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1. The Digital Marshmallow Test (DMT) Diagnostic and Monitoring Mobile Health App for Impulsive Behavior: Development and Validation Study

   https://doi.org/10.2196/25018  

   Sobolev, Michael ; Vitale, Rachel ; Wen, Hongyi ; Kizer, James ; Leeman, Robert ; Pollak, J P ; Baumel, Amit ; Vadhan, Nehal P ; Estrin, Deborah ; Muench, Frederick ( January 2021 , JMIR mHealth and uHealth)

   null (Ed.)

   Background The classic Marshmallow Test, where children were offered a choice between one small but immediate reward (eg, one marshmallow) or a larger reward (eg, two marshmallows) if they waited for a period of time, instigated a wealth of research on the relationships among impulsive responding, self-regulation, and clinical and life outcomes. Impulsivity is a hallmark feature of self-regulation failures that lead to poor health decisions and outcomes, making understanding and treating impulsivity one of the most important constructs to tackle in building a culture of health. Despite a large literature base, impulsivity measurement remains difficult due to the multidimensional nature of the construct and limited methods of assessment in daily life. Mobile devices and the rise of mobile health (mHealth) have changed our ability to assess and intervene with individuals remotely, providing an avenue for ambulatory diagnostic testing and interventions. Longitudinal studies with mobile devices can further help to understand impulsive behaviors and variation in state impulsivity in daily life. Objective The aim of this study was to develop and validate an impulsivity mHealth diagnostics and monitoring app called Digital Marshmallow Test (DMT) using both the Apple and Android platforms for widespread dissemination to researchers, clinicians, and the general public. Methods The DMT app was developed using Apple’s ResearchKit (iOS) and Android’s ResearchStack open source frameworks for developing health research study apps. The DMT app consists of three main modules: self-report, ecological momentary assessment, and active behavioral and cognitive tasks. We conducted a study with a 21-day assessment period (N=116 participants) to validate the novel measures of the DMT app. Results We used a semantic differential scale to develop self-report trait and momentary state measures of impulsivity as part of the DMT app. We identified three state factors (inefficient, thrill seeking, and intentional) that correlated highly with established measures of impulsivity. We further leveraged momentary semantic differential questions to examine intraindividual variability, the effect of daily life, and the contextual effect of mood on state impulsivity and daily impulsive behaviors. Our results indicated validation of the self-report sematic differential and related results, and of the mobile behavioral tasks, including the Balloon Analogue Risk Task and Go-No-Go task, with relatively low validity of the mobile Delay Discounting task. We discuss the design implications of these results to mHealth research. Conclusions This study demonstrates the potential for assessing different facets of trait and state impulsivity during everyday life and in clinical settings using the DMT mobile app. The DMT app can be further used to enhance our understanding of the individual facets that underlie impulsive behaviors, as well as providing a promising avenue for digital interventions. Trial Registration ClinicalTrials.gov NCT03006653; https://www.clinicaltrials.gov/ct2/show/NCT03006653 

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2. Investigating Receptivity and Affect Using Machine Learning: Ecological Momentary Assessment and Wearable Sensing Study

   https://doi.org/10.2196/46347  

   King, Zachary D ; Yu, Han ; Vaessen, Thomas ; Myin-Germeys, Inez ; Sano, Akane ( January 2024 , JMIR mHealth and uHealth)

   As mobile health (mHealth) studies become increasingly productive owing to the advancements in wearable and mobile sensor technology, our ability to monitor and model human behavior will be constrained by participant receptivity. Many health constructs are dependent on subjective responses, and without such responses, researchers are left with little to no ground truth to accompany our ever-growing biobehavioral data. This issue can significantly impact the quality of a study, particularly for populations known to exhibit lower compliance rates. To address this challenge, researchers have proposed innovative approaches that use machine learning (ML) and sensor data to modify the timing and delivery of surveys. However, an overarching concern is the potential introduction of biases or unintended influences on participants’ responses when implementing new survey delivery methods.

   This study aims to demonstrate the potential impact of an ML-based ecological momentary assessment (EMA) delivery system (using receptivity as the predictor variable) on the participants’ reported emotional state. We examine the factors that affect participants’ receptivity to EMAs in a 10-day wearable and EMA–based emotional state–sensing mHealth study. We study the physiological relationships indicative of receptivity and affect while also analyzing the interaction between the 2 constructs.

