Why it Worked: Participants’ Insights into an mHealth Antiretroviral Therapy Adherence Intervention in China

Lora L. Sabin1, *, Lauren Mansfield1, Mary Bachman DeSilva2, Taryn Vian1, Zhong Li3, Xie Wubin4, Allen L. Gifford5, 6, Yiyao Barnoon7, Christopher J. Gill1
1 Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd floor, Boston, MA, 02118, USA
2 University of New England, 716 Stevens Ave, Portland, ME, 04103, USA
3 FHI 360, Room B110, Floor 4, Building 1, No.15, Guanghua Road, Chaoyang District, Beijing, 100026, China
4 Department of Global Health, Milken Institute School of Public Health, George Washington University, 2121 I St NW, Washington, D.C., 20052, USA
5 Department of Health Policy and Management, Boston University School of Public Health, 715 Albany Street, Talbot Building, T348W, Boston, MA, 02118, USA
6 Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave, Boston, MA, 02130, USA
7 Boston Children’s Hospital, 300 Longwood Ave, Boston, MA, 02115, USA

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© 2018 Sabin et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, USA, Tel: 617-414-1272; Fax: 617-414-1261; E-mail:



Few Antiretroviral Therapy (ART) adherence trials investigate the reasons for intervention success or failure among HIV-positive individuals.


To conduct qualitative research to explore the reasons for effectiveness of a 6-month mHealth (mobile health) trial that improved adherence among ART patients in China. The intervention utilized Wireless Pill Containers (WPCs) to provide, real-time SMS reminders, WPC-generated adherence reports, and report-informed counseling.


We conducted in-depth interviews with 20 intervention-arm participants immediately following the trial. Sampling was purposeful to ensure inclusion of participants with varied adherence histories. Questions covered adherence barriers and facilitators, and intervention experiences. We analyzed data in nVivo using a thematic approach.


Of participants, 14 (70%) were male; 7 (35%) had used injectable drugs. Pre-intervention, 11 were optimal adherers and 9 were suboptimal adherers, using a 95% threshold. In the final intervention month, all but 3 (85%) attained optimal adherence. Participants identified a range of adherence barriers and facilitators, and described various mechanisms for intervention success. Optimal adherers at baseline were motivated by positive adherence reports at monthly clinic visits-similar to receiving A+ grades. For suboptimal adherers, reminders facilitated the establishment of adherence-promoting routines; data-guided counseling helped identify strategies to overcome specific barriers.


Different behavioral mechanisms appear to explain the success of an mHealth adherence intervention among patients with varying adherence histories. Positive reinforcement was effective for optimal adherers, while struggling patients benefitted from reminders and data-informed counseling. These findings are relevant for the design and scalability of mHealth interventions and warrant further investigation.

Keywords: HIV treatment, ART adherence, Behavior change, Intervention trial, mHealth, China.