REAL-TIME SUBJECTIVE ASSESSMENT OF PSYCHOLOGICAL STRESS: ASSOCIATIONS WITH OBJECTIVELY-MEASURED PHYSICAL ACTIVITY LEVELS

Feasibility and usability of microinteraction ecological momentary assessment using a smartwatch in military personnel with a history of traumatic brain injury

Introduction

Microinteraction Ecological Momentary Assessment (miEMA) addresses the challenges of traditional self-report questionnaires by collecting data in real time. The purpose of this study was to examine the feasibility and usability of employing miEMA using a smartwatch in military service members undergoing traumatic brain injury (TBI) rehabilitation.

Materials and methods

Twenty-eight United States active duty service members with a TBI history were recruited as patients from a military outpatient TBI rehabilitation center, enrolled in either a 2-week or 3-week study arm, and administered miEMA surveys via a custom smartwatch app. The 3-week arm participants were also concurrently receiving cognitive rehabilitation. Select constructs evaluated with miEMA included mood, fatigue, pain, headache, self-efficacy, and cognitive strategy use. Outcome measures of adherence were completion (percentage of questions answered out of questions delivered) and compliance (percentage of questions answered out of questions scheduled). The Mobile Health Application Usability Questionnaire (MAUQ) and System Usability Scale (SUS) assessed participants' perceptions of smartwatch and app usability.

Results

Completion and compliance rates were 80.1% and 77.4%, respectively. Mean participant completion and compliance were 81.1% ± 12.0% and 78.1% ± 13.0%, respectively. Mean participant completion increased to 87.7% ± 8.8% when using an embedded question retry mechanism. Mean participant survey set completion was 69.8% ± 18.3% during the early morning but remained steady during the late morning/early afternoon (85.7% ± 12.8%), afternoon (86.2% ± 12.6%), and late afternoon/evening (85.0% ± 14.7%). The mean overall item score for the MAUQ was 6.3 ± 1.1 out of 7. The mean SUS score was 89.0 ± 7.2 out of 100 and mean SUS percentile ranking was 96.4% ± 8.4%.

Conclusion

Overall adherence was similar to previous studies in civilian populations. Participants rated the miEMA app and smartwatch as having high usability. These findings suggest that miEMA using a smartwatch for tracking symptoms and treatment strategy use is feasible in military service members with a TBI history, including those undergoing rehabilitation for cognitive difficulties.

Health and University Students: The Mediator Role of Emotion Regulation Between Academic Stressors and Health Behaviors

PURPOSE

To determine the role of Health Behaviors and Cognitive Emotion Regulation Strategies in the relationship between Health and Academic Stress.

DESIGN

A cross-sectional study with in-person administration of questionnaires.

SETTING

Data collection took place at nine public and private universities in Peru, involving a diverse group of students from different faculties.

SAMPLE

1640 students, a majority of them female (61.8%), ranging in age between 18 and 30 years old (M = 20.72; SD = 2.22).

MEASURES

A sociodemographic form was used to collect participants' sociodemographic, academic, and health data. Academic stress was measured by the Inventory of Academic Stress (SISCO). Health habits were assessed using the University Students Lifestyle Questionnaire (CEVJU-Perú). The Cognitive Emotion Regulation Questionnaire (CER-Q) and the SF-36 Questionnaire were also used to evaluate cognitive emotion regulation strategies and health-related quality of life, respectively.

RESULTS

The SEM model results (x2/df = 2.30, CFI = .95, RMSEA = .03, SRMR = .04) reveal that Academic Stress has direct and indirect effects on Health. Negative Emotional Regulation have a negative impact on Health, this effect is direct; while Positive Emotional Regulation has an effect on Health, this effect is direct and indirect, the latter is through Sleep Management, Physical Activity and Leisure Management. In addition, Academic Stress maintains a direct effect on only one health behavior, Sleep Management.

CONCLUSIONS

This study's findings contribute to a better understanding of the role played by emotion regulation, and by positive strategies in particular, in student health.

Association between Academic Performance, Physical Activity, and Academic Stress in Compulsory Secondary Education: An Analysis by Sex

OBJECTIVES

The main objective of this study is to analyze the relationships between academic performance, physical activity, and academic stress in secondary education students, while the secondary objective is to establish differences by gender in the physical activity and academic stress levels of secondary students based on academic performance.

METHODS

The sample was composed of students from both sexes who attended public institutions. Data collection was conducted applying an ad hoc questionnaire for academic performance, the PAQ-C questionnaire for physical activity, and the QASSE questionnaire for academic stress. Data analysis was performed using descriptive statistics: Spearman's correlation coefficient was used for associations, while comparisons were conducted via the Mann-Whitney U test and Kruskal-Wallis H test.

