Validation of Self-Reported Attachment Classification Among Racially and Ethnically Diverse Parents of Young Children.

BACKGROUND: The Attachment Style Questionnaire (ASQ) was developed to measure individual differences in insecure adult attachment and was suitable for populations that may have minimal or no experience in romantic relationships. The measure was previously validated on homogenous populations. OBJECTIVES: The purpose of this study was to verify construct validity and internal consistency of the ASQ among an ethnically and racially diverse sample of caregivers of young children ages birth to 3 years. METHODS: Using a cross-sectional design, we examined the psychometric properties of the ASQ. A racially and ethnically diverse sample of caregivers of young children (birth to 3 years old) completed the 40-item measure. Factor analyses and internal consistency analyses were conducted. RESULTS: Confirmatory factor analyses showed that the previously published factor structures were not a good fit for this diverse sample. Exploratory factor analysis with promax rotation revealed a four-factor solution among 16 items, including relationship anxiety, relationships as secondary, discomfort with closeness, and relationship distrust. Adequate internal consistency was noted for the factors, and structural invariance was confirmed across Hispanic and non-Hispanic ethnicities. DISCUSSION: Nurse scientists and practitioners should take caution when using or developing indices based on previous research. There should be consideration of structural stability and replication across the intended population.

Sex, race, ADHD, and prior concussions as predictors of concussion recovery in adolescents.

OBJECTIVE: Concussions in adolescents are a growing public health concern as the popularity of high school sports increases. The aim of this study was to identify clinical (e.g., prior concussion, migraine history, learning disabilities/attention deficit hyperactivity disorders [ADHD]) and demographic factors (e.g., sex, race, health insurance, mechanism of injury/sport, education) that predict concussion recovery times. DESIGN: In a retrospective cohort study of adolescents 13-19 years old evaluated for an acute concussion (≤ 10 days from injury), recovery times were calculated from the date of concussive injury to the date of clearance to return to play or normal activities. RESULTS: The sample (N = 227) was primarily male (75%), and the median age was 15 years. Predictors of protracted recovery were ADHD (hazard ratio [HR] =.449, 95% confidence interval [CI] =.272-.741, p = .002) and prior concussion (HR =.574, 95% CI =.397-.828, p = .003) in all sex and race groups, while shorter recovery times were predicted by Hispanic and African American race (HR = 2.12, 95% CI = 1.30-3.46, p = .003), with White females as the reference group. CONCLUSIONS: Further research is needed to examine the role of sex, race, ADHD, and concussion history on concussion outcomes.

Association of cardiorespiratory fitness and adiposity with inflammatory biomarkers in young adults.

OBJECTIVES: Cardiorespiratory fitness (fitness) has been inversely associated with inflammation, but whether the association is attributed to fitness itself or lower levels of adiposity remains uncertain in young adults. The purpose of this study was to determine the association of fitness and adiposity with inflammation in young adults. METHODS: A cross-sectional study was conducted with 88 participants aged 20-34 years. Fitness was assessed by a submaximal treadmill walking test. Adiposity was assessed by body mass index (BMI) and waist circumference (WC). Inflammation was measured by plasma C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) levels using immunoassays. Biological data were log10 transformed. A separate multiple regression analysis was conducted with each inflammatory biomarker as a dependent variable. Covariates (sex, oral contraceptive use, and education level) were adjusted. RESULTS: Fitness was inversely associated with log10 CRP after adjustment for covariates but not after adjusting for BMI or WC. Fitness was inversely associated with log10 IL-6 after adjustment for WC and covariates (ß = -0.341, P = .049) but not after adjusting for BMI. Fitness × WC interaction (partial eta2 = 0.056, P = .033) indicated that high fitness was more strongly associated with low log10 IL-6 in young adults with high WC than those with low WC. CONCLUSIONS: Although adiposity has a stronger association than fitness with CRP and IL-6, higher levels of fitness could be essential for maintaining low levels of IL-6, especially in the presence of high levels of central adiposity.

Effects of Animal-assisted Activities on Biobehavioral Stress Responses in Hospitalized Children: A Randomized Controlled Study.

