Abstract and Introduction
Abstract
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.
Introduction
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. 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. 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, and informational and motivational messaging. 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 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.
Self-monitoring has been identified as a core element of evidence-based interventions for a variety of conditions, although reviews of the self-management literature in general, and for HIV specifically, 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. 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. The efficacy and causal mechanisms of self-monitoring, in particular, have not been well elaborated to date in general, 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. There is modest meta-analytic evidence for the efficacy of self-monitoring diet, physical activity, and weight to support self-management of diabetes and obesity. Notably, meta-analytic evidence does not support the efficacy of self-monitoring blood glucose alone for diabetes self-management, 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. 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 and HIV-positive participants. 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.
There are a number of studies using phone- and Web-based diary methods for capturing data with people living with HIV (PLH); 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. 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. 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. 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. 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. 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.