   We collected data from 45 healthy participants wearing 2 devices measuring electrodermal activity, accelerometer, electrocardiography, and skin temperature while answering 10 EMAs daily, containing questions about perceived mood. Owing to the nature of our constructs, we can only obtain ground truth measures for both affect and receptivity during responses. Therefore, we used unsupervised and supervised ML methods to infer affect when a participant did not respond. Our unsupervised method used k-means clustering to determine the relationship between physiology and receptivity and then inferred the emotional state during nonresponses. For the supervised learning method, we primarily used random forest and neural networks to predict the affect of unlabeled data points as well as receptivity.

   Our findings showed that using a receptivity model to trigger EMAs decreased the reported negative affect by >3 points or 0.29 SDs in our self-reported affect measure, scored between 13 and 91. The findings also showed a bimodal distribution of our predicted affect during nonresponses. This indicates that this system initiates EMAs more commonly during states of higher positive emotions.

   Our results showed a clear relationship between affect and receptivity. This relationship can affect the efficacy of an mHealth study, particularly those that use an ML algorithm to trigger EMAs. Therefore, we propose that future work should focus on a smart trigger that promotes EMA receptivity without influencing affect during sampled time points.

    

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3. Physician Stress During Electronic Health Record Inbox Work: In Situ Measurement With Wearable Sensors

   https://doi.org/10.2196/24014  

   Akbar, Fatema ; Mark, Gloria ; Prausnitz, Stephanie ; Warton, E Margaret ; East, Jeffrey A ; Moeller, Mark F ; Reed, Mary E ; Lieu, Tracy A ( January 2021 , JMIR Medical Informatics)

   null (Ed.)

   Background Increased work through electronic health record (EHR) messaging is frequently cited as a factor of physician burnout. However, studies to date have relied on anecdotal or self-reported measures, which limit the ability to match EHR use patterns with continuous stress patterns throughout the day. Objective The aim of this study is to collect EHR use and physiologic stress data through unobtrusive means that provide objective and continuous measures, cluster distinct patterns of EHR inbox work, identify physicians’ daily physiologic stress patterns, and evaluate the association between EHR inbox work patterns and physician physiologic stress. Methods Physicians were recruited from 5 medical centers. Participants (N=47) were given wrist-worn devices (Garmin Vivosmart 3) with heart rate sensors to wear for 7 days. The devices measured physiological stress throughout the day based on heart rate variability (HRV). Perceived stress was also measured with self-reports through experience sampling and a one-time survey. From the EHR system logs, the time attributed to different activities was quantified. By using a clustering algorithm, distinct inbox work patterns were identified and their associated stress measures were compared. The effects of EHR use on physician stress were examined using a generalized linear mixed effects model. Results Physicians spent an average of 1.08 hours doing EHR inbox work out of an average total EHR time of 3.5 hours. Patient messages accounted for most of the inbox work time (mean 37%, SD 11%). A total of 3 patterns of inbox work emerged: inbox work mostly outside work hours, inbox work mostly during work hours, and inbox work extending after hours that were mostly contiguous to work hours. Across these 3 groups, physiologic stress patterns showed 3 periods in which stress increased: in the first hour of work, early in the afternoon, and in the evening. Physicians in group 1 had the longest average stress duration during work hours (80 out of 243 min of valid HRV data; P=.02), as measured by physiological sensors. Inbox work duration, the rate of EHR window switching (moving from one screen to another), the proportion of inbox work done outside of work hours, inbox work batching, and the day of the week were each independently associated with daily stress duration (marginal R2=15%). Individual-level random effects were significant and explained most of the variation in stress (conditional R2=98%). Conclusions This study is among the first to demonstrate associations between electronic inbox work and physiological stress. We identified 3 potentially modifiable factors associated with stress: EHR window switching, inbox work duration, and inbox work outside work hours. Organizations seeking to reduce physician stress may consider system-based changes to reduce EHR window switching or inbox work duration or the incorporation of inbox management time into work hours. 

