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Using iPhones to keep Newly Independent Teenagers on their Medications
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Using iPhones to keep Newly Independent Teenagers on their Medications



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  • VSD – digitoxin, increases heart beat strength and maintains regularity
  • More benefit (longer life)More receptive to habit change
  • This is why we talked about teenagers
  • Posters, TV advertisements
  • Not surprising, otherwise we’d already have found a good one!
  • Motivation, Ability, Trigger
  • Email – too passive


  • 1. Using iPhones to keep Newly Independent Teenagers on their Medications
    By Max Zamkow
  • 2. The Four Questions
    Is Medication Adherence really a problem?
    Why Target Teenagers?
    Why Target Newly Independent Teenagers?
    Why use the iPhone?
  • 3. Is Medication Adherence really a problem?
  • 4. A PubMed search for: “Medication Adherence”returned 5959 articles
  • 5. Low adherence with prescribed treatments is very common. Typical adherence rates for prescribed medications are about 50% with a range from 0% to over 100% - Sackett 1979
    Even among groups of people thought to be most responsible (Company Executives, Healthcare professionals, etc.), good medication adherence is barely above 50% - Burton 2010
    “ Poor adherence to medication regimens accounts for substantial worsening of disease, death, and increased health care costs in the United States.Of all medication-related hospital admissions in the United States, 33 to 69 percent are due to poor medication adherence, with a resultant cost of approximately $100 billion a year.” – Osterberg 2005
  • 6. It’s a Win-Win situation
    The Healthcare industry (Insurers, Hospitals, etc) saves money
    Patients have better health outcomes (and less hospitalizations)
  • 7. Why Target Teenagers?
  • 8. You Can’t Teach an Old Dog New Tricks
    Actually you can, but it’s much more effective to teach a Young one
  • 9. Adolescence, especially late adolescence, is associated with low medication adherence
    One study looking at transplant recipients found that the rate of medication non-adherence among adolescent recipients is approximately 4 times higher than that among adult recipients – Fredericks
  • 10. Teenage years are associated with…
  • 11. Independence
    Less Supervision
    Multiple Studies have shown a significant correlation between increased independence and decreased adherence in adolescents – Sawyer, Fredericks, Kovacs
  • 12. Rebellion
    Concerns about poor adherence in adolescents often result in protective parent behaviors, such as constant reminders to take their medication.
    While parents hope the reminders will promote better adherence, their prompts are often interpreted by young people as unwarranted “nagging”, which often if not always has the opposite effect.
  • 13. Why Target Newly Independent Teenagers?
  • 14. “Medication adherence was significantly poorer in the newly transitioned cohort in comparison with pediatric and adult cohorts” - Fredericks
    “Ages 17 – 19 are associated with themost amount of time being noncompliant” – Kovacs
    “Poorer adherence [in adolescents] was significantly related to older age” - Fredericks
    Newly Independent Teenagers have the worst medication adherence rates
  • 15. “The developmental characteristics associated with adolescence, including the development of autonomy from family, assimilation with peers, separation from parents, and poorly developed abstract thinking and understanding of long-term consequences of present actions, are often difficult to balance with the behaviors required for optimal medication adherence.” - Fredericks
    Prepare all you can, eventually they all do it…
    Habit interventions gain power when they are applied during naturally occurring periods of change in [peoples’] lives- Verplanken 2006
  • 16. Improving Medication Adherence
  • 17. First we must discover WHY adherence is low
  • 18. In addition to the teenager specific reasons…
    Common reasons patients give include:
    Adverse Effects
    “Don’t Need It”
    Too Expensive
    Poor / Confusing Instructions
  • 19. Examples of Interventions that attempt to address 1 or more of these include…
  • 20. Information Campaigns
    Several studies showed that “telling people about adverse effects of their medications did not affect their use of the medications.” - Haynes
    “Information campaigns that successfully convey information do not necessarily change consumers’ behaviors.”
    – Verplanken
    The problem with these campaigns is the
    Disconnection between changing minds and changing behavior
  • 21. SMS-based Interventions
    Modest improvement in adherence
    Addresses “Forgetfulness”
    Limited to Simple Reminders
  • 22. Patient compliance with antihypertensive medications has previously been boosted by using battery-powered radiofrequency identification (RFID) tags embedded in the lids of pill bottles or in medication blister packs. These RFID tags record each time the bottle is opened or a pill is popped from the blister pack. Now, pharmaceutical companies are pushing the boundaries further by producing ‘robo-pills’ containing tiny microchips. The microchips send a text message to patients’ phones if they fail to take their medication and are said to increase compliance by 30–80% - Roberts
    Newer Approaches
    Pill ‘n’ chips
    tackles non-compliance
  • 23. In fact, many different interventions have been attempted
    More instruction for patients, e.g. verbal, written, or visual material
    Counseling about the patients’ target disease, the importance of therapy and compliance with therapy, the possible side-effects, patient empowerment, couple-focused therapy to increase social support
    Automated telephone, computer-assisted patient monitoring and counseling
    Manual telephone follow-up
    Family intervention
    Various ways to increase the convenience of care, e.g. provision at the worksite or at home
    Involving patients more in their care through self-monitoring of their blood pressure
    Reminders, e.g. programmed devices and tailoring the regimen to daily habits
    Special ’reminder’ pill packaging
    Dose-dispensing units of medication and medication charts
    Appointment and prescription refill reminders
    Reinforcement or rewards for both improved adherence and treatment response, e.g. reduced frequency of visits and partial payment for blood pressure monitoring equipment
    Different medication formulations, such as tablet versus syrup
    Crisis intervention conducted when necessary, e.g. for attempted suicide, aggressive and destructive behavior
    Direct observation of treatments (DOTS) by health workers or family members
    Lay health mentoring
    Augmented pharmacy services
    Psychological therapy, e.g. cognitive behavior therapy, multisystemic therapy
    Mailed communications
    Group meetings
  • 24. …yet we continue to search for a better solution
  • 25. Why iPhone?
  • 26. For long-term treatments, no simple intervention, and only some complex ones, led to improvements in health outcomes.
    They included combinations of more convenient care, information, counseling, reminders, self-monitoring, reinforcement, family therapy, psychological therapy, mailed communications, crisis intervention, manual telephone follow-up, and other forms of additional supervision or attention. – Haynes
    The solution is complex…
  • 27. The iPhone can do many of these things and more…
    Social (Facebook / Twitter / Other integration)
    Reminders (Notifications)
    Communicate with other devices (Bluetooth, Wi-Fi)
    Information (Internet)
    And much more…
  • 28. It’s with them CONSTANTLY
  • 29. Keys to Success
    For an iPhone App to improve Medication Adherence
  • 30. BJ Fogg’s Behavior Model
  • 31. Trigger
    Make the iPhone DO SOMETHING at the right time
    Send push / local notifications
    Add calendar events with alarms
  • 32. Motivate
    Make the patient WANT to take their medication
    Utilize Game Mechanics
    Imagine piloting a nanobot through the bodies of fictional cancer patients, destroying cancer cells in your path, battling bacterial infections, and managing side effects. This is the Re-Mission game, developed for adolescents and young people with cancer, thathopelab.orgbelieve will help them develop a positive attitude, learn about their cancer and has been shown to improve adherence. – Roberts
  • 33. Ability
    Cheap / FREE
    Quick and easy to set up
    Automate whatever possible
  • 34. In Conclusion…
  • 35. Medication Adherence is a problem
    Teenagers leaving home are especially at risk
    They’re also at a point where interventions are most effective
    A complex solution is needed
    The iPhone has the capabilities to meet most of these needs and be successful
  • 36. Thanks!