The most common surgery for pectus patients is associated with severe acute and persistent postoperative pain. It is, therefore, important that patients are adequately monitored after their surgery to prevent the chronification of pain. This paper provides a deeper understanding of young adolescents when they are asked to use a telemonitoring platform for their postoperative follow-up. Motivational design techniques, such as gamification mechanics, were integrated into 17 alternative designs and evaluated via a mixed-method approach with eight pectus patients and nine parents. The quantitative scoring of all 17 designs on a seven-point Likert scale showed that participants appreciated the designs and were motivated to adhere to their telemonitoring therapy when adequately supported by the platform. A thematic analysis of in-depth interviews conducted in the context of their homes confirmed that pectus patients had the will to be adherent, were invested in their own wellbeing, appreciated technical feedback, valued their privacy, and requested a professional platform to support them in their daily telemonitoring activities.

Background eHealth systems provide new opportunities for the delivery of antiretroviral therapy (ART) adherence interventions for adolescents. They may be more effective if grounded in health behavior theories and behavior change techniques (BCTs). Prior reviews have examined the effectiveness, feasibility, and acceptability of these eHealth systems. However, studies have not systematically explored the use of health behavior theories and BCTs in the design of these applications. Objective The purpose of this review was to explore whether health behavior theories and BCTs were considered to ground designs of eHealth systems supporting adolescents’ (10-24 years) ART adherence. More specifically, we examined which specific theories and BCTs were applied, and how these BCTs were implemented as design features. Additionally, we investigated the quality and effect of eHealth systems. Methods A systematic search was performed on IEEE Xplore, ACM, ScienceDirect, PubMed, Scopus, and Web of Science databases from 2000 to 2020. Theory use and BCTs were coded using the Theory Coding Scheme and the Behavior Change Technique Taxonomy version 1 (BCTTv1), respectively. Design features were identified using the lenses of motivational design for mobile health (mHealth). The number of BCTs and design features for each eHealth system and their prevalence across all systems were assessed. Results This review identified 16 eHealth systems aiming to support ART adherence among adolescents. System types include SMS text message reminders (n=6), phone call reminders (n=3), combined SMS text message and phone call reminders (n=1), electronic adherence monitoring devices (n=3), smartphone apps (n=1), smartphone serious games (n=1), gamified smartphone apps (n=1), leveraging existing social media (n=2), web-based applications (n=1), videoconferencing (n=1), and desktop applications (n=1). Nine were grounded in theory, of which 3 used theories extensively. The impact of adolescent developmental changes on ART adherence was not made explicit. A total of 42 different BCTs and 24 motivational design features were used across systems. Ten systems reported positive effects on 1 or more outcomes; however, of these ten systems, only 3 reported exclusively positive effects on all the outcomes they measured. As much as 6 out of 16 reported purely no effect in all the outcomes measured. Conclusions Basic applications (SMS text messaging and phone calls) were most frequent, although more advanced systems such as mobile apps and games are also emerging. This review indicated gaps in the use of theory and BCTs, and particularly the impact of developmental changes on ART adherence was not adequately considered. Together with adopting a developmental orientation, future eHealth systems should effectively leverage health theories and consider developing more advanced systems that open the door to using BCTs more comprehensively. Overall, the impact of eHealth systems on adolescent ART adherence and its mediators is promising, but conclusive evidence on effect still needs to be provided.

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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.