PEERNaija: A Gamified mHealth Behavioral Intervention to Improve Adherence to Antiretroviral Treatment Among Adolescents and Young Adults in Nigeria

Abstract

Background: HIV is the leading cause of death for youth in Sub-Saharan Africa (SSA). The rapid proliferation of smart phones in SSA provides an opportunity to leverage novel approaches to promote adherence to life-saving antiretroviral therapy (ART) for adolescents and young adults living with HIV (AYA-HIV) that go beyond simple medication reminders.Methods: Guided by the Integrate, Design, Assess and Share (IDEAS) framework, our multidisciplinary team developed a peer-based mHealth ART adherence intervention—PEERNaija. Grounded in Social Cognitive Theory, and principles of contingency management and supportive accountability, PEERNaija delivers a multi-faceted behavioral intervention within a smartphone application to address important obstacles to adherence.Results:PEERNaija was developed as a gamified Android-based mHealth application to support the behavioral change goal of improving ART adherence among AYA-HIV within Nigeria, a low- and middle- income country (LMIC). Identified via foundational interviews with the target population and review of the literature, key individual (forgetfulness and poor executive functioning), environmental (poor social support) and structural (indirect cost of clinic-based interventions) barriers to ART adherence for AYA-HIV informed application features. Further informed by established behavioral theories and principles, the intervention aimed to improve self-efficacy and self-regulation of AYA-HIV, leverage peer relationships among AYA to incentivize medication adherence (via contingency management, social accountability), provide peer social support through an app-based chat group, and allow for outreach of the provider team through the incorporation of a provider application. Gamification mechanics incorporated within PEERNaija include: points, progress bar, leaderboard with levels, achievements, badges, avatars and targeted behavior change messages. PEERNaija was designed as a tethered mobile personal health record application, sharing data to the widely deployed OpenMRS electronic health record application. It also uses the secure opensource Nakama gamification platform, in line with Principles of Digital Development that emphasize use of opensource systems within LMICs.Conclusions: Theory-based gamified mHealth applications that incorporate social incentives have the potential to improve adherence to AYA-HIV. Ongoing evaluations of PEERNaija will provide important data for the potential role for a gamified, smartphones application to deliver multifaceted adherence interventions for vulnerable AYA-HIV in SSA.

Applications of Behavioral Economics to HIV Programs in Low and Middle Income Countries: A Scoping Review Using the EAST Framework

“…An additional Attractive nudge included allowing youth to set their own goals for medication adherence in Uganda, which increased the likelihood they met those targets. 36,46 Attractive nudges that are currently being planned and/or evaluated are gamification in phone-based apps targeting youth in Nigeria 39 and Ghana 40 as well as messaging to adults in South Africa highlighting altruism to improve continuity of treatment and re-engagement in care. 38…”

“…These nudges include testing the fresh start effect (a Timely nudge) that uses a key date, such as the first of the month or the start of a season, to give someone a mental reset which can motivate them to change their behavior, especially around re-engagement in care. 58, 63, 64 Gamification and game-based text messaging is also being tested in various contexts, particularly with youth, 39, 40 to increase engagement in care and reduce interruptions in treatment. Gamification interventions tend to rely heavily on non-monetary rewards like “badges” and being able to advance to a higher level in an online or phone-based app, intermittent recognition, and they frequently use social comparison tools such as leaderboards.…”

“…It also includes appropriately designed rewards or sanctions. 5,[12][13][14][31][32][33][34][35][36][37][38][39][40] Reframing: gain-frame…”

Effectiveness, Acceptability and Feasibility of Technology-Enabled Health Interventions for Adolescents Living with HIV in Low- and Middle-Income Countries: A Systematic Review

“…Participants may have little control over whether other group members may share information publicly [43]. None of the interventions used specially developed smartphone applications or gamification features, although these are being developed in Nigeria (PeerNinja) [53], Ghana (Game-based SMS adherence) [54] or ongoing in South Africa (MAsakhane Siphucule Impilo Yethu; Xhosa for "Let's empower each other and improve our health"/MASI) [55].…”

Analysis of barriers of mHealth adoption in the context of sustainable operational practices in health care supply chains

“…This paper addresses the gap of poor executive functioning, lack of social support and indirect clinical support, plus many more barriers to mHealth, through a development of antiretroviral therapy by embracing SCT (Ahonkhai et al, 2021). There has been a scarcity of healthcare professionals for text messaging intervention based on social cognitive theory; this work was user centric and evidence-guided, aimed at preventing postpartum smoking recurrence in women in inner cities (Wen et al, 2014).…”