PURPOSE: This study assessed the effectiveness of animal-assisted activities (AAA) on biobehavioral stress responses (anxiety, positive and negative affect, and salivary cortisol and C-reactive protein [CRP] levels) in hospitalized children. DESIGN AND METHODS: This was a randomized, controlled study. METHOD: Forty-eight participants were randomly assigned to receive a 10-minute AAA (n=24) or a control condition (n=24). Anxiety, positive and negative affect, and levels of salivary biomarkers were assessed before and after the intervention. RESULTS: Although increases in positive affect and decreases in negative affect were larger in the AAA condition, pre- and post-intervention differences between the AAA and control conditions were not significant. In addition, pre- and post-intervention differences between the conditions in salivary cortisol and CRP were not statistically significant. Baseline levels of anxiety, cortisol, and CRP had a significant and large correlation to the corresponding post-intervention measures. Scores on the Pet Attitude Scale were high but were not associated with changes in anxiety, positive affect, negative affect, or stress biomarkers. CONCLUSIONS: Although changes were in the expected direction, the magnitude of the effect was small. Future randomized controlled trials with larger recruitment are needed to determine the effectiveness of AAAs in reducing biobehavioral stress responses in hospitalized children. PRACTICE IMPLICATIONS: Nurses are positioned to recommend AAA as a beneficial and safe experience for hospitalized children.

Biobehavioral Factors in Child Health Outcomes: The Roles of Maternal Stress, Maternal-Child Engagement, Salivary Cortisol, and Salivary Testosterone.

BACKGROUND: Exposure to high levels of maternal stress and ineffective maternal-child engagement (MC-E) may adversely affect child health-related outcomes. OBJECTIVE: The aim of this study was to examine the impact of maternal stress and MC-E on maternal and child biological responses (salivary cortisol and testosterone) and child health outcome in mother-child dyads of preschool children (3-5.9 years) in a low socioeconomic setting. METHODS: Observational and biobehavioral data were collected from 50 mother-child dyads in a preschool setting. Assessments included maternal stress with the Perceived Stress Scale, child health outcomes with the Pediatric Quality of Life Inventory, and MC-E with videotaped mother-child interactions and scored with the Keys to Interactive Parenting Scale. Morning and evening saliva samples were collected from mother and child for biological assays. RESULTS: Maternal stress was negatively correlated with MC-E (r = -.32, p < .05) and child health outcome (r = -.33, p < .05). Lower levels of MC-E predicted higher morning cortisol (p = .02) and higher morning and bedtime testosterone levels in children (p = .03 and p = .04, respectively). Child biological responses did not predict child health outcome. DISCUSSION: Maternal stress and MC-E during mother-child interactions play a significant role in the regulation of child stress physiology and child health outcome. Elevated cortisol and testosterone related to high maternal stress and low MC-E may increase the child's vulnerability to negative health outcomes-if sustained. More biobehavioral research is needed to understand how parent-child interactions affect child development and health outcomes in early childhood.

Animal-Assisted Activity in Critically Ill Older Adults: A Randomized Pilot and Feasibility Trial.

BACKGROUND: Limited evidence suggests the efficacy of animal-assisted activities (AAA) in improving biobehavioral stress responses in older patients in intensive care units (ICUs). OBJECTIVES: To assess the feasibility of an AAA (dog) intervention for improving biobehavioral stress response, measured by self-reported stress and anxiety and salivary cortisol, C-reactive protein, and interleukin-1ß in older ICU patients, we examined enrollment, attrition, completion, data collection, and biobehavioral stress responses. METHODS: ICU patients ≥60 years old were randomly assigned to a 10-min AAA intervention or control/usual ICU care. Attitudes toward pets were assessed before the intervention. Self-reported stress and anxiety and salivary stress biomarkers were collected before and after the intervention and the usual care condition. RESULTS: The majority of patients were ineligible due to lack of decisional capacity, younger age, inability to provide saliva specimens, or critical illness. Though 15 participants were randomly allocated (AAA = 9; control = 6), only 10 completed the study. All participants completed the questionnaires; however, saliva specimens were significantly limited by volume. AAA was associated with decreases in stress and anxiety. Biomarker results were variable and revealed no specific trends associated with stress responses. Conclusions: Barriers to recruitment included an insufficient number of patients eligible for AAA based on hospital policy, difficulty finding patients who met study eligibility criteria, and illness-related factors. Recommendations for future studies include larger samples, a stronger control intervention such as a visitor without a dog, greater control over the AAA intervention, and use of blood from indwelling catheters for biomarkers.

