Technological advances in adherence interventions are not expected panacea
Technological advances in adherence interventions are not expected panacea
Electronic messaging can't do it all
Researchers and clinicians working on medication adherence interventions have a variety of technological tools to help them both measure and, theoretically, improve medication adherence.
The technology includes pager messaging, beeper reminders on pill bottles, cell phone texts and alarms, and others.
The problem is that even if people say their main reason for not taking their medication is because they forgot, the technology won't lift all obstacles to optimal adherence, says Peter J. Dunbar, MB, ChB, MBA, an associate professor of anesthesiology and an adjunct associate professor of health services at the University of Washington in Seattle, WA. Dunbar has studied adherence in both HIV and non-HIV research.
"If you look at the literature, the results of messaging technology is highly variable, from not being effective at all to being quite effective," Dunbar says.
It's naïve to think clinicians could ensure super adherence by giving HIV patients technologically-advanced alarms and reminder devices, he says.
"If that were the case then every bottle of penicillin would come with an electronic cap with reminder, and they could do this for less than a dollar," Dunbar says. "The bottle beeps, and if it was that easy we'd be done."
The trouble is that adherence is a behavioral issue, and reminding people that it's time to take their medication addresses only one part of the problem, he says.
Behavioral obstacles include a lack of motivation, which might apply to people who will ignore the beeping alarm. Or, patients might feel they need a medication vacation, and they stop taking pills because of their fatigue with the regimen. Side effects also account for some adherence issues, and many HIV patients simply are overwhelmed by other issues in their lives, and medication adherence is at the bottom of their priority list.
The key is to gear interventions, including those that have technology tools, toward addressing the behavioral obstacles, Dunbar says.
Making HIV medicine-taking a routine daily process could work in the same way oral contraceptions work for many women, he notes.
"Ninety% of women taking oral contraceptions take these pills each day and don't miss doses," Dunbar says.
Now that HIV medications are available in a once-daily pill, adherence should improve, but HIV adherence remains an issue, he adds.
This is where messaging technology, combined with sociobehavioral interventions, could be effective with certain HIV patients.
If technology is used just as a reminder then it might work for very short term adherence improvement, but adherence will fall off in the long-run, as has been shown in many studies, Dunbar notes.
"If these things worked, they'd be used by everybody," he says.
"What I believe from messaging technology is that you have to have the messaging technology tailored to the individual," Dunbar says. "The content of the message is far more important than it's given credit in the literature."
In one of Dunbar's early studies using wireless messaging, dating back to the mid-1990s when such technology was in its infancy, investigators found that patients responded very well to personalized messages. The messages used their names and were created to be engaging and interesting, and study subjects were excited and positive with the way the message was delivered, Dunbar recalls.
"It was pilot work," he adds. "Ever since then we've been trying to resynthesize and redevelop that initial enthusiasm people had for messaging."
Messaging technology now is ubiquitous and perhaps less exciting to people in a world with Twitter, Facebook, iPhones, and Blackberrys. But new technology, combined with the right delivery can still be a powerful hook to many people, Dunbar says.
The key is to use the technology in a way that creates a personal relationship between the technological object and the patient, he explains.
"Personal relationships are the most powerful way of changing behavior," Dunbar says. "Look at AA [Alcoholics Anonymous] — that's a perfect example of this."
Messaging technology should use a distinctive voice that helps to create an emotional bond with patients, giving them the subconscious sense that if they don't take their medication they're letting someone down, he says.
"One of the most powerful motivators is creating a sense of obligation on the part of the patient," Dunbar says. "A nurse, aide, or doctor can do this too, just so the patient feels he owes them to take his medication properly."
This is the same reason people hire personal trainers because the attachment and relationship motivate them to work harder.
Robotic technology also can be the object of this attachment, and a good example is the iRobot Roomba vacuum cleaner. It cleans floors automatically and is shaped like a saucer. But the most interesting thing about the Roomba is that people who own them begin to develop emotional attachments to the devices, going so far as to name them, pre-clean for them, and treat them like pets, Dunbar says.
Research, including Dunbar's own studies, have shown that people can become attached to technological devices in a way that would help adherence.
"It's the message, not the medium," Dunbar says. "What matters is the message you're communicating and that it's one that encourages attachment so the patient would have an obligation to the device."
Researchers and clinicians working on medication adherence interventions have a variety of technological tools to help them both measure and, theoretically, improve medication adherence.Subscribe Now for Access
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