Abstract
BackgroundMedication adherence is an important but highly complex set of behaviors, which for life-threatening and infectious diseases such as HIV carry critical consequences for individual and public health. There is growing evidence that mobile phone text messaging interventions (mHealth) connecting providers with patients positively impact medication adherence, particularly two-way engagement platforms that require bidirectional communication versus one-way in which responses are not mandatory. However, mechanisms of action have not been well defined. The Behavior Change Wheel is a comprehensive framework for behavior change that includes an all-encompassing model of behavior known as Capability Opportunity Motivation-Behavior and is complemented by a taxonomy of behavior change techniques. Evaluating mHealth interventions for medication adherence using these tools could provide useful insights that may contribute to optimizing their integration into the healthcare system and successful scaling-up.ObjectiveThis study aimed to help address the current knowledge gap regarding how two-way mHealth interventions for medication adherence may work by applying the Behavior Change Wheel to characterize WelTel: an interactive digital health outreach platform with robust evidence for improving adherence to antiretroviral therapy.MethodsTo characterize how WelTel may promote medication adherence, we applied the Behavior Change Wheel to systematically (1) generate a behavioral diagnosis through mapping known antiretroviral therapy adherence barriers onto the Capability Opportunity Motivation-Behavior model of behavior, (2) specify the behavior change techniques that WelTel delivers, (3) link identified behavior change techniques to corresponding intervention functions of the Behavior Change Wheel, and (4) connect these behavior change techniques and intervention functions to respective Capability Opportunity Motivation-Behavior influences on behavior to determine potential mechanisms of action.ResultsOur evaluation of WelTel using the Behavior Change Wheel suggests that most of its impact is delivered primarily through its personalized communication component, in which 8 different behavior change techniques were identified and linked with 5 intervention functions (environmental restructuring, enablement, education, persuasion, and training). Its mechanisms of action in promoting antiretroviral therapy adherence may involve addressing all Capability Opportunity Motivation-Behavior influences on behavior (physical and psychological capability, physical and social opportunity, reflective and automatic motivation).ConclusionsSystematically unpacking the potential active ingredients of effective interventions facilitates the creation and implementation of more parsimonious, tailored, and targeted approaches. Evaluating WelTel using the Behavior Change Wheel has provided valuable insights into how and why such interactive two-way mHealth interventions may produce greater impact than one-way in addressing both nonintentional and intentional forms of nonadherence. The application of the Behavior Change Wheel for evidence synthesis across mHealth interventions targeting various conditions would contribute to strengthening the knowledge base regarding how they may work to impact medication adherence behavior.
Highlights
Medication Adherence Is a Significant Global ChallengeIn chronic disease management worldwide, only 50% of patients on average adhere to their prescribed long-term therapies [1]
Viral suppression achieved through adherence is essential for achieving global “90-90-90” targets declared by the Joint United Nations Programme on HIV/AIDS: by 2020, 90% of all people living with HIV will know their status, 90% of all people diagnosed as HIV-positive will receive uninterrupted antiretroviral therapy (ART), and 90% of all people taking ART will achieve viral suppression [5]
Barriers related to a lack of social opportunity may be appropriately mapped out onto both reflective and automatic motivation. This suggests that facilitating social opportunity could promote the latter Capability Opportunity Motivation-Behavior (COM-B) influences on behavior simultaneously, and this association could even contribute to inducing ART adherence synergistically
Summary
Medication Adherence Is a Significant Global ChallengeIn chronic disease management worldwide, only 50% of patients on average adhere to their prescribed long-term therapies [1]. Adherence to antiretroviral therapy (ART) for people living with HIV combats chronic infection through viral suppression, optimizes an individual’s immune recovery, mitigates drug resistance, and reduces odds of viral transmission [2,3,4]. Given that medication adherence is often subject to multilevel influences beyond the individual, investigating mechanisms of action through which interventions may promote this behavior facilitates the delivery of systematically created and targeted approaches. There is growing evidence that mobile phone text messaging interventions (mHealth) connecting providers with patients positively impact medication adherence, two-way engagement platforms that require bidirectional communication versus one-way in which responses are not mandatory. Evaluating mHealth interventions for medication adherence using these tools could provide useful insights that may contribute to optimizing their integration into the healthcare system and successful scaling-up
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