is important for brain and cognitive health and may help to delay or prevent Alzheimer's disease and related dementias. Most PA interventions designed to improve brain health in older adults have been conducted in laboratory, gym, or group settings that require extensive resources and travel to the study site or group sessions. Research is needed to develop novel interventions that leverage mobile health (mHealth) technologies to help older adults increase their engagement in PA in free-living environments, reducing participant burden and increasing generalizability of research findings. Moreover, promoting engagement in moderate-to-vigorous PA (MVPA) may be most beneficial to brain health; thus, using mHealth to help older adults increase time spent in MVPA in free-living environments may help to offset the burden of Alzheimer's disease and related dementias and improve quality of life in older age.

OBJECTIVE

We developed a novel PA intervention that leverages mHealth to help older adults achieve more minutes of MVPA independently. This pilot study was a 12-week randomized controlled trial to investigate the feasibility of providing just-in-time (JIT) feedback about PA intensity during free-living exercise sessions to help older adults meet current PA recommendations (150 minutes per week of MVPA).

METHODS

Participants were eligible if they were cognitively healthy English speakers aged between 65 and 80 years without major cardiovascular, neurologic, or mental health conditions; could ambulate independently; and undergo magnetic resonance imaging. Enrollment occurred from October 2017 to March 2020. Participants randomized to the PA condition received an individualized exercise prescription and an mHealth device that provided heart rate-based JIT feedback on PA intensity, allowing them to adjust their behavior in real time to maintain MVPA during exercise sessions. Participants assigned to the healthy aging education condition received a reading prescription consisting of healthy aging topics and completed weekly quizzes based on the materials.

RESULTS

In total, 44 participants were randomized to the intervention. A follow-up manuscript will describe the results of the intervention as well as discuss screening, recruitment, adverse events, and participants' opinions regarding their participation in the intervention.

CONCLUSIONS

The long-term goal of this intervention is to better understand how MVPA affects brain and cognitive health in the real world and extend laboratory findings to everyday life. This pilot randomized controlled trial was conducted to determine the feasibility of using JIT heart rate zone feedback to help older adults independently increase time spent in MVPA while collecting data on the plausible mechanisms of change (frontal and medial temporal cerebral blood flow and cardiorespiratory fitness) that may affect cognition (memory and executive function) to help refine a planned stage 2 behavioral trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03058146; https://clinicaltrials.gov/ct2/show/NCT03058146.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42980.

Design and Evaluation of a Just-in-Time Adaptive Intervention (JITAI) to Reduce Sedentary Behavior at Work: Experimental Study

Background

Employees in sedentary occupations tend to spend prolonged hours physically inactive. Physical inactivity is a main factor in the increase in the risks of a wide range of chronic diseases, including obesity, diabetes, hypertension, and heart disease. This has drawn researchers’ attention to investigate methods of increasing the level of activity of employees during working hours and in their daily lifestyle.

Objective

The objective of this paper is to investigate the effectiveness of using personalized messages that include user information, user goals, daily routine, and the surrounding environment to increase the level of activity among employees. In this study, we hypothesize that sending context-aware motivational messages to workers in sedentary occupations after sitting for 40 minutes can break sedentary behavior and increase daily active time compared to static reminder messages.

Methods

A 66-day between-group study using a mixed methods design approach was conducted with employees who are located in Qatar and spend most of their working day sedentary. The 58 participants used 2 different interventions: The control group (n=29, 50%) used a mobile app that only sends a static message after prolonged sitting (MotiFit Lite), and the intervention group (n=29, 50%) used a mobile app that sends context-aware personalized messages to promote physical activity (PA; MotiFit). Both apps log the received messages, the step count before and after the messages are sent, and the user response to the messages to obtain an idea of the impact of the messages. The study received approval from the Qatar Biomedical Research Institute’s institutional review board (IRB application #2019-10-037).

