Original articleReview articleAre electronic diaries useful for symptoms research? A systematic review
Introduction
Diary studies, in which patients record their symptoms or thoughts regularly, have been a feature of psychosomatic research for over 25 years [1]. Traditionally, they have been completed on paper and used to track the variation of a single symptom or interactions between symptoms and other variables such as mood [2] or stress [3].
Compared to conventional questionnaire studies, diaries are less prone to recall bias [4]. Recall bias is potentially a major confounder in symptoms research, as retrospective recall is affected by both current state and experiences since the recalled event [5]. Diary studies are associated with their own unique problems, and there have been doubts about both the accuracy and the timing of responses, particularly their susceptibility to being completed from memory after the stated time [3], [6].
Since the early 1990s, developments in handheld computer technology have offered an opportunity to exploit electronic diaries, into which users enter data via a touch screen and a stylus. User-friendliness is achieved by selecting options from on-screen lists or by completing Likert-type or visual analog scales (VAS). All entries are date stamped and time stamped, and data are stored in the device for later retrieval either by connection to another computer for download or by telephone. Electronic recording of symptom information has start-up costs higher than those of other methods (handheld devices typically range in price from 100 to 400 euros or US dollars and require additional modification and programming before use). However, a number of free and commercial software programs for developing handheld computer diaries are available [7], and principles of electronic diary design have been published [8]. Electronic diaries are being increasingly used in a wide range of clinical and research circumstances, both for condition monitoring and as a primary data collection method for pharmacological trials.
Traditionally, paper diaries have been completed once daily, typically toward the end of the day, but this procedure is prone to recall bias, with selective memory for both the most severe and the most recent events [4]. In recent years, Schwartz and Stone [9] have pioneered a technique known as ecological momentary assessment in which multiple data entries are requested each day and the subject is asked to record how one feels at that point in time. Such studies have been particularly valuable in addiction research, where moment-to-moment changes may have major implications for relapse [10]. To avoid repetition at set times of day, electronic diaries for this type of study are set to sound an alarm at semirandom intervals.
Electronic diary studies generate data with many repeated measures of multiple variables, typically with 50-150 time points. While simple monitoring of trends may be sufficient for descriptive studies of day-to-day variation, more complex study designs, such as those seeking associations or causal sequences, require particular caution in interpretation. Most time-series data from diary studies show marked autocorrelation [4], [9] whereby values depend on preceding values in the series. This violates the assumption of independence, which underlies parametric statistical methods such as multivariate regression [11].
Three main analytical approaches are used. In the first approach, data are treated to remove autocorrelation and trend, either by differencing or by the use of specific time-series modeling techniques such as autoregressive moving average models [3]. The second approach uses multilevel modeling (MLM) techniques in order to carry out analysis at both within-person and between-persons levels [11], [12]. Finally, there are specific true multivariate time-series analysis methods, which require both long data series and considerable statistical skills [13]. New techniques from nonlinear science have potential but have not yet been tested adequately [14].
Section snippets
Aims
We conducted a systematic qualitative review of electronic symptom diary studies in pain and symptoms research, which either evaluated their accuracy and usability or investigated the associations between physical and psychological variables. The aims were: (a) to determine whether electronic diaries generate valid data for symptoms research; and (b) to summarize evidence regarding the interaction of somatic and psychological symptoms that has been acquired from electronic diary studies.
Methods
Searches in Medline, Embase, and PsycInfo databases for studies of symptom disorders using electronic diaries between 1985 and November 2005 were carried out. The specific search criteria were for intersections of the following: (pain or symptom$ or somatoform) and (diary or diaries or handheld) and (computer$ or electronic). Relevant additional studies identified from references were reviewed. A further search for electronic diary studies in psychology and using the term “ecological momentary
Results
The search strategy identified 32 papers from 24 studies. It also identified three narrative reviews of methodological issues in diary studies [4], [15], [16] and a set of reporting recommendations [11]. Studies were allocated into one of two groups based on whether they reported interactions of symptoms and other variables (Group 1), or whether they were concerned solely with the accuracy or usability of electronic diaries (Group 2). Twenty-one papers from 15 studies were allocated to Group 1,
Discussion
This review found an increasing number of studies using and evaluating electronic diaries. It suggests that electronic diaries are both acceptable to users and sufficiently accurate for research purposes. Data from electronic diaries are easy to obtain and, with care, are amenable to a variety of analysis methods. Studies comparing electronic and pen-and-paper diaries have cast doubts over the accuracy of the latter, as the documented tendency to record data retrospectively in paper diaries
Conclusion
Electronic diaries are a powerful and efficient tool—fit for collecting complex self-report data. By recording marked variations in symptoms and related constructs, they offer a unique insight into the processes of symptom experience. To be useful, however, the data that they capture must be meaningful and compatible with theories of how constructs change, both over time and in relation to each other.
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