Inbal Nahum-Shani

Anna L. Trella, Kelly W. Zhang, Inbal Nahum-Shani et al. · harvard

Online reinforcement learning (RL) algorithms are increasingly used to personalize digital interventions in the fields of mobile health and online education. Common challenges in designing and testing an RL algorithm in these settings include ensuring the RL algorithm can learn and run stably under real-time constraints, and accounting for the complexity of the environment, e.g., a lack of accurate mechanistic models for the user dynamics. To guide how one can tackle these challenges, we extend the PCS (Predictability, Computability, Stability) framework, a data science framework that incorporates best practices from machine learning and statistics in supervised learning (Yu and Kumbier, 2020), to the design of RL algorithms for the digital interventions setting. Further, we provide guidelines on how to design simulation environments, a crucial tool for evaluating RL candidate algorithms using the PCS framework. We illustrate the use of the PCS framework for designing an RL algorithm for Oralytics, a mobile health study aiming to improve users' tooth-brushing behaviors through the personalized delivery of intervention messages. Oralytics will go into the field in late 2022.

Anna L. Trella, Kelly W. Zhang, Inbal Nahum-Shani et al. · harvard

Dental disease is one of the most common chronic diseases despite being largely preventable. However, professional advice on optimal oral hygiene practices is often forgotten or abandoned by patients. Therefore patients may benefit from timely and personalized encouragement to engage in oral self-care behaviors. In this paper, we develop an online reinforcement learning (RL) algorithm for use in optimizing the delivery of mobile-based prompts to encourage oral hygiene behaviors. One of the main challenges in developing such an algorithm is ensuring that the algorithm considers the impact of the current action on the effectiveness of future actions (i.e., delayed effects), especially when the algorithm has been made simple in order to run stably and autonomously in a constrained, real-world setting (i.e., highly noisy, sparse data). We address this challenge by designing a quality reward which maximizes the desired health outcome (i.e., high-quality brushing) while minimizing user burden. We also highlight a procedure for optimizing the hyperparameters of the reward by building a simulation environment test bed and evaluating candidates using the test bed. The RL algorithm discussed in this paper will be deployed in Oralytics, an oral self-care app that provides behavioral strategies to boost patient engagement in oral hygiene practices.

Anna L. Trella, Kelly W. Zhang, Hinal Jajal et al. · harvard

Dental disease is a prevalent chronic condition associated with substantial financial burden, personal suffering, and increased risk of systemic diseases. Despite widespread recommendations for twice-daily tooth brushing, adherence to recommended oral self-care behaviors remains sub-optimal due to factors such as forgetfulness and disengagement. To address this, we developed Oralytics, a mHealth intervention system designed to complement clinician-delivered preventative care for marginalized individuals at risk for dental disease. Oralytics incorporates an online reinforcement learning algorithm to determine optimal times to deliver intervention prompts that encourage oral self-care behaviors. We have deployed Oralytics in a registered clinical trial. The deployment required careful design to manage challenges specific to the clinical trials setting in the U.S. In this paper, we (1) highlight key design decisions of the RL algorithm that address these challenges and (2) conduct a re-sampling analysis to evaluate algorithm design decisions. A second phase (randomized control trial) of Oralytics is planned to start in spring 2025.

Anna L. Trella, Susobhan Ghosh, Erin E. Bonar et al. · harvard

Online AI decision-making algorithms are increasingly used by digital interventions to dynamically personalize treatment to individuals. These algorithms determine, in real-time, the delivery of treatment based on accruing data. The objective of this paper is to provide guidelines for enabling effective monitoring of online decision-making algorithms with the goal of (1) safeguarding individuals and (2) ensuring data quality. We elucidate guidelines and discuss our experience in monitoring online decision-making algorithms in two digital intervention clinical trials (Oralytics and MiWaves). Our guidelines include (1) developing fallback methods, pre-specified procedures executed when an issue occurs, and (2) identifying potential issues categorizing them by severity (red, yellow, and green). Across both trials, the monitoring systems detected real-time issues such as out-of-memory issues, database timeout, and failed communication with an external source. Fallback methods prevented participants from not receiving any treatment during the trial and also prevented the use of incorrect data in statistical analyses. These trials provide case studies for how health scientists can build monitoring systems for their digital intervention. Without these algorithm monitoring systems, critical issues would have gone undetected and unresolved. Instead, these monitoring systems safeguarded participants and ensured the quality of the resulting data for updating the intervention and facilitating scientific discovery. These monitoring guidelines and findings give digital intervention teams the confidence to include online decision-making algorithms in digital interventions.

Susobhan Ghosh, Yongyi Guo, Pei-Yao Hung et al.