Results

The questionnaires showed satisfaction of the designed apps’ subjective quality and perceived impact. The quantitative analysis showed a high level of engagement in the intervention group compared to the control group (P<.001). The results support the original hypothesis that using context-aware motivational messages can increase PA at work compared to static messages (P<.001). However, the analysis showed no significant impact of the message type on the overall activity level during the day (P=.06).

Conclusions

Context-aware motivational messages motivate employees to increase their PA in the workplace. However, future research will further develop the analysis to investigate the impact on increasing the overall activity level during the day.

Sequential multiple assignment randomized trial studies should report all key components: a systematic review

OBJECTIVE

Sequential Multiple Assignment Randomised Trial (SMART) designs allow multiple randomisations of participants; this allows assessment of stage-specific questions (individual randomisations) and adaptive interventions (i.e. treatment strategies). We assessed the quality of reporting of the information required to design SMART studies.

STUDY DESIGN AND SETTING

We systematically searched four databases (PubMed, Ovid, Web of Science and Scopus) for all trial reports, protocols, reviews, and methodological papers which mentioned SMART designs up to June 15, 2020.

RESULTS

Of the 157 selected records, 12 (7.64%) were trial reports, 24 (15.29%) were study protocols, 91 (58%) were methodological papers, and 30 (19.1%) were review papers. All these trials were powered using stage-specific aims. Only four (33.33%) of these trials reported parameters required for sample size calculations. A small number of the trials (16.67 %) were interested in determining the best embedded adaptive interventions. Most of the trials did not report information about multiple testing adjustment. Furthermore, most of records reported designs that were mainly focused on stage-specific aims.

CONCLUSIONS

Some features of SMART designs are seldomly reported and/or used. Furthermore, studies using this design tend to not adequately report information about all the design parameters, limiting their transparency and interpretability.

[Research Progress of Adaptive Intervention]

Adaptive intervention(AI)is a methodology which dynamically evaluates adaptive variables at decision points and timely adjusts and develops tailored strategies to meet individual needs.The study reviewed the origin and development and elaborated the core elements(including intervention outcomes,intervention options,decision points,tailoring variables,and decision rules)and the classification of AI.Based on the literature,the key points of the design and implementation of AI were prospected,which can provide evidence for the research and development of health behavior intervention.

Adaptive intervention for prevention of adolescent suicidal behavior after hospitalization: a pilot sequential multiple assignment randomized trial

BACKGROUND

The need for effective interventions for psychiatrically hospitalized adolescents who have varying levels of postdischarge suicide risk calls for personalized approaches, such as adaptive interventions (AIs). We conducted a nonrestricted pilot Sequential, Multiple Assignment, Randomized Trial (SMART) to guide the development of an AI targeting suicide risk after hospitalization.

METHODS

Adolescent inpatients (N = 80; ages 13-17; 67.5% female) were randomized in Phase 1 to a Motivational Interview-Enhanced Safety Plan (MI-SP), delivered during hospitalization, alone or in combination with postdischarge text-based support (Texts). Two weeks after discharge, participants were re-randomized in Phase 2 to added telephone booster calls or to no calls. Mechanisms of change were assessed with daily diaries for four weeks and over a 1- and 3-month follow-up. This trial is registered with clinicaltrials.gov (identifier: NCT03838198).

RESULTS

Procedures were feasible and acceptable. Mixed effects models indicate that adolescents randomized to MI-SP + Texts (Phase 1) and those randomized to booster calls (Phase 2) experienced significant improvement in daily-level mechanisms, including safety plan use, self-efficacy to refrain from suicidal action, and coping by support seeking. Those randomized to MI-SP + Texts also reported significantly higher coping self-efficacy at 1 and 3 months. Although exploratory, results were in the expected direction for MI-SP + Texts, versus MI-SP alone, in terms of lower risk of suicide attempts (Hazard ratio = 0.30; 95% CI = 0.06, 1.48) and suicidal behavior (Hazard ratio = 0.36; 95% CI = 0.10, 1.37) three months after discharge. Moreover, augmentation with booster calls did not have an overall meaningful impact on suicide attempts (Hazard ratio = 0.65; 95% CI = 0.17, 3.05) or suicidal behavior (Hazard ratio = 0.78; 95% CI = 0.23, 2.67); however, boosters benefited most those initially assigned to MI-SP + Texts.

