Smartphone Self-monitoring to Support Self-management Among People Living With HIV

Perceived Benefits and Theory of Change From a Mixed-Methods Randomized Pilot Study

Dallas Swendeman, PhD, MPH; Nithya Ramanathan, PhD; Laura Baetscher, BA; Melissa Medich, PhD; Aaron Scheffler, BS; W. Scott Comulada, DrPH; Deborah Estrin, PhD


J Acquir Immune Defic Syndr. 2015;69(S1):S80-S91. 

In This Article

Abstract and Introduction


Background Self-monitoring by mobile phone applications offers new opportunities to engage patients in self-management. Self-monitoring has not been examined thoroughly as a self-directed intervention strategy for self-management of multiple behaviors and states by people living with HIV (PLH).

Methods PLH (n = 50), primarily African American and Latino, were recruited from 2 AIDS services organizations and randomly assigned to daily smartphone (n = 34) or biweekly Web-survey only (n = 16) self-monitoring for 6 weeks. Smartphone self-monitoring included responding to brief surveys on medication adherence, mental health, substance use, and sexual risk behaviors, and brief text diaries on stressful events. Qualitative analyses examine biweekly open-ended user-experience interviews regarding perceived benefits and barriers of self-monitoring, and to elaborate a theoretical model for potential efficacy of self-monitoring to support self-management for multiple domains.

Results Self-monitoring functions include reflection for self-awareness, cues to action (reminders), reinforcements from self-tracking, and their potential effects on risk perceptions, motivations, skills, and behavioral activation states. Participants also reported therapeutic benefits related to self-expression for catharsis, nonjudgmental disclosure, and in-the-moment support. About one-third of participants reported that surveys were too long, frequent, or tedious. Some smartphone group participants suggested that daily self-monitoring was more beneficial than biweekly due to frequency and in-the-moment availability. About twice as many daily self-monitoring group participants reported increased awareness and behavior change support from self-monitoring compared with biweekly Web-survey only participants.

Conclusions Self-monitoring is a potentially efficacious disruptive innovation for supporting self-management by PLH and for complementing other interventions, but more research is needed to confirm efficacy, adoption, and sustainability.


Self-management is a fundamental component of HIV treatment and prevention as HIV/AIDS has transitioned to a chronic illness with the advent of effective treatments.[1] A major challenge for all chronic conditions is engagement of patients in active self-management during their daily routines and between clinical and behavioral intervention visits.[2–4] The nearly ubiquitous integration of mobile phones into our daily routines is creating many novel opportunities to enhance engagement in self-management through common functions, such as medication reminders,[5,6] and informational and motivational messaging.[7,8] Self-monitoring, that is, the active observation and recording of behaviors, states, and their determinants and effects, is a core element of self-regulation and self-management[9–11] that can be easily implemented and scaled through mobile phones. Self-monitoring is a self-directed intervention activity that does not entail the costs and provider burdens associated with traditional counseling interventions and may be a massively scalable disruptive innovation in which even small effects can have significant impacts at scale.[12]

Self-monitoring has been identified as a core element of evidence-based interventions for a variety of conditions,[13,14] although reviews of the self-management literature in general,[2,3,15] and for HIV specifically,[1,16] rarely mention self-monitoring. Similarly, the evaluation of multicomponent evidence-based intervention packages has resulted in "black box" barriers to understanding specific intervention components' efficacy and mechanisms of change.[12,17] Elaborating causal mechanisms of behavior change and identifying the impacts of specific behavior change tools is a new priority focus for the National Institutes of Health (NIH) through the Science of Behavior Change (SOBC) program.[18] The efficacy and causal mechanisms of self-monitoring, in particular, have not been well elaborated to date in general,[14,19] nor for multiple HIV-related self-management domains of medical adherence, mental health, substance use, and sexual behaviors. This article aims to help fill this gap in the literature and bring renewed attention to self-monitoring as a behavior change intervention strategy that is made more feasible by the integration of mobile phones into our daily routines.

Early research on self-monitoring suggests that it is integral to self-regulation and self-management through processes involving response to feedback from self-observation, such as reflection in comparison with criteria (eg, perceived norms or personal standard), self-correction, and reinforcement through self-reward or critique.[10,11] There is modest meta-analytic evidence for the efficacy of self-monitoring diet, physical activity, and weight to support self-management of diabetes[20] and obesity.[21] Notably, meta-analytic evidence does not support the efficacy of self-monitoring blood glucose alone for diabetes self-management,[22] which suggests the importance of self-monitoring behaviors, rather than biomarkers alone, for behavior change and maintenance. Evidence also emerges for the potential efficacy of self-monitoring from alcohol, tobacco, and drug (ATOD) abuse intervention research identifying "assessment effects" in which control groups experience improvements in targeted outcomes.[23,24] There is similar evidence for sexual risk reduction on the order of 15% to up to 30% in control groups in some HIV prevention trials with both HIV-negative[17,25,26] and HIV-positive participants.[27] Qualitative process studies of ATOD intervention trials find that participants recognize the impact of assessments on their behaviors and that more frequent monitoring might result in greater effects.[23]

There are a number of studies using phone- and Web-based diary methods for capturing data with people living with HIV (PLH);[28–32] however, only a handful of studies have examined self-monitoring as an intervention tool for self-management of HIV-related health and risk behaviors. One small randomized controlled trial compared self-monitoring by pill diary for 2 weeks after baseline to a single session behavioral intervention (based on motivational interviewing, cognitive-behavioral, and problem-solving techniques), finding similar improvements in antiretroviral therapy (ART) adherence at 12-week follow-up for both interventions.[33] Two other small-scale efficacy studies examining self-monitoring by interactive voice response and smartphone application have identified potential enhancements to engagement and efficacy of motivational interviewing for reducing ATOD use among PLH in clinical settings.[34,35] A larger randomized controlled trial of computer-based self-monitoring at routine medical visits compared with standard care found some support for reducing sexual risk behaviors by PLH over time.[36] The study also found that improvements positively correlated with the number of assessments completed, indicating that self-monitoring frequency and intersecting motivational factors may moderate self-monitoring effects.[36] Another recent study of reactivity (ie, behavior changes) in response to Web-based daily diary assessments by gay and bisexual men found a heterogeneity of effects based on motivational factors, suggesting that different mechanisms of self-monitoring function at various stages of activation and motivation.[37] Although these studies suggest the efficacy of self-monitoring as an intervention strategy and some potential mediating or moderating factors (eg, motivation), the theoretical and causal pathways of the impacts of self-monitoring on multiple HIV-related health behaviors and states have not been thoroughly elaborated. This study aims to begin to fill this gap in the literature.

This article presents qualitative results from a pilot study of daily self-monitoring through smartphone and biweekly Web surveys by PLH for multiple HIV-related domains over 6 weeks. The primary aim of this article is to elaborate a theoretical model for the potential benefits of self-monitoring in supporting self-management of medication adherence, mental health, substance use, and sexual risk behaviors by PLH, through analysis of open-ended user-experience interview responses. Secondary aims explore potential differences in efficacy of daily versus biweekly self-monitoring as well as barriers and challenges reported, to inform application of self-monitoring for future research, intervention, and practice.