Just-In-Time Adaptive Interventions: Scientific Motivation and Key Components

Transcription

1 Just-In-Time Adaptive Interventions: Scientific Motivation and Key Components Institute for Translational Research in Children s Mental Health Oct 2016 Inbal (Billie) Nahum-Shani Institute for Social Research University of Michigan

2 2 Outline o What are Just In Time Adaptive Interventions (JITAIs) o Why do we need them? o Key components o Is our science up to the task? o Micro-randomized Trial Suddenly Time and Timing are everywhere (Ancona et al., 2001; AMR)

3 JITAIs in Health Behavior Change Obesity/Weight Management (e.ghsu et al, 2014) Eating disorders (e.g., Bauer et al. 2010) Smoking cessation (e.g., MD2K, 2016) Physical activity (e.g., Thomas & Bond, 2015) Other chronic disorders (e.g., Kristjánsdóttir et al., 2013) Alcohol use disorders (e.g., Gustafson et al., 2014) Mental illnesses (e.g., Ben-Zeev et al., 2013)

4 JITAI Example o Can we help people regulate stress as it occurs in real-life? o Stress is a heuristic but vague construct (Hobfoll, 1989) Psychological and physiological response to demands /threats State characterized by a combination of arousal and displeasure (Kristensen, 1996; Posner et al., 2005) Can be triggered by various circumstances in real-life Performing brief exercises can buffer/blunt real-life stress ***But people fail to use them***

5 5 JITAI Example o Goal: smoking cessation support o Stress presents risk for lapse (slip) o Wearable sensors monitor physiology o Algorithm classifies every minute as either stress or no stress o If stress is detected recommendation to engage in a stress-regulation exercise

6 6 What are JITAIs? Just-In-Time Adaptive Interventions

7 7 Intervention Design o Guides how to offer support or treatments JITAI Experimental Design Data analytic methods

8 8 What are JITAIs? Just-In-Time Adaptive Interventions

9 9 Just-In-Time o Do the right thing / the right type of support o At the right time o While minimizing waste (disruptions)

10 10 Just-In-Time o Assumptions: Timing is salient in support effectiveness Timing => event-based Event-based timing is unexpected (Ancona et al., 2001) Hence, the need to monitor Time is salient when it s running out (Wessman & Gorman, 1977) Conditions that define the right time change rapidly, over short time-frames a few days, hours, minutes, seconds

11 11 Just-In-Time o Provide support to addresses condition that change Rapidly Unexpectedly o How? Monitor continuously Identify the right time Provide the right type of support As soon as the right time occurs Only when the right time occurs

12 12 Just-In-Time o Provide support to addresses condition that change Rapidly Unexpectedly Adaptation o How? Monitor continuously Identify the right time Provide the right type of support As soon as the right time occurs Only when the right time occurs

13 13 What are JITAIs? Just-In-Time Adaptive Interventions

14 14 Adaptation o A process by which ongoing/dynamic information about the individual is used to decide what to do o Operationalized via decision rules o How? Monitor continuously Identify the right time Provide the right type of support As soon as the right time occurs Only when the right time occurs

15 15 Adaptation o Decision rules? Every minute If Stress =Yes Then, IO = {Prompt} Else if Stress = No Then, IO = {Nothing}

16 16 Adaptation 1. Tailoring Variable Every minute If Stress =Yes Then, IO = {Prompt} Else if Stress = No Then, IO = {Nothing}

17 17 Adaptation Every minute If Stress =Yes Then, IO = {Prompt} Else if Stress = No Then, IO = {Nothing} 2. Intervention options

18 18 Adaptation 3. Decision rule Every minute If Stress =Yes Then, IO = {Prompt} Else if Stress = No Then, IO = {Nothing}

19 19 Adaptation 4. Decision Point Every minute If Stress =Yes Then, IO = {Prompt} Else if Stress = No Then, IO = {Nothing}

20 20 Adaptation Risk for lapse Every minute If Stress =Yes Then, IO = {Prompt} Else if Stress = No Then, IO = {Nothing} Risk for waste 5. Outcomes Distal Long-term goal of intervention: Smoking cessation Proximal Short-term goal of decision rules Reduce lapse probability; Increase time to next stress episode

21 21 Five Elements of JITAI Decision Points Tailoring Variable Decision rule Intervention Options Trigger Monitoring Individualizing Delivering Adaptation process Outcomes: Proximal + Distal Guide

22 22 What is a JITAI Just In Time Support Address conditions that are likely to occur Adaptation process Rapidly Unexpectedly Vulnerability and/or Opportunity

