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.

Keywords: Africa; Uganda; digital health; ecological momentary assessment; ecological momentary intervention; mHealth; mobile phone; randomized trial; smartphone.

Conflict of interest statement

Conflicts of Interest: emocha Mobile Health Inc developed the application used in this study. LWC is entitled to royalties on certain nonresearch revenues generated by this company and owns company equity. Specific to this study, LWC received no royalties or compensation from emocha Mobile Health Inc. This arrangement has been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies. None of the other study team members had known competing interests.

©Laura K Beres, Ismail Mbabali, Aggrey Anok, Charles Katabalwa, Jeremiah Mulamba, Alvin G Thomas, Eva Bugos, Gertrude Nakigozi, Mary K Grabowski, Larry W Chang. Originally published in JMIR Formative Research (https://formative.jmir.org), 20.07.2021.

Figures

Figure 1

Study design.

Figure 2

Participant flow diagram. EMA: ecological momentary assessment; EMAI: ecological momentary assessment and intervention.

Figure 3

Mean proportion of days on which behavior occurred by participant according to study arm and period (n=24 per arm).