RESULTS

The results show that academic stress is negatively correlated with physical activity and academic performance. Men present significantly higher values in physical activity, while women present higher mean values in general academic stress and the academic overload dimension. Lastly, regarding academic performance, significant differences were observed in the family pressure dimension, with students who perform better academically presenting lower mean values in this dimension of academic stress.

CONCLUSIONS

In conclusion, the more the general academic stress, the lower the physical activity levels and academic performance. In addition, physical activity appears as a potential coping strategy for academic stress, and its influence on academic performance should be further studied in secondary education.

Exploring the longitudinal impacts of academic stress and lifestyle factors among Chinese students

Background

Several cross-sectional and longitudinal investigations have demonstrated a robust association between academic stress, physical activity, mental health history, and time management skills. However, the existing literature exhibits inconsistencies in the relationship between academic stress and its predictive effects on physical activity and mental health history. In addition, there is a scarcity of scholarly research that concentrates on the significance of time management skills within this particular context. Furthermore, limited research has investigated these variables' longitudinal associations and causal pathways. Therefore, the present research explores the longitudinal relationships among academic stress, physical activity, mental health history, and time management skills among university students.

Methods

The data were gathered from Wuhan University, China, employing a two-wave longitudinal survey methodology with an annual interval. A cohort of 980 university-level students engaged in the completion of questionnaires, which encompassed measures of academic stress via the Educational Stress Scale for Adolescents (ESSA), physical activity ascertained through Cho's five-item questionnaire, mental health history assessed by the Kessler Psychological Distress Scale, and time management skills evaluated using the Time Management Behaviour Scale (TMBS). Subsequently, a cross-lagged path model was utilised to examine the prospective associations among these constructs.

Results

The outcomes of the cross-lagged path analysis indicated the presence of significant bidirectional relationships between academic stress and physical activity, mental health history, and time management skills. In addition, bidirectional interconnections existed between physical activity and mental health history. Furthermore, unilateral correlations were detected between physical activity and time management skills.

Conclusions

These findings underscore the importance of an integrated approach to student health initiatives and highlight the need for comprehensive support systems that address student well-being's psychological and physical aspects.

Perceived stress and associations between physical activity, sedentary time, and interstitial glucose in healthy adolescents

BACKGROUND

Less moderate to vigorous physical activity (MVPA), more sedentary time (ST), and higher perceived stress are related to type 2 diabetes mellitus (T2DM) occurrence, but observational evidence addressing the interaction of these factors is lacking in youth. This pilot study investigated momentary stress as a moderator in the acute associations of MVPA and ST with subsequent glucose in healthy adolescents.

METHODS

Participants (N=15, Mage=13.1±1.0 years, 10 girls, 5 with overweight/obesity) simultaneously wore a continuous glucose monitor (CGM), thigh-mounted accelerometer, and reported momentary stress via random ecological momentary assessments (EMA; Time T) for 7-14 days. MVPA and ST (min) were calculated for 60- and 120-minute time windows before each EMA prompt (Time T-1). Mean CGM-measured interstitial glucose (mg/dL) was calculated after each prompt (Mmin=120.0±25.4; Time T+1). Multilevel models assessed whether within-subject MVPA and ST (Time T-1) predicted mean glucose (Time T+1), with momentary stress as a moderator (Time T).

RESULTS

There were 513 time-matched EMA reports of stress, accelerometer, and CGM data. Momentary stress moderated the effects of MVPA 60 (β=-0.22, p=.001) and 120 min (β=-0.08, p=.02) before the prompt on subsequent glucose levels. When youth spent more time in MVPA than their average and when momentary stress was higher than their average, subsequent glucose was lower. Stress did not moderate associations of ST with glucose (p>.05).

CONCLUSIONS

Higher momentary stress may interact with higher MVPA to lower subsequent glucose in youth. Accelerometers, EMA, and CGMs can be integrated in future studies to further understand these associations in free-living environments.

Sequential mediation analysis of physical activity, healthy diet, BMI, and academic burnout in the Pakistani educational landscape

Research has indicated a negative impact of physical activity on academic burnout among students, however, there is a paucity of evidence about the underlying mechanism of this association in Pakistani students. The present research seeks to investigate the relationship between physical activity and academic burnout by investigating the potential mediating effects of adherence to the Mediterranean diet (MD) and body mass index (BMI). A sample of 596 students using a cross-sectional survey design was gathered from two public universities (Riphah International University and Mohammed Ali Jinnah University) in Rawalpindi, Pakistan from June to July 2022. The study participants were asked to fill out the Physical Activity Rating Scale-3, the Learning Burnout Scale, and the Test of Adherence to MD questionnaires. The study employed descriptive, bivariate, and path analysis through regression utilizing the SPSS software version 27. The findings demonstrated a negative correlation between academic burnout and BMI, physical activity, and adherence to the MD. The relationship between physical activity and academic burnout was mediated by BMI. Physical activity and academic burnout were inversely correlated, with adherence to the MD and BMI interacting as sequential mediators. The outcomes of this research have expanded our knowledge of the association between physical activity and academic burnout and have suggested crucial and appropriate strategies for addressing student academic burnout.