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4. A Technology-Based Pregnancy Health and Wellness Intervention (Two Happy Hearts): Case Study

   https://doi.org/10.2196/30991  

   Jimah, Tamara ; Borg, Holly ; Kehoe, Priscilla ; Pimentel, Pamela ; Turner, Arlene ; Labbaf, Sina ; Asgari Mehrabadi, Milad ; Rahmani, Amir M. ; Dutt, Nikil ; Guo, Yuqing ( January 2021 , JMIR Formative Research)

   Background The physical and emotional well-being of women is critical for healthy pregnancy and birth outcomes. The Two Happy Hearts intervention is a personalized mind-body program coached by community health workers that includes monitoring and reflecting on personal health, as well as practicing stress management strategies such as mindful breathing and movement. Objective The aims of this study are to (1) test the daily use of a wearable device to objectively measure physical and emotional well-being along with subjective assessments during pregnancy, and (2) explore the user’s engagement with the Two Happy Hearts intervention prototype, as well as understand their experiences with various intervention components. Methods A case study with a mixed design was used. We recruited a 29-year-old woman at 33 weeks of gestation with a singleton pregnancy. She had no medical complications or physical restrictions, and she was enrolled in the Medi-Cal public health insurance plan. The participant engaged in the Two Happy Hearts intervention prototype from her third trimester until delivery. The Oura smart ring was used to continuously monitor objective physical and emotional states, such as resting heart rate, resting heart rate variability, sleep, and physical activity. In addition, the participant self-reported her physical and emotional health using the Two Happy Hearts mobile app–based 24-hour recall surveys (sleep quality and level of physical activity) and ecological momentary assessment (positive and negative emotions), as well as the Perceived Stress Scale, Center for Epidemiologic Studies Depression Scale, and State-Trait Anxiety Inventory. Engagement with the Two Happy Hearts intervention was recorded via both the smart ring and phone app, and user experiences were collected via Research Electronic Data Capture satisfaction surveys. Objective data from the Oura ring and subjective data on physical and emotional health were described. Regression plots and Pearson correlations between the objective and subjective data were presented, and content analysis was performed for the qualitative data. Results Decreased resting heart rate was significantly correlated with increased heart rate variability (r=–0.92, P<.001). We found significant associations between self-reported responses and Oura ring measures: (1) positive emotions and heart rate variability (r=0.54, P<.001), (2) sleep quality and sleep score (r=0.52, P<.001), and (3) physical activity and step count (r=0.77, P<.001). In addition, deep sleep appeared to increase as light and rapid eye movement sleep decreased. The psychological measures of stress, depression, and anxiety appeared to decrease from baseline to post intervention. Furthermore, the participant had a high completion rate of the components of the Two Happy Hearts intervention prototype and shared several positive experiences, such as an increased self-efficacy and a normal delivery. Conclusions The Two Happy Hearts intervention prototype shows promise for potential use by underserved pregnant women. 

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5. GLOBEM: Cross-Dataset Generalization of Longitudinal Human Behavior Modeling

   https://doi.org/10.1145/3569485  

   Xu, Xuhai ; Liu, Xin ; Zhang, Han ; Wang, Weichen ; Nepal, Subigya ; Sefidgar, Yasaman ; Seo, Woosuk ; Kuehn, Kevin S. ; Huckins, Jeremy F. ; Morris, Margaret E. ; et al ( December 2022 , Proceedings of the ACM on Interactive, Mobile, Wearable and Ubiquitous Technologies)

   There is a growing body of research revealing that longitudinal passive sensing data from smartphones and wearable devices can capture daily behavior signals for human behavior modeling, such as depression detection. Most prior studies build and evaluate machine learning models using data collected from a single population. However, to ensure that a behavior model can work for a larger group of users, its generalizability needs to be verified on multiple datasets from different populations. We present the first work evaluating cross-dataset generalizability of longitudinal behavior models, using depression detection as an application. We collect multiple longitudinal passive mobile sensing datasets with over 500 users from two institutes over a two-year span, leading to four institute-year datasets. Using the datasets, we closely re-implement and evaluated nine prior depression detection algorithms. Our experiment reveals the lack of model generalizability of these methods. We also implement eight recently popular domain generalization algorithms from the machine learning community. Our results indicate that these methods also do not generalize well on our datasets, with barely any advantage over the naive baseline of guessing the majority. We then present two new algorithms with better generalizability. Our new algorithm, Reorder, significantly and consistently outperforms existing methods on most cross-dataset generalization setups. However, the overall advantage is incremental and still has great room for improvement. Our analysis reveals that the individual differences (both within and between populations) may play the most important role in the cross-dataset generalization challenge. Finally, we provide an open-source benchmark platform GLOBEM- short for Generalization of Longitudinal BEhavior Modeling - to consolidate all 19 algorithms. GLOBEM can support researchers in using, developing, and evaluating different longitudinal behavior modeling methods. We call for researchers' attention to model generalizability evaluation for future longitudinal human behavior modeling studies. 

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