Positive reinforcement using praise text messaging: Can this be the way to optimize and maintain adherence behavior in teens with chronic conditions?

Medication nonadherence remains a major challenge among adolescents and young adults (AYA) with chronic medical conditions, including liver transplant,^1–3 and it has been associated with worse health outcomes and impaired health-related quality of life.^4–7 Mobile health (mHealth) or digital behavioral interventions have shown high acceptability and feasibility as well as promising efficacy improving adherence levels with important clinical benefits.^8–12 Nevertheless, cost-effectiveness of these interventions has not been established.¹³ Moreover, ongoing engagement with different interventions continues to be suboptimal.¹⁴ This dilemma brings two key questions: (1) what strategies can we use to optimize engagement with mHealth or digital behavioral interventions? (2) when and how often should patients receive or get the interventions? Is it only when low adherence or other predictors identified? And (3) what is the minimal effective intervention dose a given patient needs to achieve a reasonable adherence level with meaningful clinical benefits?

In this issue of Pediatric Transplantation, Sayegh and colleagues tried to answer some of these questions. The authors reported the results of a pilot randomized trial of a text messaging intervention with praise statements to improve adherence among AYA with liver transplant.¹⁵ The study included 35 participants with an age range of 13–21 years old, and it was focused primarily on assessing feasibility and acceptability of the intervention.¹⁵ AYA on the intervention arm receiving praise text messaging were about 2.5 times more likely to report taking their medicine according to instructions and be highly confident in their ability to take their medicine, which were all statistically significant as well. Patients reported high acceptability of and satisfaction with the intervention.¹⁵

The study had a few key strengths.¹⁵ Using text messaging through REDCap is an interesting, economic approach (low-cost, <1 cent, and feasible, <10 minutes, per participant) that can be replicated across different institutions and for a variety of chronic medical conditions.¹⁵ The authors used validated measures to evaluate study outcomes over time and followed a rigorous statistical analysis plan. Few weaknesses should be noted too.¹⁵ The study lacked an established theoretical framework for behavioral change, which the authors acknowledged and suggested the use of the Information-Motivation-Behavioral Skills Model. Other models could also be considered, such as the Behavior Change Wheel with COM-B (Capability, Opportunity, Motivation, and Behavior) Model or the Pediatric Self-Management Model. Additionally, praise text messages were one-way, not immediate, and not personalized enough, which all was included during participants’ feedback. Finally, laboratory markers of adherence were not well correlated with self-report data, and the use of other measures of adherence could have been helpful as well.

In conclusion, using praise text messaging seems to be a promising approach for engaging AYA with liver transplant and helping to improve adherence levels compared to standard of care. More customization of the messages as well as immediate feedback through a two-way process maybe more preferred by patients and could increase the likelihood of engagement overtime. Providing the research or clinical team with indicators whether they were delivered or received or not may have benefits to minimize dropout rates. Finally, integration with electronic medical records may facilitate onboarding patients and further streamline the process in a busy clinical setting.

Abbreviations:

AYA

adolescents and young adults

COM-B

Capability, Opportunity, Motivation, and Behavior

mHealth

mobile health

Data availability statement:

Not applicable (no data available for this editorial manuscript)