The escalating prevalence of cannabis use poses a significant public health challenge globally. In the U.S., cannabis use is more prevalent among emerging adults (EAs) (ages 18-25) than any other age group, with legalization in the multiple states contributing to a public perception that cannabis is less risky than in prior decades. To address this growing concern, we developed MiWaves, a reinforcement learning (RL) algorithm designed to optimize the delivery of personalized intervention prompts to reduce cannabis use among EAs. MiWaves leverages domain expertise and prior data to tailor the likelihood of delivery of intervention messages. This paper presents a comprehensive overview of the algorithm's design, including key decisions and experimental outcomes. The finalized MiWaves RL algorithm was deployed in a clinical trial from March to May 2024.

Shuangning Li, Lluis Salvat Niell, Sung Won Choi et al.

Mobile health aims to enhance health outcomes by delivering interventions to individuals as they go about their daily life. The involvement of care partners and social support networks often proves crucial in helping individuals managing burdensome medical conditions. This presents opportunities in mobile health to design interventions that target the dyadic relationship -- the relationship between a target person and their care partner -- with the aim of enhancing social support. In this paper, we develop dyadic RL, an online reinforcement learning algorithm designed to personalize intervention delivery based on contextual factors and past responses of a target person and their care partner. Here, multiple sets of interventions impact the dyad across multiple time intervals. The developed dyadic RL is Bayesian and hierarchical. We formally introduce the problem setup, develop dyadic RL and establish a regret bound. We demonstrate dyadic RL's empirical performance through simulation studies on both toy scenarios and on a realistic test bed constructed from data collected in a mobile health study.

Susobhan Ghosh, Yongyi Guo, Pei-Yao Hung et al.

The escalating prevalence of cannabis use, and associated cannabis-use disorder (CUD), poses a significant public health challenge globally. With a notably wide treatment gap, especially among emerging adults (EAs; ages 18-25), addressing cannabis use and CUD remains a pivotal objective within the 2030 United Nations Agenda for Sustainable Development Goals (SDG). In this work, we develop an online reinforcement learning (RL) algorithm called reBandit which will be utilized in a mobile health study to deliver personalized mobile health interventions aimed at reducing cannabis use among EAs. reBandit utilizes random effects and informative Bayesian priors to learn quickly and efficiently in noisy mobile health environments. Moreover, reBandit employs Empirical Bayes and optimization techniques to autonomously update its hyper-parameters online. To evaluate the performance of our algorithm, we construct a simulation testbed using data from a prior study, and compare against commonly used algorithms in mobile health studies. We show that reBandit performs equally well or better than all the baseline algorithms, and the performance gap widens as population heterogeneity increases in the simulation environment, proving its adeptness to adapt to diverse population of study participants.

Anna L. Trella, Kelly W. Zhang, Inbal Nahum-Shani et al. · harvard

Online reinforcement learning (RL) algorithms offer great potential for personalizing treatment for participants in clinical trials. However, deploying an online, autonomous algorithm in the high-stakes healthcare setting makes quality control and data quality especially difficult to achieve. This paper proposes algorithm fidelity as a critical requirement for deploying online RL algorithms in clinical trials. It emphasizes the responsibility of the algorithm to (1) safeguard participants and (2) preserve the scientific utility of the data for post-trial analyses. We also present a framework for pre-deployment planning and real-time monitoring to help algorithm developers and clinical researchers ensure algorithm fidelity. To illustrate our framework's practical application, we present real-world examples from the Oralytics clinical trial. Since Spring 2023, this trial successfully deployed an autonomous, online RL algorithm to personalize behavioral interventions for participants at risk for dental disease.

Ziping Xu, Hinal Jajal, Sung Won Choi et al.

Medication adherence is critical for the recovery of adolescents and young adults (AYAs) who have undergone hematopoietic cell transplantation (HCT). However, maintaining adherence is challenging for AYAs after hospital discharge, who experience both individual (e.g. physical and emotional symptoms) and interpersonal barriers (e.g., relational difficulties with their care partner, who is often involved in medication management). To optimize the effectiveness of a three-component digital intervention targeting both members of the dyad as well as their relationship, we propose a novel Multi-Agent Reinforcement Learning (MARL) approach to personalize the delivery of interventions. By incorporating the domain knowledge, the MARL framework, where each agent is responsible for the delivery of one intervention component, allows for faster learning compared with a flattened agent. Evaluation using a dyadic simulator environment, based on real clinical data, shows a significant improvement in medication adherence (approximately 3%) compared to purely random intervention delivery. The effectiveness of this approach will be further evaluated in an upcoming trial.

Anna L. Trella, Kelly W. Zhang, Stephanie M. Carpenter et al.

