Mobile Ecological Momentary Assessment and Intervention and Health Behavior Change Among Adults in Rakai, Uganda: Pilot Randomized Controlled Trial

Abstract

Background An extraordinary increase in mobile phone ownership has revolutionized the opportunities to use mobile health approaches in lower- and middle-income countries (LMICs). Ecological momentary assessment and intervention (EMAI) uses mobile technology to gather data and deliver timely, personalized behavior change interventions in an individual’s natural setting. To our knowledge, there have been no previous trials of EMAI in sub-Saharan Africa. Objective To advance the evidence base for mobile health (mHealth) interventions in LMICs, we conduct a pilot randomized trial to assess the feasibility of EMAI and establish estimates of the potential effect of EMAI on a range of health-related behaviors in Rakai, Uganda. Methods This prospective, parallel-group, randomized pilot trial compared health behaviors between adult participants submitting ecological momentary assessment (EMA) data and receiving behaviorally responsive interventional health messaging (EMAI) with those submitting EMA data alone. Using a fully automated mobile phone app, participants submitted daily reports on 5 different health behaviors (fruit consumption, vegetable consumption, alcohol intake, cigarette smoking, and condomless sex with a non–long-term partner) during a 30-day period before randomization (P1). Participants were then block randomized to the control arm, continuing EMA reporting through exit, or the intervention arm, EMA reporting and behavioral health messaging receipt. Participants exited after 90 days of follow-up, divided into study periods 2 (P2: randomization + 29 days) and 3 (P3: 30 days postrandomization to exit). We used descriptive statistics to assess the feasibility of EMAI through the completeness of data and differences in reported behaviors between periods and study arms. Results The study included 48 participants (24 per arm; 23/48, 48% women; median age 31 years). EMA data collection was feasible, with 85.5% (3777/4418) of the combined days reporting behavioral data. There was a decrease in the mean proportion of days when alcohol was consumed in both arms over time (control: P1, 9.6% of days to P2, 4.3% of days; intervention: P1, 7.2% of days to P3, 2.4% of days). Decreases in sex with a non–long-term partner without a condom were also reported in both arms (P1 to P3 control: 1.9% of days to 1% of days; intervention: 6.6% of days to 1.3% of days). An increase in vegetable consumption was found in the intervention (vegetable: 65.6% of days to 76.6% of days) but not in the control arm. Between arms, there was a significant difference in the change in reported vegetable consumption between P1 and P3 (control: 8% decrease in the mean proportion of days vegetables consumed; intervention: 11.1% increase; P=.01). Conclusions Preliminary estimates suggest that EMAI may be a promising strategy for promoting behavior change across a range of behaviors. Larger trials examining the effectiveness of EMAI in LMICs are warranted. Trial Registration ClinicalTrials.gov NCT04375423; https://www.clinicaltrials.gov/ct2/show/NCT04375423

Acceptability and feasibility of mobile phone-based ecological momentary assessment and intervention in Uganda: A pilot randomized controlled trial

“…The study was an assessment of the feasibility and acceptability of using mobile smartphones to implement EMAI in a prospective, parallel group, randomized pilot trial in Rakai, Uganda [15]. The trial purposively sampled adult participants (18-49 years) from the Rakai Community Cohort Study (RCCS), an open, population-based HIV and health surveillance cohort established in 1994 [16,17].…”

“…Due to unforeseen resource limitations, the study recruited approximately half the number expected in the study protocol. However, purposeful sampling ensured inclusion of the desired range of participant characteristics in the pilot trial [15]. Participants were informed of the study and, if they agreed to participate, were then contacted in-person and enrolled, contingent on their written voluntary informed consent.…”

“…We previously reported on a prospective, parallel group, randomized pilot trial in Rakai, Uganda comparing behavioral outcomes among adults submitting ecological momentary assessments (EMA) versus EMAI, which offered preliminary evidence that EMAI may support behavior change in this setting [15]. To advance future implementation of EMAI and to better understand feasibility and acceptability, we now assess and report on implementation-related issues around using smartphones to collect near real-time, geolocated behavioral information and to send tailored health messages based upon these data.…”

Leveraging Ecological Momentary Assessment Data to Characterize Individual Mobility: Exploratory Pilot Study in Rural Uganda

“…A pilot trial using EMA messaging to influence certain health-related behaviors was conducted in Rakai, Uganda in 2017 [ 9 ]. In addition to supporting healthful behaviors (eg, fruit and vegetable consumption), an EMA app sent real-time messages to support users in reducing smoking, drinking alcoholic beverages, and having condomless sex with a non-long-term partner.…”

Gender and Context Matter: Behavioral and Structural Interventions for People Who Use Alcohol and Other Drugs in Africa

“…Ultimately, 35 full-text articles were included in this review. Several relevant protocol [ 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ], baseline or pilot [ 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ], and feasibility studies [ 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 ] were identified; however, they did not meet the inclusion criteria because trial outcomes were the focus of this review.…”