Content and Usability Evaluation of Medication Adherence Mobile Applications for Use in Pediatrics

Julia K. Carmody, PHD; Lee A. Denson, MD; Kevin A. Hommel, PHD


J Pediatr Psychol. 2019;44(3):333-342. 

In This Article

Abstract and Introduction


Objective: The objective of this study was to systematically evaluate commercially available medication adherence apps for the inclusion of behavior change techniques (BCTs) and to conduct a usability analysis on a subset of apps with adolescents and young adults living with a chronic illness.

Methods: Medication adherence apps were identified via a search of iTunes app store in August 2016. Seventy-five apps meeting initial inclusion criteria were independently coded by two researchers for the presence/absence of 26 BCTs. Twenty adolescents and young adults (ages: 13–20 years) with inflammatory bowel disease conducted usability testing on a subset of apps (n = 4).

Results: Across 75 apps coded for presence/absence of 26 BCTs, only 7 unique BCTs were identified. The number of BCTs per app ranged from 2 to 6, with an average of 3.3 BCTs. In usability testing, quality ratings varied across apps. Medisafe received the highest average scores on engagement, functionality, aesthetics, and information subscales. Medisafe and MyTherapy ranked first and second, respectively, on overall quality and perceived impact ratings.

Conclusion: Content evaluation revealed only a limited number of BCTs that have been translated to medication adherence apps. Among apps with comparable content, clear user preferences emerged based on perceived quality and usability. Greater collaboration is needed between psychologists and health technologists to incorporate more evidence-based BCTs in apps. Findings also indicate a need for app developers to consider and incorporate the preferences of younger end users to improve app quality and engagement for pediatric populations.


Nonadherence to medication among children, adolescents, and young adults is a pervasive problem. Across chronic conditions, it is estimated that approximately 50% of children and as high as 75% of adolescents and young adults do not take their medications as prescribed (Rapoff, 2010). Consequences of nonadherence to medication include medical complications, treatment failure, impairments to daily functioning and quality of life, and higher health care utilization (McGrady & Hommel, 2013; Rapoff, 2009, 2010). Meta-analytic reviews indicate that pediatric adherence-promoting interventions lead to improved adherence, better health outcomes, enhanced patient and caregiver quality of life, and reduced health-care utilization (Graves, Roberts, Rapoff, & Boyer, 2010; Kahana, Drotar, & Frazier, 2008; McGrady et al., 2015; Pai & McGrady, 2014). The most effective adherence-promoting interventions are multicomponent and include educational and behavioral techniques (Pai & McGrady, 2014). However, patient access to such interventions may be limited by geographical, resource, and time constraints. Mobile adherence applications (apps) represent an innovative and widely available approach to enhancing treatment adherence in youth. Adolescents and young adults in particular stand to benefit from mobile adherence promotion platforms, as 89% of adolescents (ages: 12–17 years) and 98% of young adults (ages: 18–24 years) have access to a smartphone (Pew Research Center, 2017).

Currently, an abundance of apps aimed at helping users take their medications is publicly available; however, the degree to which apps incorporate evidence-based techniques to promote health behavior change is unclear. A recent review by Nguyen et al., (2016) examined the content of medication reminder apps based on a list of features designated by the authors as important for pediatric adherence promotion. Specifically, the authors examined apps for the inclusion of medication reminder features, educational material, and five behavior modification features. Results showed that while most apps contained several medication reminder features (e.g., record medications and set reminder), apps contained on average less than one educational and less than one behavioral modification feature. While this review highlights the available reminder features and lack of educational content in apps, it does not offer a comprehensive review of included behavior change techniques (BCTs). To fully characterize the degree to which apps incorporate a comprehensive range of evidence-based techniques used in traditional health promotion interventions, the current study sought to systematically review available apps according to Abraham and Michie's taxonomy of BCTs (2008). The taxonomy of BCTs is a coding system that allows researchers to reliably identify operationalized, theory-linked BCTs used in behavior change interventions. Twenty-six individual BCTs are defined in the taxonomy, including techniques such as provide information on behavior–health link, prompt specific goal setting, and provide feedback on performance. The taxonomy has been widely used to evaluate health behavior interventions, including interventions delivered on mobile platforms (Brannon & Cushing, 2015; Dahlke, Fair, Hong, Beaudoin, Pulczinski, & Ory, 2015; Yang, Maher, & Conroy, 2015).

While the most effective adherence promotion interventions for children, adolescents, and young adults include behavioral approaches, there is not clear consensus on which behavioral techniques (e.g., specific goal-setting, self-monitoring, and social comparison) are central to effective medication adherence interventions (Dean, Walters, & Hall, 2010; Pai & McGrady, 2014). In the adult literature, two systematic reviews of medication adherence interventions for adults with chronic illness found that the inclusion of medication monitoring with tailored feedback and reinforcement or rewards significantly predicted intervention effectiveness (Demonceau et al., 2013; Kripalani, Yao, & Haynes, 2007). Van Genugten and colleagues conducted a meta-analysis of 52 Internet-based health behavior interventions and found that barrier identification/problem-solving and providing rewards were significant positive predictors of intervention effect size (van Genugten, Dusseldorp, Webb, & van Empelen, 2016). When used in combination, barrier identification/problem-solving and providing rewards were found to have an even greater influence on intervention effectiveness. Because the pediatric/young adult medication adherence promotion literature has not clarified a specific technique or combination of techniques that are most effective for adherence promotion, the current study coded for the presence or absence of all 26 BCTs included in the taxonomy. Given the findings in the adult literature, our content evaluation also aimed to specifically examine whether those BCTs with the most evidence for adherence promotion in the adult literature (i.e., monitoring with feedback, reinforcement/rewards, and barrier identification/problem-solving) were included in medication adherence apps.

In addition to the inclusion of evidence-based BCTs, the potential for any app to improve health behaviors depends on its usability, meaning the quality of engagement, functionality, aesthetics, and information (Stoyanov et al., 2015). Several studies have evaluated the usability of various mobile health apps according to researcher ratings (Bardus, van Beurden, Smith, & Abraham, 2016; Mani, Kavanagh, Hides, & Stoyanov, 2015; Nguyen et al., 2016). However, to our knowledge, no studies to date have examined usability from the perspectives of adolescent or young adult end users. Therefore, the second aim of this study was to evaluate the usability of a subset of medication adherence promotion apps from the perspectives of adolescents and young adults living with a chronic illness. Taken together, the overarching goal of this study was to systematically evaluate and identify apps to recommend to pediatric and young adult patients with a variety of medical needs and conditions based on app content (included BCTs) and usability ratings.