Within-Person Associations of Accelerometer-Assessed Physical Activity With Time-Varying Determinants in Older Adults: Time-Based Ecological Momentary Assessment Study

BACKGROUND

Despite the availability of physical activity (PA) interventions, many older adults are still not active enough. This might be partially explained by the often-limited effects of PA interventions. In general, health behavior change interventions often do not focus on contextual and time-varying determinants, which may limit their effectiveness. However, before the dynamic tailoring of interventions can be developed, one should know which time-dependent determinants are associated with PA and how strong these associations are.

OBJECTIVE

The aim of this study was to examine within-person associations between multiple determinants of the capability, opportunity, motivation, and behavior framework assessed using Ecological Momentary Assessment (EMA) and accelerometer-assessed light PA, moderate to vigorous PA, and total PA performed at 15, 30, 60, and 120 minutes after the EMA trigger.

METHODS

Observational data were collected from 64 healthy older adults (36/64, 56% men; mean age 72.1, SD 5.6 y). Participants were asked to answer a time-based EMA questionnaire 6 times per day that assessed emotions (ie, relaxation, satisfaction, irritation, and feeling down), the physical complaint fatigue, intention, intention, and self-efficacy. An Axivity AX3 was wrist worn to capture the participants' PA. Multilevel regression analyses in R were performed to examine these within-person associations.

RESULTS

Irritation, feeling down, intention, and self-efficacy were positively associated with subsequent light PA or moderate to vigorous PA at 15, 30, 60, or 120 minutes after the trigger, whereas relaxation, satisfaction, and fatigue were negatively associated.

CONCLUSIONS

Multiple associations were observed in this study. This knowledge in combination with the time dependency of the determinants is valuable information for future interventions so that suggestions to be active can be provided when the older adult is most receptive.

Movement matters: short-term impacts of physical activity on mood and well-being

Few studies have investigated the short-term, momentary relationships between physical activity (PA) and well-being. This study focuses on investigating the dynamic relationships between PA and affective well-being among adults with type 1 diabetes. Participants (n = 122) wore an accelerometer and completed daily EMA surveys of current activities and affective states (e.g., happy, stressed, excited, anxious) via smartphone over 14 days. Within-person, increased sedentary time was associated with less positive affect (r =  - 0.11, p < 0.001), while more PA of any intensity was associated with greater positive affect and reduced fatigue, three hours later. Between-person, increased light PA was associated with increased stress (r = 0.21, p = 0.02) and diabetes distress (r = 0.30, p = 0.001). This study provides evidence that positive affect and fatigue are predicted by previous activity regardless of the different activities that people engaged in. Positive affect increased after engaging in PA. However, participants with higher amounts of light PA reported higher stress ratings.

Recommendations for Identifying Valid Wear for Consumer-Level Wrist-Worn Activity Trackers and Acceptability of Extended Device Deployment in Children

BACKGROUND

Self-reported physical activity is often inaccurate. Wearable devices utilizing multiple sensors are now widespread. The aim of this study was to determine acceptability of Fitbit Charge HR for children and their families, and to determine best practices for processing its objective data.

METHODS

Data were collected via Fitbit Charge HR continuously over the course of 3 weeks. Questionnaires were given to each child and their parent/guardian to determine the perceived usability of the device. Patterns of data were evaluated and best practice inclusion criteria recommended.

RESULTS

Best practices were established to extract, filter, and process data to evaluate device wear, r and establish minimum wear time to evaluate behavioral patterns. This resulted in usable data available from 137 (89%) of the sample.

CONCLUSIONS

Activity trackers are highly acceptable in the target population and can provide objective data over longer periods of wear. Best practice inclusion protocols that reflect physical activity in youth are provided.

Exploring the Effects of Perceived Stress on the Within-Person Relationships Between Daily Activity Levels and Sleep in Women: An Ecological Momentary Assessment Study

BACKGROUND

Many studies show positive bidirectional associations between physical activity (PA) and sleep at the between-person level. There is an increased interest in investigating these associations at the within-person level. Few studies examined the effects of time-varying moderators on the within-person bidirectional associations between PA and sleep. This study aimed to examine the bidirectional within-person day-level associations between activity levels and self-reported sleep duration and explore the moderating effects of perceived stress on these day-level associations.

METHOD

Data from 158 women that included 7-day free-living monitoring over 4 measurement periods was analyzed using multilevel modeling to explore the moderating effects of daily stress on the bidirectional, within-person associations between activity levels and self-reported sleep duration. Moderate-to-vigorous PA (MVPA) and sedentary behavior (SB) were estimated from a waist-worn accelerometer. Self-reported sleep duration and perceived stress were collected by ecological momentary assessment.