Predicting Daily Sheltering Arrangements among Youth Experiencing Homelessness Using Diary Measurements Collected by Ecological Momentary Assessment.

Youths experiencing homelessness (YEH) often cycle between various sheltering locations including spending nights on the streets, in shelters and with others. Few studies have explored the patterns of daily sheltering over time. A total of 66 participants completed 724 ecological momentary assessments that assessed daily sleeping arrangements. Analyses applied a hypothesis-generating machine learning algorithm (component-wise gradient boosting) to build interpretable models that would select only the best predictors of daily sheltering from a large set of 92 variables while accounting for the correlated nature of the data. Sheltering was examined as a three-category outcome comparing nights spent literally homeless, unstably housed or at a shelter. The final model retained 15 predictors. These predictors included (among others) specific stressors (e.g., not having a place to stay, parenting and hunger), discrimination (by a friend or nonspecified other; due to race or homelessness), being arrested and synthetic cannabinoids use (a.k.a., "kush"). The final model demonstrated success in classifying the categorical outcome. These results have implications for developing just-in-time adaptive interventions for improving the lives of YEH.

Heart rate variability in response to pain stimulus in VLBW infants followed longitudinally during NICU stay.

The objective of this longitudinal study, conducted in a neonatal intensive care unit, was to characterize the response to pain of high-risk very low birth weight infants (<1,500 g) from 23 to 38 weeks post-menstrual age (PMA) by measuring heart rate variability (HRV). Heart period data were recorded before, during, and after a heel lanced or wrist venipunctured blood draw for routine clinical evaluation. Pain response to the blood draw procedure and age-related changes of HRV in low-frequency and high-frequency bands were modeled with linear mixed-effects models. HRV in both bands decreased during pain, followed by a recovery to near-baseline levels. Venipuncture and mechanical ventilation were factors that attenuated the HRV response to pain. HRV at the baseline increased with post-menstrual age but the growth rate of high-frequency power was reduced in mechanically ventilated infants. There was some evidence that low-frequency HRV response to pain improved with advancing PMA.

Randomization for clinical research: an easy-to-use spreadsheet method.

In this article, we illustrate a new method for random selection and random assignment that we developed in a pilot study for a randomized clinical trial. The randomization database is supported by a commonly available spreadsheet. Formulas were written for randomizing participants and for creating a "shadow" system to verify integrity of the randomization. Advantages of this method are that it is easy to use, effective, and portable, allowing it to be shared among multiple investigators at multiple study sites. Clinical researchers may find the method useful for research projects that are pilot studies or conducted with limited funding.

Contribution of skin temperature regularity to the risk of developing pressure ulcers in nursing facility residents.

OBJECTIVES: The purpose of the study was to determine whether characterizing skin temperature regulation as a functional property of the skin as it relates to tissue tolerance improves the clinician's understanding of pressure ulcer risk prediction. DESIGN: A 2-group time-series design was used to observe skin temperature regularity (entropy) and self-similarity (spectral exponent). METHODS: Twenty nursing facility residents wore skin temperature monitors continuously for 5 days. One bathing episode was observed because bathing is a commonly occurring care procedure. PRIMARY OUTCOME MEASURE: Difference in skin temperature multiscale entropy and spectral exponent by risk category and pressure ulcer outcome. RESULTS: Multiscale entropy (MSE) for skin temperature was lowest in those who developed pressure ulcers, F1,18 = 35.14, P < .001. Skin temperature mean MSE, F1,17 = 5.55, P = .031 and the skin temperature spectral exponent, F1,17 = 6.19, P = .023 differentiated the risk groups. The change in skin temperature entropy during bathing was significant, t(16) = 2.55, P = .021. CONCLUSIONS: Skin temperature MSE and the spectral exponent were significantly different between low-risk and higher risk residents and residents who did and did not develop pressure ulcers. The study supports measurement of skin temperature regulation as a component of tissue tolerance to pressure.

Clinical and demographic predictors of concussion resolution in adolescents: A retrospective study.

