The Feasibility of Smartwatch Micro Ecological Momentary Assessment for Tracking Eating Patterns of Malaysian Children and Adolescents in the SEACO Child Health Update 2020: a Cross-Sectional Study

Background Mobile-phone ecological momentary assessment (EMA) methods are a well-established measure of eating and drinking behaviours, but compliance can be poor. Micro-EMA (μEMA), which collects information with single tap response to brief questions on smartwatches, offers a novel application that may improve response rates. To our knowledge, there is no data evaluating μEMA to measure eating habits in children or in low-to-middle income countries. Objective We investigated the feasibility of micro-EMA to measure eating patterns in Malaysian children and adolescents. Methods We invited 100 children and adolescents aged 7-18 in Segamat, Malaysia to participate in 2021-2022. Smartwatches were distributed to 83 children and adolescents who agreed to participate. Participants were asked to wear the smartwatch for 8 days and respond to 12 prompts hourly from 8am to 8pm, asking for information on their meals, snacks and drinks consumed. A questionnaire captured their experiences using the smartwatch and μEMA interface. Response rate (proportion of prompts responded to) assessed participants’ adherence. We explored associations between response rate with time of day, across days, age and sex using multi-level binomial logistic regression modelling. Results Eighty-two participants provided usable smartwatch data. The median number (inter-quartile range) of meals, drinks and snacks per day were 2 (2 - 4), 3 (1 - 5) and 1 (0 - 2) respectively on the first day of the study. The median response rate across the study was 68% (quartiles: [50, 83]). The response rate decreased across study days from 74% (68, 78) on day 1 to 40% (30, 50) on day 7 (odds ratio [OR] per study day: 0.73 [95% confidence interval [CI]: 0.64, 0.83]). Response rate was lowest at the start of the day, and highest between the hours of 12:00-14:00. Female participants responded to more prompts than male participants (OR: 1.72 95% CI: [1.03, 2.86). There was no evidence of differential response by age (OR: 0.73 95% CI: [0.41, 1.28]). Most participants (65%) rated their experience using the smartwatch positively, with 33% saying they were happy to participate in future studies using the smartwatch. For children that didn’t wear the smartwatch for the full study duration (n=22), discomfort was the most common complaint (41%). Conclusions In this study of the feasibility of μEMA on smartwatches to measure eating in Malaysian children we found the method was acceptable. However, response rates declined across study days resulting in substantial missingness. Future studies (e.g. through focus groups) should explore approaches to improving response to event prompts, trial alternative devices to increase children’s comfort and evaluate revised protocols for reporting of intake events.