RESULTS

No significant within-person associations between MVPA minutes and self-reported sleep duration were found in either direction. However, engaging in more MVPA than one's usual level was associated with longer sleep later that night when perceived stress was higher than usual (p = .04). Bidirectional negative within-person association between SB minutes and self-reported sleep duration was found (ps < .01). The negative association between SB and sleep duration later that night was stronger when perceived stress was lower than usual (p = .01).

CONCLUSION

Daily stress played an important role in the day-to-day associations between activity levels and sleep.

Temporal associations between objectively measured physical activity and depressive symptoms: An experience sampling study

Background

This study aimed to examine the relationship between the timing of physical activity and within-individual differences in depressive symptoms, positive affect, and negative affect in individuals with different baseline levels of depressive symptoms.

Methods

Experience sampling methodology (ESM) was used to measure real-time depressive symptoms, positive affect, and negative affect in a convenience sample of 78 healthy adults (aged M = 25.46 years, SD = 6.18; 57 females) five times per day for 14 days. We measured physical activity throughout the 14 days by using activity sensors. Baseline levels of depressive symptoms were assessed with the PHQ-9 to build subgroups with low vs. mild-moderate depressive symptoms.

Results

Physical activity predicted decreased depressive symptom levels, negative affect, and increased positive affect. Associations were stronger for individuals with higher baseline levels of depressive symptoms and for physical activity between 0 and 30 min compared to physical activity between 30 and 180 min before the mood rating. Conversely, levels of depressive symptoms, positive and negative affect did not predict physical activity.

Limitations

The convenience sample may not have been representative of the general population or people with depression. Accelerometers may not have detected some types of physical activities such as bicycling. Causality could not be inferred because of the observational study design.

Conclusion

Individuals with higher levels of depressive symptoms may benefit from physical activity. While the effects were strongest for physical activity immediately before the mood ratings, the effects were in the same direction for up to 3 h before the mood ratings.

The association of stress and physical activity: Mind the ecological fallacy

Psychological stress and physical activity are interrelated, constituting a relevant association to human health, especially in children. However, the association’s nature remains elusive, i.e., why psychological stress predicts both decreased and increased physical activity. To test whether effects vary as a function of the level of analyses, we derived intensive longitudinal data via accelerometers and stress questionnaires from 74 children across 7 days as they went about their daily routines (n = 513 assessments). Multilevel modelling analyses revealed that between children, higher psychological stress predicted decreased physical activity (standardized beta coefficient = −0.14; p = 0.046). Concurrently, within those children, higher psychological stress predicted increased physical activity across days (standardized beta coefficient = 0.09; p = 0.015). Translated to practice, children who experienced more stress than others moved less, but children were more active on days when they experienced heightened stress. This suggests that the analyses level is crucial to the understanding of the association between psychological stress and physical activity and should be considered to receive unequivocal results. If replicated, e.g., including high-frequency sampling and experimental manipulation in everyday life for in-depth insights on underlying mechanisms and causality, our findings may be translated to individually tailored (digital) prevention and intervention strategies which target children’s distress-feelings despite impairing their heightened physical activity in stressful situations and identify tipping points of chronic stress phases. Therefore, we especially call for more intensive longitudinal data approaches to tackle thus far neglected within-subject issues in the field of physical activity, sport and exercise research.

Momentary associations between stress and physical activity among children using ecological momentary assessment

Chronic and acute stress may have a detrimental effect on children's physical activity. Research on stress as a predictor of children's physical activity has mostly focused on stress between children, rather than how children's within-day variation in stress may predict physical activity. The current study assessed the within- and between-effects of stress on subsequent physical activity in three different time windows using ecological momentary assessment (EMA) and accelerometry. Children (N = 190; M_{Baseline Age} =10.1±0.9, 53% female, 56% self-identified Hispanic/Latino) completed six semi-annual assessment bursts across three years. During each burst, participants responded to up to seven (weekend) or three (weekday) randomly prompted EMA surveys on smartphones for seven days and wore a waist-worn accelerometer. Multi-level structural equation modeling examined within- and between-subjects effects of stress as a predictor of children's subsequent moderate-to-vigorous physical activity (MVPA) in the 15, 30, and 60 minutes following the EMA prompt. Latent variables were created for within- and between-subjects stress were comprised of three EMA stress items. Higher than average levels of stress (within-subjects) significantly predicted lower MVPA in the subsequent 15, 30 and 60 minutes (ps < .05). Between-subjects stress was not significantly associated with subsequent MVPA (ps > .05). Results indicate that elevated momentary stress predicts less subsequent MVPA. These findings suggest that within-day fluctuations in stress may be a barrier for children engaging in physical activity. Childhood physical activity promotion and interventions should consider the role of children's stress, aim to reduce the stress children experience throughout the day, and incorporate stress coping strategies.