Concussions in adolescents are a growing public health concern. The aim of this study was to identify clinical (e.g., concussion history, migraine history, learning disabilities/ADHD) and demographic factors (e.g., age, sex, race, health insurance status, mechanism of injury, education) that predict concussion recovery times. In a retrospective cohort study of 118 adolescents 13-19 years old who were evaluated for an acute concussion (≤10 days from injury), recovery times were calculated from the date of concussive injury to the date of clearance to return to play and/or normal activities. The median time to recovery was 17 days. Predictors of longer recovery included ADHD (HR = .221, 95% CI = .095 - .514, p < .001) and prior concussion (HR = .564, 95% CI = .332 - .959, p = .03). Student athletic insurance and public insurance were predictors of shorter recovery times (HR = 3.98, 95% CI = 1.25 - 12.65, p = .02 and HR = 3.33, 95% CI = 1.09 - 10.15, p = .03, respectively). In adolescents with prior concussion or ADHD, clearance to return to play/ normal activities may be delayed. Further research is needed to validate the impact of SES/health insurance on concussion recovery time.

Cranial Electrotherapy Stimulation for the Management of Depression, Anxiety, Sleep Disturbance, and Pain in Patients With Advanced Cancer: A Preliminary Study.

CONTEXT: Cranial electrotherapy stimulation (CES) is a safe modulation of brain activity for treating depression, anxiety, insomnia, and pain. However, there are no published studies in patients with advanced cancer (ACPs). OBJECTIVES: The aim of the study was to determine the feasibility and preliminary efficacy of a four-week CES intervention on depression, anxiety, sleep disturbance, and pain scores. Concurrent salivary biomarker studies were conducted. METHODS: In this one group open label pre- and post-intervention study with a four-week CES intervention, ACPs with one or more of four moderate intensity (≥3/10) Edmonton Symptom Assessment Scale (ESAS) symptoms (depression, anxiety, sleep disturbance, and pain) were eligible. Adherence (0%-100%), satisfaction rates (0-10), and safety were assessed. ESAS, Hospital Anxiety and Depression Scale (HADS), Pittsburgh Sleep Quality Index, Brief Pain Inventory, and salivary levels (cortisol, alpha amylase, C-reactive protein, and interleukin-1ß, and interleukin-6) were assessed from baseline to Week 4. RESULTS: Thirty-three of 36 patients (92%) completed the CES. Median (interquartile range) adherence CES use and satisfaction scores were 93% (89-100) and 10% (9-10), respectively, and the adherence criteria was met in the study. CES use was safe (no Grade 3 or higher adverse events). HADS anxiety (P < 0.001), HADS depression (P = 0.024), ESAS anxiety (P = 0.001), ESAS depression (P = 0.025), Brief Pain Inventory pain (P = 0.013), Pittsburgh Sleep Quality Index daytime dysfunction (P = 0.002), and medication use (P = 0.006) scores improved after four-week CES treatment. CONCLUSION: In this preliminary study, we found that the use of CES was safe and feasible in ACP. The use of CES was associated with significant improvement of depression, anxiety, pain, and sleep scores. These findings support further studies of CES in ACP for symptom control.

Longitudinal assessment of heart rate variability in very low birth weight infants during their NICU stay.

BACKGROUND: Maturation of the autonomic nervous system has not been studied in high-risk very low birth weight (VLBW) infants in the first few weeks of life. AIM: To characterize developmental changes in autonomic nervous system activity of high-risk VLBW infants from 23 to 38 weeks post-menstrual age by measuring heart rate variability (HRV). STUDY DESIGN AND SUBJECTS: In this prospective cohort study 38 infants admitted to Children's Memorial Hermann Hospital NICU were longitudinally followed weekly or biweekly. Heart period data were recorded while infants were resting in active sleep. OUTCOME MEASURES: Growth of spectral power of HRV in low-frequency (0.05-0.25 Hz) and high-frequency (0.25-1.00 Hz) bands was modeled with linear mixed-effects models. The high-frequency power provides a measure of respiratory sinus arrhythmia (RSA). RESULTS: Low-frequency power increases with post-menstrual age, and intubated infants have lower HRV. The increase in low-frequency power is faster (0.50+/-0.12 dB/week) than the increase in RSA (0.17+/-0.09 dB/week). CONCLUSION: This longitudinal data exhibits developmental maturation of the RSA and of the low-frequency power of HRV in high-risk VLBW infants.

Cosinor analysis for temperature time series data of long duration.