CONCLUSIONS

The current SMART was feasible and acceptable for the purpose of informing an AI for suicidal adolescents, warranting additional study. Findings also indicate that postdischarge text-based support offers a promising augmentation to safety planning delivered during hospitalization.

Effects of Goal Type and Reinforcement Type on Self-Reported Domain-Specific Walking Among Inactive Adults: 2×2 Factorial Randomized Controlled Trial

Background

WalkIT Arizona was a 2×2 factorial trial examining the effects of goal type (adaptive versus static) and reinforcement type (immediate versus delayed) to increase moderate to vigorous physical activity (MVPA) among insufficiently active adults. The 12-month intervention combined mobile health (mHealth) technology with behavioral strategies to test scalable population-health approaches to increasing MVPA. Self-reported physical activity provided domain-specific information to help contextualize the intervention effects.

Objective

The aim of this study was to report on the secondary outcomes of self-reported walking for transportation and leisure over the course of the 12-month WalkIT intervention.

Methods

A total of 512 participants aged 19 to 60 years (n=330 [64.5%] women; n=425 [83%] Caucasian/white, n=96 [18.8%] Hispanic/Latinx) were randomized into interventions based on type of goals and reinforcements. The International Physical Activity Questionnaire-long form assessed walking for transportation and leisure at baseline, and at 6 months and 12 months of the intervention. Negative binomial hurdle models were used to examine the effects of goal and reinforcement type on (1) odds of reporting any (versus no) walking/week and (2) total reported minutes of walking/week, adjusted for neighborhood walkability and socioeconomic status. Separate analyses were conducted for transportation and leisure walking, using complete cases and multiple imputation.

Results

All intervention groups reported increased walking at 12 months relative to baseline. Effects of the intervention differed by domain: a significant three-way goal by reinforcement by time interaction was observed for total minutes of leisure walking/week, whereas time was the only significant factor that contributed to transportation walking. A sensitivity analysis indicated minimal differences between complete case analysis and multiple imputation.

Conclusions

This study is the first to report differential effects of adaptive versus static goals for self-reported walking by domain. Results support the premise that individual-level PA interventions are domain- and context-specific and may be helpful in guiding further intervention refinement.

Trial Registration

Preregistered at clinicaltrials.gov: (NCT02717663) https://clinicaltrials.gov/ct2/show/NCT02717663

International Registered Report Identifier (IRRID)

RR2-10.1016/j.cct.2019.05.001

Interventions to Reduce Unhealthy Alcohol Use among Primary Care Patients with HIV: the Health and Motivation Randomized Clinical Trial

BACKGROUND

Unhealthy alcohol use has adverse effects on HIV treatment. Screening, brief intervention, and referral to treatment (SBIRT) has some evidence of efficacy but may not be sufficient for those with low motivation or comorbid substance use.

OBJECTIVE

To examine the effectiveness of motivational interviewing (MI) and emailed feedback (EF) among primary care HIV-positive patients, compared with treatment as usual care (UC) only, which included SBIRT.

DESIGN

Randomized clinical trial.

PARTICIPANTS

Six hundred fourteen adult HIV-positive patients in Kaiser Permanente Northern California who reported prior-year unhealthy alcohol use.

INTERVENTION

Participants were randomized to either three sessions of MI (one in person and two by phone), information regarding alcohol risks via EF through a patient portal, or UC alone. MI and EF participants who reported unhealthy alcohol use at 6 months were offered additional MI and EF treatment, respectively.

MAIN MEASURES

Participant-reported unhealthy alcohol use (defined as ≥ 4/≥ 5 drinks per day for women/men), alcohol problems at 12 months, based on blinded telephone interviews. Secondary outcomes included drug use and antiretroviral (ART) adherence.