The impact of mental and somatic stressors on physical activity and sedentary behaviour in adults with type 2 diabetes mellitus: a diary study

Background

Adopting an active lifestyle is key in the management of type 2 diabetes mellitus (T2DM). Nevertheless, the majority of individuals with T2DM fails to do so. Additionally, individuals with T2DM are likely to experience mental (e.g., stress) and somatic (e.g., pain) stressors. Research investigating the link between these stressors and activity levels within this group is largely lacking. Therefore, current research aimed to investigate how daily fluctuations in mental and somatic stressors predict daily levels of physical activity (PA) and sedentary behaviour among adults with T2DM.

Methods

Individuals with T2DM (N = 54) were instructed to complete a morning diary assessing mental and somatic stressors and to wear an accelerometer for 10 consecutive days. The associations between the mental and somatic stressors and participants’ levels of PA and sedentary behaviour were examined using (generalized) linear mixed effect models.

Results

Valid data were provided by 38 participants. We found no evidence that intra-individual increases in mental and somatic stressors detrimentally affected participants’ activity levels. Similarly, levels of sedentary behaviour nor levels of PA were predicted by inter-individual differences in the mental and somatic stressors.

The combination of psychosocial working conditions, occupational balance and sociodemographic characteristics and their associations with no or negligible stress symptoms among Swedish occupational therapists - a cross-sectional study

Background

The numbers of people who are on sick leave due to mental health problems, such as exhaustion disorder, are increasing in Sweden. One of the most affected groups is healthcare professionals. In order to develop preventive strategies to promote a sustainable working life for occupational therapists, there is a need to understand the associations between psychosocial working conditions, occupational balance and no or negligible stress symptoms. To the best of our knowledge, neither the combination of these factors nor the salutogenic perspective, have been taken into consideration when exploring factors associated with stress symptoms among occupational therapists in previous research.

Methods

Purposeful sampling was used. All currently working members of the Swedish Association of Occupational Therapists were invited to take part in the present study in 2018. The final sample was 3658 (48% response rate). A web-survey with questions about signs of exhaustion, psychosocial working conditions, occupational balance and sociodemographic characteristics was used. Logistic regression analyses were used in order to calculate associations between psychosocial working conditions, occupational balance, sociodemographic characteristics and no or negligible signs of exhaustion.

Results

Experiencing high occupational balance, low workload, high control, high sense of community and high justice, were associated with no or negligible stress symptoms. Furthermore, a satisfying financial situation, having children living at home, being married and long professional experience were significant in this model.

Conclusions

It seems important to consider not only psychosocial working conditions, but also occupational balance to prevent exhaustion disorder among occupational therapists in Sweden. Organisational programmes, which reduce the workload, strengthen the control and sense of community and facilitate occupational balance, seem to be important areas for health promotion in this group.

From Physical Activity Intention to Behavior: The Moderation Role of Mental Toughness Among College Students and Wage Earners

This study explored the correlation between mental toughness (MT) and physical activity (PA), and the moderation role between PA intention and subsequent behavior among college students and wage earners. Five hundred ninety-one college students (251 male, 340 female) aged from 19 to 24 and 285 (157 male, 127 female) wage earners aged from 27 to 58 recruited from seven colleges and five cities in China. A Theory of Planned Behavior (TPB) questionnaire, MT Inventory, and the International PA Questionnaire was completed online. Results showed that attitudes, subjective norms, and perceived behavioral control explained 46.5 and 38.3% variance in PA intention among college students and wage earners separately. Intention predicted PA behavior significantly among college students and wage earners. Structural equation modeling indicated that the TPB model and the moderation model have an adequate to good fit except the TPB model among wage earners. MT was positively correlated with PA among college students and wage earners and had a significant moderation role in intention-behavior gap among college students and partially affected the transfer of PA intention to behavior among college students. Individuals with high MT had high levels of PA regardless of intention, while PA of those with low MT was low and unstable. Future research should further explore the correlation between intention and PA and the moderation role of MT in different populations using a longitudinal study in order to better understand the correlation between intention and PA, and the transition from intention to PA and better guidance PA intervention to promote PA.

Testing the cross-stressor hypothesis under real-world conditions: exercise as a moderator of the association between momentary anxiety and cardiovascular responses