The application of cosinor models to long time series requires special attention. With increasing length of the time series, the presence of noise and drifts in rhythm parameters from cycle to cycle lead to rapid deterioration of cosinor models. The sensitivity of amplitude and model-fit to the data length is demonstrated for body temperature data from ambulatory menstrual cycling and menopausal women and from ambulatory male swine. It follows that amplitude comparisons between studies cannot be made independent of consideration of the data length. Cosinor analysis may be carried out on serial-sections of the series for improved model-fit and for tracking changes in rhythm parameters. Noise and drift reduction can also be achieved by folding the series onto a single cycle, which leads to substantial gains in the model-fit but lowers the amplitude. Central values of model parameters are negligibly changed by consideration of the autoregressive nature of residuals.

Effects of Cognitive Behavior Therapy on Heart Rate Variability in Young Females with Constipation-predominant Irritable Bowel Syndrome: A Parallel-group Trial.

BACKGROUND/AIMS: The relation between heart rate variability (HRV) as non-invasive biomarkers of autonomic function and cognitive behavior therapy (CBT) as non-pharmacological treatments has rarely been examined in patients with constipation-predominant irritable bowel syndrome (IBS-C). The purpose of this study is to evaluate the efficacy of an 8-week CBT intervention on HRV and IBS symptoms, and the correlation of changes in HRV with changes in IBS symptoms among young female nursing students with IBS-C. METHODS: This study consisted of an exploratory subgroup analysis of 43 participants with IBS-C who had been randomly assigned to receive either 8 weeks of CBT (n = 23) or general medical information (control, n = 20). At baseline and 8, 16, and 24 weeks, participants completed a questionnaire assessing their gastrointestinal (GI) symptoms, anxiety, depression, and stress, and their HRV was measured via electrocardiography. RESULTS: At the 8-week follow-up, the high-frequency (HF) power was significantly higher, and the low-frequency (LF)/HF ratio was lower in the CBT group than in the control group (P < 0.001 for both), and the severity of GI symptoms (P = 0.003), anxiety (P < 0.001), depression (P < 0.001), and stress (P < 0.001) was significantly lower in the CBT group than in the control group. Changes in the HF power were significantly and inversely associated with changes in GI symptoms, anxiety, depression, and stress at 16 and 24 weeks (P < 0.05 for all; range of r from -0.37 to -0.68). Changes in the LF/HF ratio were also significantly and positively associated with changes in GI symptoms, anxiety, depression, and stress at 16 and 24 weeks (P < 0.05 for all; range of r from 0.38 to 0.60). CONCLUSIONS: CBT was effective in managing symptoms in young IBS-C patients and the improvement of symptoms was sustained at 24 weeks following the completion of CBT. Furthermore, indirect measurement of autonomic function using HRV may be a useful objective parameter for assessing response to CBT in young IBS-C patients.

Pressure ulcer risk detection from complexity of activity.

Activity levels in nursing home residents were measured with accelerometers over one week as part of a multicenter randomized controlled trial, and complexity of the resulting activity patterns were characterized. Among 813 study participants on whom activity data had been collected, 16 participants developed pressure ulcers by the end of the study. The fractal dimension D0 of the activity series was lower (p=0.039) in residents who developed pressure ulcers than in controls matched on the basis of race, randomization group, score on the Braden scale, and diagnoses of cardiovascular disease and dementia. Hurst exponents indicated that the scaling of the power spectrum was close to 1/f in pressure ulcer cases. At timescales exceeding 30 minutes, approximate entropy tended to be higher in the controls than in the pressure ulcer cases. The fractal structure of the activity time series and its information content offer the ability to predict higher risk of development of pressure ulcers in nursing home residents.

Two-year prognosis after acute coronary syndrome in younger patients: Association with feeling depressed in the prior year, and BDI-II score and Endothelin-1.