23 23 What is a JITAI Just In Time Support Address conditions that are likely to occur Adaptation process Rapidly Unexpectedly Vulnerability and/or Opportunity In the person s natural environment

24 24 Stress for Example o Is likely to occur Outside of standard treatment setting As people go about their daily lives

25 25 We need A Therapist in the Pocket Every minute If Stress =Yes Then, IO = {Recommendation} Else if Stress = No Then, IO = {Nothing} To o Monitor the participant physiology continuously o Use this information to decide whether stress occurs o Deliver the intervention as soon as stress occurs In the person s natural environment

26 26 A Phone in Your Pocket o Continuously monitor the person s status and context Wide range of embedded sensors: e.g., accelerometer, camera, GPS, microphone, and the touchscreen sensors. Other wearable sensors: e.g., hand movement sensors, electrocardiogram, galvanic skin response sensors. Ecological Momentary Assessment (EMAs) o Deliver the intervention as soon as needed, in the natural environment. Advances in mobile and wireless technology enable the delivery of JITAIs

27 27 As People go about their Daily Lives o Multiple demands compete for their time and effort

28 28 JITAI Aim to o Address conditions that o Change rapidly, Unexpectedly, And in the person s natural environment. Represent vulnerability/opportunity While minimizing disruptions to the daily life and routine of the participant. Vulnerability Opportunity Receptivity

29 29 JITAI Example Sense2Stop Every minute If Stress =Yes and min since last intervention >60 and driving=no Then, IO = {Prompt} Else if Stress = No or min since last intervention 60 or riving=yes Then, IO = {Nothing}

30 30 Is our science up to the task? o Open scientific questions: What personal and/or contextual conditions represent vulnerability or opportunities with respect to the proximal outcomes. How rapidly these conditions are likely to change? What intervention options could address or capitalize on these conditions in a timely manner? What personal and/or contextual conditions represent unreceptivity o Risk that intervention provision be wasteful/disruptive?

31 Example: When to provide prompt? State of vulnerability: Heightened risk for lapse Prompt only when stress occurs: to break the link between stress and lapse. State of unreceptivity: Limited cognitive capacity Prompt only when person is not stressed: to practice stress-regulation skills

32 Micro-Randomized Trials (MRT) o o Randomize each participant between intervention options at each decision point Each person may be randomized 100 s or 1000 s of times and multiple times per day. These are sequential, full factorial, designs. Extension of A/B testing & Single Case Designs Liao, P., Klasnja, P., Tewari, A., and Murphy, S. A. (2016) Sample size calculations for micro-randomized trials in mhealth. Statist. Med., 35:

33 Scientific Questions to be answered with MRT o o Do the intervention options (e.g., prompt) impact the proximal outcome (time to next stress episode)? Does the context (e.g., current stress) impact the effectiveness of the intervention options on the proximal outcome? Is the prompt better is increasing time to next stress episode when provided under stress vs. no stress?

34 Sense2Stop MRT Day Smoking Status Treatment 1 SMOKING In-person Treatment Observational 2 SMOKING 3 SMOKING 4 TAPERING In-person Treatment Intervention Trial 5 QUIT DAY In-person Treatment 6 POST-QUIT Phone Coaching 7 POST-QUIT 8 POST-QUIT Phone Coaching 9 POST-QUIT 10 POST-QUIT 11 POST-QUIT 12 POST-QUIT 13 POST-QUIT 14 POST-QUIT 10 day study Chronic smokers, >6 cigs/day Following the person s quit date.

35 MRT Protocol o o Classify output every minute as Stress/Not stress/unclear. At every minute in which the participant is receptive s/he gets micro-randomized to prompt/no intervention No Prompt Prompt Stressed Not Stressed

36 MRT: When are they (not) useful? 36 Useful When the conditions you attempt to target change rapidly (e.g., stress, craving, PA, eating) Proximal outcome can be assessed unobtrusively (e.g., via self-reports or sensors) with precision No useful When the conditions you attempt to target change rarely (e.g., job loss, social norms, risk for suicide attempt) Proximal outcome cannot be assessed with precision

37 37 Is our science up to the task? There is increased awareness among researchers that time is an important topic however, although progress has been made, many questions remain unanswered, and we are more at the beginning than at the end of a very exciting journey Sonnentag et al., (2014)

38 Questions? Bonnie Spring Inbal (Billie) Nahum-Shani Kevin Moran Susan Murphy Gwen Ledford David Conroy Mustafa Al Absi Dave Wetter Santosh Kumar