The cross-stressor adaptation hypothesis of exercise training has not been investigated under real-life conditions. Using ecological momentary assessment, we tested whether usual exercise level moderates the relationship of self-reported anxiety to concurrent ambulatory heart rate (HR) and systolic/diastolic blood pressure (SBP/DBP). Participants (N = 832) completed 24-h ambulatory monitoring of HR/BP, using a brachial BP cuff that took readings at 28-min intervals. Anxiety levels were concurrently reported on a visual analog scale (VAS) using a Palm Pilot. Usual exercise behavior was assessed by a self-report questionnaire. Random coefficients linear regression models predicting momentary HR/BP readings from time-matched anxiety scores were estimated, yielding the average within-person effect (slope) of anxiety. The interaction of exercise level (i.e., no weekly exercise, 1-149, and ≥ 150 min/week; a between-person factor) with anxiety was added to the model in order to estimate the average anxiety slope for participants in each exercise category. The relationship of HR/BP to anxiety did not differ significantly among exercise categories, hence not providing evidence for the cross-stressor hypothesis. In an exploratory analysis of the difference in HR/BP between occasions when anxiety was in the top versus bottom person-specific quintiles of responses, the difference in HR (but not SBP or DBP) varied significantly by exercise level (F(2,625) = 4.92, p = 0.008). Though our pre-specified analysis did not support the hypothesis, we provide some post hoc evidence supporting the cross-stressor hypothesis of exercise training for the HR response to anxiety.

Using Ecological Momentary Assessment to Examine the Effects of Duty Status on Acute Stress and Tiredness in Firefighters: A Pilot Study

OBJECTIVE

Characterize firefighters' acute stress and tiredness by duty status (ie, "off night/day," "on night/day").

METHODS

Thirty nine career firefighters completed three, eight-day smartphone-based ecological momentary assessment periods with seven surveys per day assessing stress and tiredness. Mixed-effects location scale models examined duty status effects on stress and tiredness.

RESULTS

Firefighters' lowest stress and tiredness levels were when off-duty (β = 16.27 and β = 24.71, respectively) and their highest levels were when on-duty (β = 24.47 and β = 32.18, respectively). Within-subject effects of duty status accounted for a larger proportion of variability in stress and tiredness for all duty types, except for stress when "on-duty night/off-duty day."

CONCLUSIONS

Firefighters had more similar stress and tiredness outcomes when they were on-duty and less similar outcomes when off-duty. This could be due to firefighters having more similar experiences when they are on- versus off-duty.

Pursuing Sustainable Happiness through Participation in Exercise for South Korean Students: Structural Relationships among Exercise, Mental Health Factors, School Satisfaction, and Happiness

The purpose of this study was to explore the possibility that exercise participation can be an important factor in the pursuit of sustainable happiness. For this purpose, this study focused on the causal relationships among the frequency of exercise, self-esteem, stress, depression, school satisfaction and degree of happiness in elementary, junior high and high school students (n = 11,132) in South Korea. The data used for this study were collected in 2016 by the National Youth Policy Institute (NYPI) for the “UN convention on the rights of the child.” The results were as follows; firstly, the exercise frequency had a significant causal relationship with self-esteem, stress, school satisfaction and happiness but not with depression. However, it was found that exercise frequency had an indirect effect on depression through stress. In detail, exercise frequency could positively reduce stress, and less stress affects depression. Secondly, there were significant direct or indirect effects on self-esteem, stress, depression, degree of happiness and school satisfaction. Lastly, only depression did not affect school satisfaction and happiness.

mHealth technology for ecological momentary assessment in physical activity research: a systematic review

OBJECTIVE

To systematically review the publications on ecological momentary assessment (EMA) relating to physical activity (PA) behavior in order to classify the methodologies, and to identify the main mHealth technology-based tools and procedures that have been applied during the first 10 years since the emergence of smartphones. As a result of this review, we want to ask if there is enough evidence to propose the use of the term "mEMA" (mobile-based EMA).

DESIGN

A systematic review according to PRISMA Statement (PROSPERO registration: CRD42018088136).

METHOD

Four databases (PsycINFO, CINALH, Medline and Web of Science Core Collection) were searched electronically from 2008 to February 2018.

RESULTS

A total of 76 studies from 297 potential articles on the use of EMA and PA were included in this review. It was found that 71% of studies specifically used "EMA" for assessing PA behaviors but the rest used other terminology that also adjusted to the inclusion criteria. Just over half (51.3%) of studies (39) used mHealth technology, mainly smartphones, for collecting EMA data. The majority (79.5%) of these studies (31 out of 39) were published during the last 4 years. On the other hand, 58.8% of studies that only used paper-and-pencil were published during the first 3 years of the 10-year period analyzed. An accelerometer was the main built-in sensor used for collecting PA behavior by means of mHealth (69%). Most of the studies were carried out on young-adult samples, with only three studies in older adults. Women were included in 60% of studies, and healthy people in 82%. The studies lasted between 1 and 7 days in 57.9%, and between three and seven assessments per day were carried out in 37%. The most popular topics evaluated together with PA were psychological state and social and environmental context.