KEY RESULTS

At 12 months, there were no overall group differences, but in all three arms, there were declines in unhealthy alcohol use and alcohol-related problems (p < 0.001). Participants reporting low motivation to reduce drinking at baseline were less likely to report unhealthy alcohol use if they received MI vs. EF and UC (p = 0.013). At 6 months, reported illegal drug use/misuse of prescription drugs other than marijuana was lower in the MI arm than EF or UC (p = 0.012). There were no differences in ART adherence between groups.

CONCLUSIONS

In a randomized trial of HIV-positive patients using two behavioral interventions compared with SBIRT alone, participants in all three conditions reduced unhealthy alcohol use. MI may provide added benefit for patients with low motivation or who report illegal drug use/misuse of prescription drugs.

TRIAL REGISTRATION

NCT01671501 ( ClinicalTrials.gov ).

Urban Nature Experiences Reduce Stress in the Context of Daily Life Based on Salivary Biomarkers

Stress reduction through contact with nature is well established, but far less is known about the contribution of contact parameters - duration, frequency, and nature quality. This study describes the relationship between duration of a nature experience (NE), and changes in two physiological biomarkers of stress - salivary cortisol and alpha-amylase. It is the first study to employ long-term, repeated-measure assessment and the first evaluation wherein study participants are free to choose the time of day, duration, and the place of a NE in response to personal preference and changing daily schedules. During an 8-week study period, 36 urban dwellers were asked to have a NE, defined as spending time in an outdoor place that brings a sense of contact with nature, at least three times a week for a duration of 10 min or more. Their goal was compliance within the context of unpredictable opportunity for taking a nature pill. Participants provided saliva samples before and after a NE at four points over the study period. Before-NE samples established the diurnal trajectory of each stress indicator and these were in line with published outcomes of more closely controlled experiments. For salivary cortisol, an NE produced a 21.3%/hour drop beyond that of the hormone's 11.7% diurnal drop. The efficiency of a nature pill per time expended was greatest between 20 and 30 min, after which benefits continued to accrue, but at a reduced rate. For salivary alpha-amylase, there was a 28.1%/h drop after adjusting for its diurnal rise of 3.5%/h, but only for participants that were least active sitting or sitting with some walking. Activity type did not influence cortisol response. The methods for this adaptive management study of nature-based restoration break new ground in addressing some complexities of measuring an effective nature dose in the context of normal daily life, while bypassing the limitations of a clinical pharmacology dose-response study. The results provide a validated starting point for healthcare practitioners prescribing a nature pill to those in their care. This line of inquiry is timely in light of expanding urbanization and rising healthcare costs.

Individually Tailored, Adaptive Intervention to Manage Gestational Weight Gain: Protocol for a Randomized Controlled Trial in Women With Overweight and Obesity

Background

High gestational weight gain is a major public health concern as it independently predicts adverse maternal and infant outcomes. Past interventions have had only limited success in effectively managing pregnancy weight gain, especially among women with overweight and obesity. Well-designed interventions are needed that take an individualized approach and target unique barriers to promote healthy weight gain.

Objective

The primary aim of the study is to describe the study protocol for Healthy Mom Zone, an individually tailored, adaptive intervention for managing weight in pregnant women with overweight and obesity.

Methods

The Healthy Mom Zone Intervention, based on theories of planned behavior and self-regulation and a model of energy balance, includes components (eg, education, self-monitoring, physical activity/healthy eating behaviors) that are adapted over the intervention (ie, increase in intensity) to better regulate weight gain. Decision rules inform when to adapt the intervention. In this randomized controlled trial, women are randomized to the intervention or standard care control group. The intervention is delivered from approximately 8-36 weeks gestation and includes step-ups in dosages (ie, Step-up 1 = education + physical activity + healthy eating active learning [cooking/recipes]; Step-up 2 = Step-up 1 + portion size, physical activity; Step-up 3 = Step-up 1 + 2 + grocery store feedback, physical activity); 5 maximum adaptations. Study measures are obtained at pre- and postintervention as well as daily (eg, weight), weekly (eg, energy intake/expenditure), and monthly (eg, psychological) over the study period. Analyses will include linear mixed-effects models, generalized estimating equations, and dynamical modeling to understand between-group and within-individual effects of the intervention on weight gain.

