Chiang N, Guo M, Amico KR, Atkins L, Lester RT. (2018). Interactive two-way mHealth interventions for improving medication adherence: An evaluation using the Behavior Change Wheel framework. JMIR mHealth and uHealth. 6(4): e87. doi: 10.2196/mhealth.9187
Researchers used the Behavior Change Wheel (BCW) to theorize potential mechanisms of action describing WelTel’s influence on antiretroviral (ART) medication adherence. The BCW includes 3 levels of influence on behavior change: sources of behavior, intervention functions, and policy factors. Sources of behavior were derived from the Capability Opportunity Motivation – Behavior (COM-B) model, which asserts a person needs capability, opportunity, and motivation to engage in a behavior. Intervention functions described strategies to influence behavior change (i.e., education, persuasion, modeling, incentivization, coercion, training, enablement, environmental restructuring, restrictions). Policy factors described outside factors that influence behavior (i.e., service provision, marketing, environmental/social planning, legislation, regulation, fiscal measures, guidelines). Researchers mapped barriers to ART adherence onto COM-B components. Researchers then identified behavior change techniques (BCTs) utilized in the automated and two-way text messaging components of WelTel and linked these BCTs to potential mechanisms of action. Researchers identified 9 barriers to ART adherence (i.e., stigma, side effects, confusing instructions, forgetting medication, skepticism about ART, not understanding importance of adherence, feeling well and forgoing treatment, medication access, competing priorities). Researchers determined automated text messaging prompting influenced ART adherence through environmental restructuring. Two-way communication utilizes prompts, social support, reduction of negative emotions, a credible information source, instructions, and natural consequences to influence behavior through environmental restructuring, enablement, education, persuasion, training. Researchers described 2 potential mechanisms of action explaining WelTel’s impact on ART adherence: 1) WelTel influences users’ opportunity and automatic motivation through environmental restructuring and enablement (i.e., delivery of an external trigger and social support), and 2) WelTel influences users’ capability, opportunity, and motivation through education, persuasion, training, and enablement (i.e., delivery of relevant information and social support).