In-App Messaging and Engagement of Adolescent Heart Transplant Patients during Mobile App-Based Video Directly Observed Therapy: A Content Analysis

Background and Purpose: Adolescents heart transplant (HT) recipients experience difficulty with adherence to immunosuppressive medication leading to increased risk of organ rejection, hospitalization, and mortality. Few interventions have been successful to promote medication adherence in adolescent HT patients as most fail to engage the patient in the behavioral change process and support patient-provider communication. We examined a mobile health application with adolescent HT recipients which supported daily medication adherence and importantly facilitated patient engagement, interpersonal communication, social support to motivate users through social facilitation, social learning, and recognition. The purpose of this study was to explore the nature and degree of in-app communication between adolescent HT recipients and nursing staff during an asynchronous mobile video directly observed therapy (DOT) intervention.

Methods: The study examined the adolescent HT recipients’ and transplant staff’s engagement during the prospective, single-group pilot of the 12-week asynchronous DOT intervention. A content analysis was conducted of 894 in-app messages exchanged between 10 adolescent HT patients and transplant team members (nurses and social workers) during the 12-week intervention. The first two authors developed a codebook a priori that included initial codes based on the Persuasive Systems Design model and other relevant theory and research. Coding involved an inductive, iterative process to guide a thematic analysis of the asynchronous in-app messages with high inter-rater reliability ranging from 81.5%-100%.

Results: Of the 894 messages, 227 (25.4%) were sent by the patients and 613 by the transplant nurses (68.6%). The mean number of exchanged messages per patient over 12 weeks was 89.30 (SD=17.96) between patients and each nurses and transplant social workers. In-app messages fell under three broad content categories: 1) interpersonal support and rapport-building, 2) medically-related questions and information, or 3) functional information about the DOT intervention and the mHealth app. Patients most often sent messages providing information (n=160, 70.5%), rapport-building (n=73, 32.2%), and gratitude (n=40, 17.6%). Importantly, patients and nurses were similarly likely to send messages coded as requesting communication (p=.204, ϕ=.055), expressing gratitude (p=.529, ϕ=.022), and building rapport (p=.065, ϕ=.066). Nurses were more likely to send messages containing praise (p<.001, ϕ=.337), feedback (p<.001, ϕ=.292), education (p<.001, ϕ=.131), functional information (p<.001, ϕ=.301), questions (p<.001, ϕ=.224), and expressions of empathy (p<.001, ϕ=.131). Greater medication adherence observed during DOT was associated with greater exchange of praise (𝜌=.604, p=.065, moderate effect size although not statistically significant) and gratitude messages (𝜌=.728, p=.017).

Conclusions and Implications: Results demonstrated the degree to which interpersonal engagement occurred during the intervention, the nature of these exchanges, and its relationship to medication adherence. The study provides insights into the feasibility and benefits of two-way communication features of the DOT intervention in promoting engagement and in improving medication adherence among adolescent HT patients. Overall, this exploration of patient engagement in an mHealth intervention informs patient engagement and promotion of medication adherence in adolescent HT recipients. Continued research and clinical focus on patient engagement and impact of interpersonal communication could aid in the translation of this intervention into care at pediatric transplant centers.