Results

Recruitment of 31 pregnant women with overweight and obesity has occurred from January 2016 through July 2017. Baseline data have been collected for all participants. To date, 24 participants have completed the intervention and postintervention follow-up assessments, 3 are currently in progress, 1 dropped out, and 3 women had early miscarriages and are no longer active in the study. Of the 24 participants, 13 women have completed the intervention to date, of which 1 (8%, 1/13) received only the baseline intervention, 3 (23%, 3/13) received baseline + step-up 1, 6 (46%, 6/13) received baseline + step-up 1 + step-up 2, and 3 (23%, 3/13) received baseline + step-up 1 + step-up 2 +step-up 3. Data analysis is still ongoing through spring 2018.

Conclusions

This is one of the first intervention studies to use an individually tailored, adaptive design to manage weight gain in pregnancy. Results from this study will be useful in designing a larger randomized trial to examine efficacy of this intervention and developing strategies for clinical application.

Registered Report Identifier

RR1-10.2196/9220

Augmented outcome-weighted learning for estimating optimal dynamic treatment regimens

Dynamic treatment regimens (DTRs) are sequential treatment decisions tailored by patient's evolving features and intermediate outcomes at each treatment stage. Patient heterogeneity and the complexity and chronicity of many diseases call for learning optimal DTRs that can best tailor treatment according to each individual's time-varying characteristics (eg, intermediate response over time). In this paper, we propose a robust and efficient approach referred to as Augmented Outcome-weighted Learning (AOL) to identify optimal DTRs from sequential multiple assignment randomized trials. We improve previously proposed outcome-weighted learning to allow for negative weights. Furthermore, to reduce the variability of weights for numeric stability and improve estimation accuracy, in AOL, we propose a robust augmentation to the weights by making use of predicted pseudooutcomes from regression models for Q-functions. We show that AOL still yields Fisher-consistent DTRs even if the regression models are misspecified and that an appropriate choice of the augmentation guarantees smaller stochastic errors in value function estimation for AOL than the previous outcome-weighted learning. Finally, we establish the convergence rates for AOL. The comparative advantage of AOL over existing methods is demonstrated through extensive simulation studies and an application to a sequential multiple assignment randomized trial for major depressive disorder.

Adaptive Interventions and SMART Designs: Application to child behavior research in a community setting

Heterogeneity between and within people necessitates the need for sequential personalized interventions to optimize individual outcomes. Personalized or adaptive interventions (AIs) are relevant for diseases and maladaptive behavioral trajectories when one intervention is not curative and success of a subsequent intervention may depend on individual characteristics or response. AIs may be applied to medical settings and to investigate best prevention, education, and community-based practices. AIs can begin with low-cost or low-burden interventions and followed with intensified or alternative interventions for those who need it most. AIs that guide practice over the course of a disease, program, or school year can be investigated through sequential multiple assignment randomized trials (SMARTs). To promote the use of SMARTs, we provide a hypothetical SMART in a Head Start program to address child behavior problems. We describe the advantages and limitations of SMARTs, particularly as they may be applied to the field of evaluation.

Comparing dynamic treatment regimes using repeated-measures outcomes: modeling considerations in SMART studies

A dynamic treatment regime (DTR) is a sequence of decision rules, each of which recommends a treatment based on a patient's past and current health status. Sequential, multiple assignment, randomized trials (SMARTs) are multi-stage trial designs that yield data specifically for building effective DTRs. Modeling the marginal mean trajectories of a repeated-measures outcome arising from a SMART presents challenges, because traditional longitudinal models used for randomized clinical trials do not take into account the unique design features of SMART. We discuss modeling considerations for various forms of SMART designs, emphasizing the importance of considering the timing of repeated measures in relation to the treatment stages in a SMART. For illustration, we use data from three SMART case studies with increasing level of complexity, in autism, child attention deficit hyperactivity disorder, and adult alcoholism. In all three SMARTs, we illustrate how to accommodate the design features along with the timing of the repeated measures when comparing DTRs based on mean trajectories of the repeated-measures outcome.