Dental disease is still one of the most common chronic diseases in the United States. While dental disease is preventable through healthy oral self-care behaviors (OSCB), this basic behavior is not consistently practiced. We have developed Oralytics, an online, reinforcement learning (RL) algorithm that optimizes the delivery of personalized intervention prompts to improve OSCB. In this paper, we offer a full overview of algorithm design decisions made using prior data, domain expertise, and experiments in a simulation test bed. The finalized RL algorithm was deployed in the Oralytics clinical trial, conducted from fall 2023 to summer 2024.

Supriya Nagesh, Alexander Moreno, Stephanie M. Carpenter et al.

Ecological Momentary Assessments (EMAs) are an important psychological data source for measuring current cognitive states, affect, behavior, and environmental factors from participants in mobile health (mHealth) studies and treatment programs. Non-response, in which participants fail to respond to EMA prompts, is an endemic problem. The ability to accurately predict non-response could be utilized to improve EMA delivery and develop compliance interventions. Prior work has explored classical machine learning models for predicting non-response. However, as increasingly large EMA datasets become available, there is the potential to leverage deep learning models that have been effective in other fields. Recently, transformer models have shown state-of-the-art performance in NLP and other domains. This work is the first to explore the use of transformers for EMA data analysis. We address three key questions in applying transformers to EMA data: 1. Input representation, 2. encoding temporal information, 3. utility of pre-training on improving downstream prediction task performance. The transformer model achieves a non-response prediction AUC of 0.77 and is significantly better than classical ML and LSTM-based deep learning models. We will make our a predictive model trained on a corpus of 40K EMA samples freely-available to the research community, in order to facilitate the development of future transformer-based EMA analysis works.

Ashley E. Walton, Linda M. Collins, Predrag Klasnja et al.

Just-in-time adaptive interventions (JITAIs) are time-varying adaptive interventions that use frequent opportunities for the intervention to be adapted such as weekly, daily, or even many times a day. This high intensity of adaptation is facilitated by the ability of digital technology to continuously collect information about an individual's current context and deliver treatments adapted to this information. The micro-randomized trial (MRT) has emerged for use in informing the construction of JITAIs. MRTs operate in, and take advantage of, the rapidly time-varying digital intervention environment. MRTs can be used to address research questions about whether and under what circumstances particular components of a JITAI are effective, with the ultimate objective of developing effective and efficient components. The purpose of this article is to clarify why, when, and how to use MRTs; to highlight elements that must be considered when designing and implementing an MRT; and to discuss the possibilities this emerging optimization trial design offers for future research in the behavioral sciences, education, and other fields. We briefly review key elements of JITAIs, and then describe three case studies of MRTs, each of which highlights research questions that can be addressed using the MRT and experimental design considerations that might arise. We also discuss a variety of considerations that go into planning and designing an MRT, using the case studies as examples.

Mashfiqui Rabbi, Meredith Philyaw-Kotov, Jinseok Li et al.

Mobile health (mHealth) applications are a powerful medium for providing behavioral interventions, and systematic reviews suggest that theory-based interventions are more effective. However, how exactly theoretical concepts should be translated into features of technological interventions is often not clear. There is a gulf between the abstract nature of psychological theory and the concreteness of the designs needed to build health technologies. In this paper, we use SARA, a mobile app we developed to support substance-use research among adolescents and young adults, as a case study of a process of translating behavioral theory into mHealth intervention design. SARA was designed to increase adherence to daily self-report in longitudinal epidemiological studies. To achieve this goal, we implemented a number of constructs from the operant conditioning theory. We describe our design process and discuss how we operationalized theoretical constructs in the light of design constraints, user feedback, and empirical data from four formative studies.

Alexander Moreno, Zhenke Wu, Jamie Yap et al.

Panel count data describes aggregated counts of recurrent events observed at discrete time points. To understand dynamics of health behaviors, the field of quantitative behavioral research has evolved to increasingly rely upon panel count data collected via multiple self reports, for example, about frequencies of smoking using in-the-moment surveys on mobile devices. However, missing reports are common and present a major barrier to downstream statistical learning. As a first step, under a missing completely at random assumption (MCAR), we propose a simple yet widely applicable functional EM algorithm to estimate the counting process mean function, which is of central interest to behavioral scientists. The proposed approach wraps several popular panel count inference methods, seamlessly deals with incomplete counts and is robust to misspecification of the Poisson process assumption. Theoretical analysis of the proposed algorithm provides finite-sample guarantees by expanding parametric EM theory to our general non-parametric setting. We illustrate the utility of the proposed algorithm through numerical experiments and an analysis of smoking cessation data. We also discuss useful extensions to address deviations from the MCAR assumption and covariate effects.