OBJECTIVE: To examine the effects of depressive symptoms and Endothelin (ET)-1 on 2-year prognosis in younger patients with acute coronary syndrome (ACS). Depression is associated with poor post-ACS prognosis; however, few investigations have focused on younger patients. Importantly, the studies that did emphasize younger patients suggested that the influence of depression on prognosis could be more robust in younger subgroups. The particular links between depression and poor prognosis in younger patients have yet to be definitively determined. ET-1 is a potent endogenous vasoconstrictor that has been previously linked to adverse post-ACS outcomes. METHODS: The sample (n=153) included male (age≤50years) and female (age≤55years) ACS patients. Blood samples for ET-1 assessment were collected within 2-3h of ACS hospital admission. Depressive symptoms were assessed with the Beck Depression Inventory (BDI) II within 2-5days of admission. The primary outcome was defined as a composite of major adverse cardiovascular events (MACE), including recurrent myocardial infarction, emergent coronary revascularization, and all-cause mortality within 2years after index admission. RESULTS: During the follow-up period, 23 patients experienced MACE. Neither the BDI-II score nor ET-1 predicted MACE in unadjusted analyses or in analyses adjusted for demographic characteristics, comorbidities and troponin levels. In the supplementary analyses, feeling depressed in the year preceding ACS predicted MACE. CONCLUSIONS: In this cohort of younger ACS patients, feeling depressed in the year preceding ACS admission predicted MACE in the 2years after baseline ACS event, while neither the BDI-II score, nor circulating ET-1 level predicted this outcome.

Effect of self-monitoring clusters on weight and hemoglobin A1c.

We investigated whether participants with higher adherence to smartphone or paper-based self-monitoring of diet, physical activity, blood glucose, and body weight have a beneficial impact on their body weight and hemoglobin A1c measures over a 3-month period. Data were combined from two intervention studies that recruited overweight or obese participants with type 2 diabetes. Three clusters of adherence to self-monitoring were identified. Participants in a cluster with high adherence to self-monitoring of diet and moderate adherence to glucose self-monitoring were found to have the biggest reductions in weight and hemoglobin A1c, as compared to clusters with either high or low adherence to self-monitoring of all four factors.

Association between Daytime Activity, Fatigue, Sleep, Anxiety, Depression, and Symptom Burden in Advanced Cancer Patients: A Preliminary Report.

BACKGROUND: There is limited research in advanced cancer patients (ACP) regarding association between objectively measured daytime activity and sleep (as measured by actigraphy), patient characteristics, and cancer symptoms (fatigue, sleep, anxiety, depression, cachexia, and symptom distress scores [SDSs]). OBJECTIVES: Our aim of the study was to determine the association between mean daytime activity (MDTA) and the following items: fatigue (FACIT-F), SDSs (Edmonton Symptom Assessment Scale [ESAS]), sleep quality (Pittsburg Sleep Quality Index [PSQI]), objective sleep variables (OSV) (sleep onset, sleep efficacy, wake after sleep onset, total sleep time), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), body composition scores, and overall survival (OS). We also examined the association between sleep [PSQI and OSV scores] and FACIT-F, HADS, and ESAS. METHODS: Secondary analysis of a recent clinical trial of cancer-related fatigue in advanced cancer (NCT00424099). Association between MDTA and OSV (measured by actigraphy) during the first week of the study and patient characteristics, symptoms (FACIT-F, ESAS, HADS, and PSQI), and OS were analyzed. RESULTS: Seventy-nine eligible patients were evaluable. The median age was 57 years. Median MDTA was 248.43 counts/minute. Multivariate analysis shows that low MDTA was significantly associated with age, gender, Functional Assessment of Cancer Therapy (FACT)-Functional Well-Being (FWB), ESAS dyspnea, HADS-anxiety, and total sleep time. MDTA was not associated with FACIT-F (p = 0.997) and OS (p = 0.18). Sleep quality (PSQI) was significantly associated with FACIT-F, HADS, ESAS anxiety, and depression, but none of these variables was associated with OSV. CONCLUSION: In ACP, lower MDTA was significantly associated with age, gender, FACT-FWB, ESAS dyspnea, HADS-anxiety, and total sleep time. Both sleep quality and cancer-related fatigue scores were strongly associated with depression and anxiety. More research is needed.

Pattern of active and inactive sequences of diabetes self-monitoring in mobile phone and paper diary users.

In a pilot randomized controlled trial involving overweight or obese participants with type 2 diabetes, we find that smartphone users have sharply higher adherence to self-monitoring of diet, physical activity, blood glucose, and body weight, as compared to paper diary users. By characterizing the pattern of adherence with the probability of continuation of active and inactive sequences of self-monitoring, we find that smartphone users have longer active sequences of self-monitoring of all four behaviors that were being monitored. Smartphone users are also quicker to resume self-monitoring of diet and physical activity after a lapse in self-monitoring, whereas paper diary users have shorter inactive sequences for monitoring blood glucose and body weight. The findings are informative for data collection methodology in this burgeoning area of research.