Protocol: Adaptive Implementation of Effective Programs Trial (ADEPT): cluster randomized SMART trial comparing a standard versus enhanced implementation strategy to improve outcomes of a mood disorders program

BACKGROUND

Despite the availability of psychosocial evidence-based practices (EBPs), treatment and outcomes for persons with mental disorders remain suboptimal. Replicating Effective Programs (REP), an effective implementation strategy, still resulted in less than half of sites using an EBP. The primary aim of this cluster randomized trial is to determine, among sites not initially responding to REP, the effect of adaptive implementation strategies that begin with an External Facilitator (EF) or with an External Facilitator plus an Internal Facilitator (IF) on improved EBP use and patient outcomes in 12 months.

METHODS/DESIGN

This study employs a sequential multiple assignment randomized trial (SMART) design to build an adaptive implementation strategy. The EBP to be implemented is life goals (LG) for patients with mood disorders across 80 community-based outpatient clinics (N = 1,600 patients) from different U.S. regions. Sites not initially responding to REP (defined as < 50% patients receiving ≥ 3 EBP sessions) will be randomized to receive additional support from an EF or both EF/IF. Additionally, sites randomized to EF and still not responsive will be randomized to continue with EF alone or to receive EF/IF. The EF provides technical expertise in adapting LG in routine practice, whereas the on-site IF has direct reporting relationships to site leadership to support LG use in routine practice. The primary outcome is mental health-related quality of life; secondary outcomes include receipt of LG sessions, mood symptoms, implementation costs, and organizational change.

DISCUSSION

This study design will determine whether an off-site EF alone versus the addition of an on-site IF improves EBP uptake and patient outcomes among sites that do not respond initially to REP. It will also examine the value of delaying the provision of EF/IF for sites that continue to not respond despite EF.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02151331.

A "SMART" design for building individualized treatment sequences

Interventions often involve a sequence of decisions. For example, clinicians frequently adapt the intervention to an individual's outcomes. Altering the intensity and type of intervention over time is crucial for many reasons, such as to obtain improvement if the individual is not responding or to reduce costs and burden when intensive treatment is no longer necessary. Adaptive interventions utilize individual variables (severity, preferences) to adapt the intervention and then dynamically utilize individual outcomes (response to treatment, adherence) to readapt the intervention. The Sequential Multiple Assignment Randomized Trial (SMART) provides high-quality data that can be used to construct adaptive interventions. We review the SMART and highlight its advantages in constructing and revising adaptive interventions as compared to alternative experimental designs. Selected examples of SMART studies are described and compared. A data analysis method is provided and illustrated using data from the Extending Treatment Effectiveness of Naltrexone SMART study.

Adapting judicial supervision to the risk level of drug offenders: discharge and 6-month outcomes from a prospective matching study

This article reports recent findings from a program of experimental research examining the effects of adapting judicial supervision to the risk level of drug-abusing offenders. Prior studies revealed that high-risk participants with (1) antisocial personality disorder or (2) a history of drug abuse treatment performed significantly better in drug court when they were scheduled to attend frequent, bi-weekly judicial status hearings in court. Low-risk participants performed equivalently regardless of the schedule of court hearings. The current study prospectively matched misdemeanor drug court clients to the optimal schedule of court hearings based upon an assessment of their risk status, and compared outcomes to those of clients randomly assigned to the standard schedule of court hearings. Results confirmed that high-risk participants graduated at a higher rate, provided more drug-negative urine specimens at 6 months post-admission, and reported significantly less drug use and alcohol intoxication at 6 months post-admission when they were matched to bi-weekly hearings as compared to the usual schedule of hearings. These findings yield practical information for enhancing the efficacy and cost-efficiency of drug court services. Directions for future research on adaptive programming for drug offenders are discussed.