Behavioral Theories and Motivational Features Underlying eHealth Interventions for Adolescent Antiretroviral Adherence: A Systematic Review (Preprint)

BACKGROUND Electronic health (eHealth) interventions provide new opportunities for the delivery of ART adherence interventions for adolescents. Reviews have examined their effectiveness, feasibility and acceptability. However, studies have not systematically explored the extent to which interventions are grounded in theory to guide the selection of behavior change techniques (BCTs) and their design in the application. OBJECTIVE The purpose of this systematic review was to explore which health behavior theories support eHealth ART interventions for adolescents, and which BCTs are present in the design of the chosen platforms. Additionally, we investigated whether more extensive use of theory was associated with higher quality of the study and higher impact of the intervention. METHODS A systematic search was applied on IEEE Xplore, ACM, ScienceDirect, PubMed, SCOPUS, and Web of Science databases. The results were reported following the PRISMA guidelines. Theory use and BCTs were coded using the Theory Coding Scheme (TCS) and the Behavior Change Technique Taxonomy version 1 (BCTTv1) respectively. Design principles were identified using the Lenses of Motivational Design for mHealth. RESULTS Twenty-four papers describing fifteen different eHealth interventions were included. Out of the fifteen interventions, ten were grounded in theory, of which only three used theories extensively. None of the included studies relied on theories addressing adolescent developmental psychology. Interventions used forty-two different behavior change techniques, most commonly ‘prompts/cues’. Moreover, twenty-four motivational design principles were applied, most common was the technique of ‘reminding’. Simplistic applications (SMS texting and phone calls) were most frequent delivery platforms, yet smartphone apps were also emerging. Most of the included eHealth applications reported positive impact. CONCLUSIONS The overall evaluation of the design process of eHealth interventions indicated gaps in the use of theory, behavior change techniques, and how these were translated into design principles in the chosen technology platform. None of the theory-based interventions provided strong justifications why and how the respective theories were selected, or how appropriate these theories are for adolescents in particular. Moreover, none of the included interventions considered specific theories on adolescent developmental psychology to guide ART adherence interventions. In sum, theories, BCTs and features that tailor specifically to adolescents are still missing; instead adolescents are simply considered young adults.