CONCLUSIONS

We have classified the EMA methodologies used for assessing PA behaviors. A total of 71% of studies used the term "EMA" and 51.3% used mHealth technology. Accelerometers have been the main built-in sensor used for collecting PA. The change of trend in the use of tools for EMA in PA coincides with the technological advances of the last decade due to the emergence of smartphones and mHealth technology. There is enough evidence to use the term mEMA when mHealth technology is being used for monitoring real-time lifestyle behaviors in natural situations. We define mEMA as the use of mobile computing and communication technologies for the EMA of health and lifestyle behaviors. It is clear that the use of mHealth is increasing, but there is still a lot to be gained from taking advantage of all the capabilities of this technology in order to apply EMA to PA behavior. Thus, mEMA methodology can help in the monitoring of healthy lifestyles under both subjective and objective perspectives. The tendency for future research should be the automatic recognition of the PA of the user without interrupting their behavior. The ecological information could be completed with voice messages, image captures or brief text selections on the touch screen made in real time, all managed through smartphone apps. This methodology could be extended when EMA combined with mHealth are used to evaluate other lifestyle behaviors.

Content validity and methodological considerations in ecological momentary assessment studies on physical activity and sedentary behaviour: a systematic review

Background

Ecological momentary assessment (EMA) is a method of collecting real-time data based on repeated measures and observations that take place in participant’s daily environment. EMA has many advantages over more traditional, retrospective questionnaires. However, EMA faces some challenges to reach its full potential. The aims of this systematic review are to (1) investigate whether and how content validity of the items (i.e. the specific questions that are part of a larger EMA questionnaire) used in EMA studies on physical activity and sedentary behaviour was assessed, and (2) provide an overview of important methodological considerations of EMA in measuring physical activity and sedentary behaviour.

Methods

Thirty papers (twenty unique studies) were systematically reviewed and variables were coded and analysed within the following 4 domains: (1) Content validity, (2) Sampling approach, (3) Data input modalities and (4) Degree of EMA completion.

Results

Only about half of the studies reported the specific items (n = 12) and the source of the items (n = 11). None of the studies specifically assessed the content validity of the items used. Only a minority (n = 5) of the studies reported any training, and one tested the comprehensibility of the EMA items. A wide variability was found in the design and methodology of the EMA. A minority of the studies (n = 7) reported a rationale for the used prompt frequency, time selection, and monitoring period. Retrospective assessment periods varied from ‘now’ to ‘in the last 3.5 hours’. In some studies there was a possibility to delay (n = 6) or deactivate (n = 10) the prompt, and some provided reminders after the first prompt (n = 9).

Conclusions

Almost no EMA studies reported the content validation of the items used. We recommend using the COSMIN checklist (COnsensus-based Standards for the selection of health Measurement INstruments) to report on the content validity of EMA items. Furthermore, as often no rationale was provided for several methodological decisions, the following three recommendations are made. First, provide a rationale for choosing the sampling modalities. Second, to ensure assessment ‘in the moment’, think carefully about the retrospective assessment period, reminders, and deactivation of the prompt. Third, as high completion rates are important for representativeness of the data and generalizability of the findings, report completion rates.

Trial registration

This review is registered in PROSPERO, the International prospective register of systematic reviews (registration number: CRD42017077996).

Everyday stress components and physical activity: examining reactivity, recovery and pileup

The experience of naturally-occurring stress in daily life has been linked with lower physical activity levels. However, most of this evidence comes from general and static reports of stress. Less is known how different temporal components of everyday stress interfere with physical activity. In a coordinated secondary analysis of data from two studies of adults, we used intensive, micro-longitudinal assessments (ecological momentary assessments, EMA) to investigate how distinct components of everyday stress, that is, reactivity to stressor events, recovery from stressor events, and pileup of stressor events and responses predict physical activity. Results showed that components of everyday stress predicted subsequent physical activity especially for indicators of stress pileup. In both studies, the accumulation of stress responses over the previous 12 h was more predictive of subsequent physical activity than current stress reactivity or recovery responses. Results are compared to the effects of general measures of perceived stress that showed an opposite pattern of results. The novel everyday stress approach used here may be fruitful for generating new insights into physical activity specifically and health behaviors in general.

Daily stress as link between disadvantage and smoking: an ecological momentary assessment study

Background

There is a well-established social gradient in smoking, but little is known about the underlying behavioral mechanisms. Here, we take a social-ecological perspective by examining daily stress experience as a process linking social disadvantage to smoking behavior.

Method

A sample of 194 daily smokers, who were not attempting to quit, recorded their smoking and information about situational and contextual factors for three weeks using an electronic diary. We tested whether socioeconomic disadvantage (indicated by educational attainment, income and race) exerts indirect effects on smoking (cigarettes per day) via daily stress. Stress experience was assessed at the end of each day using Ecological Momentary Assessment methods. Data were analyzed using random effects regression with a lower-level (2-1-1) mediation model.

Results

On the within-person level lower educated and African American smokers reported significantly more daily stress across the monitoring period, which in turn was associated with more smoking. This resulted in a small significant indirect effect of daily stress experience on social disadvantage and smoking when using education and race as indicator for social disadvantage. No such effects were found when for income as indicator for social disadvantage.

Conclusion

These findings highlight the potential for future studies investigating behavioral mechanisms underlying smoking disparities. Such information would aid in the development and improvement of interventions to reduce social inequality in smoking rates and smoking rates in general.

Relationship between Academic Stress, Physical Activity and Diet in University Students of Education

(1) Background: Several research works have shown the relationship between physical activity (PA), adherence to the Mediterranean diet (MD) and health. Nevertheless, there are few studies that demonstrate the relationship of these habits with academic performance, and specifically with academic stress. (2) Methods: This descriptive, non-experimental, and cross-sectional study aims to analyse the associations between these variables in a sample composed of 515 university students, using as main instruments the KIDMED, PAQ-A and the Scale of Academic Stress. (3) Results: The university students analysed showed higher levels of academic stress for women, and especially in the academic obligations and communication of own ideas. In addition, it was shown that those university students that had a body mass index (BMI) associated with being overweight or under-weight were the respondents with higher levels of stress. Finally, the students with a low adherence to MD had higher scores for stress associated with the communication of their own ideas, while PA was not related to academic stress. When sex and BMI variables were controlled in the regression model, no associations were obtained between stress and diet quality. (4) Conclusions: This study shows interesting implications in the treatment of academic stress. Although stress was not associated with diet and physical activity, it was linked to a worse state of health associated with states of being overweight, being of special interest the treatment of stress in women.

Neighborhood Social Environment and Cardiovascular Disease Risk

Purpose of review

Limited physical activity (PA) and obesity are two primary risk factors for cardiovascular disease (CVD). Within a socio-ecological framework, neighborhood social environment may play a key role in influencing PA and obesity. However, the mechanisms underlying this relationship remain ambiguous. Our goals in this review are: (1) to summarize findings from the recent studies on neighborhood social environment in relation to PA and obesity as CVD risk factors, and (2) to briefly describe several innovative approaches to assessing neighborhood social environment.

Recent findings

Almost all recent studies assessed neighborhood social environment around residential areas. There were consistent associations between neighborhood social environment and PA and obesity, with some exceptions (indicating null associations or paradoxical associations). However, a focus on residential social environment may limit results because these studies did not account for any exposures occurring away from individuals' homes. Additionally, the majority of studies utilized a cross-sectional design, which limits our ability to make inferences regarding the causality of the association between social environment and PA or obesity as CV risk factors.

Summary

The majority of the studies on neighborhood social environment characterized factors around residential areas and assessed participant activity via self-reported surveys. Future research should leverage tools to account for the spatial mismatch between environmental exposures and outcomes by using global positioning systems, ecological momentary assessments, virtual neighborhood audits, and simulation modeling. These approaches can overcome major limitations by tracking individuals' daily activity and real-time perceptions of neighborhood social environments linked to CVD events.

Time Series Visualizations of Mobile Phone-Based Daily Diary Reports of Stress, Physical Activity, and Diet Quality in Mostly Ethnic Minority Mothers: Feasibility Study

Background

Health behavior patterns reported through daily diary data are important to understand and intervene upon at the individual level in N-of-1 trials and related study designs. There is often interest in relationships between multiple outcomes, such as stress and health behavior. However, analyses often utilize regressions that evaluate aggregate effects across individuals, and standard analyses target single outcomes.

Objective

This paper aims to illustrate how individuals’ daily reports of stress and health behavior (time series) can be explored using visualization tools.

Methods

Secondary analysis was conducted on 6 months of daily diary reports of stress and health behavior (physical activity and diet quality) from mostly ethnic minority mothers who pilot-tested a self-monitoring mobile health app. Time series with minimal missing data from 14 of the 44 mothers were analyzed. Correlations between stress and health behavior within each time series were reported as a preliminary step. Stress and health behavior time series patterns were visualized by plotting moving averages and time points where mean shifts in the data occurred (changepoints).

Results

Median correlation was small and negative for associations of stress with physical activity (r=−.14) and diet quality (r=−.08). Moving averages and changepoints for stress and health behavior were aligned for some participants but not for others. A third subset of participants exhibited little variation in stress and health behavior reports.

Conclusions

Median correlations in this study corroborate prior findings. In addition, time series visualizations highlighted variations in stress and health behavior across individuals and time points, which are difficult to capture through correlations and regression-based summary measures.

Reconsidering the experience machine: Self-reported versus objective measures of physical activity to increase positive affect

This article tests the utility of self-report and objective assessment of physical activity to predict increased positive affect. Participants wore Fitbit activity trackers and responded to single-item assessments of momentary affect and self-reported physical activity following an experience sampling method protocol. A test of the within-person mediation indicated that, on average, 63 percent of the relationship between objective physical activity and affect was accounted for by self-reported physical activity. This research adds to the body of literature demonstrating the benefits of physical activity and discusses the utility of perceived over actual assessments of physical activity in naturalistic settings.