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The Meanings in the messages: how SMS reminders and real-time adherence monitoring improve antiretroviral therapy adherence in rural Uganda

Ware, Norma C.; Pisarski, Emily E.; Tam, Melanie; Wyatt, Monique A.; Atukunda, Esther; Musiimenta, Angella; Bangsberg, David R.; Haberer, Jessica E.

doi: 10.1097/QAD.0000000000001035
Epidemiology and Social

Objective: To understand how a pilot intervention combining SMS reminders with real-time adherence monitoring improved adherence to HIV antiretroviral therapy (ART) for adults initiating treatment in rural Uganda.

Design: Qualitative study, conducted with a pilot randomized controlled trial.

Methods: Sixty-two pilot intervention study participants took part in qualitative interviews on: preferences for content; frequency and timing of SMS adherence reminders; understandings and experiences of SMS reminders; and understandings and experiences of real-time adherence monitoring. Analysis of interview data was inductive and derived categories describing how participants experienced the intervention, and what it meant to them.

Results: SMS reminders prompted taking individual doses of antiretroviral therapy, and helped to develop a ‘habit’ of adherence. Real-time adherence monitoring was experienced as ‘being seen’; participants interpreted ‘being seen’ as an opportunity to demonstrate seriousness of commitment to treatment and ‘taking responsibility’ for adherence. Both SMS reminders and real-time monitoring were interpreted as signs of ‘caring’ by the healthcare system. Feeling ‘cared about’ offset depressed mood and invigorated adherence.

Conclusion: Although serving as reminders, SMS messages and real-time adherence monitoring also had larger emotional and moral meanings for participants that they felt improved their adherence. Understanding the larger ‘meanings in the messages,’ as well as their more literal content and function, will be central in delineating how SMS reminders and other adherence interventions using cellular technology work or do not work in varying contexts.

aDepartment of Global Health and Social Medicine, Harvard Medical School

bDivision of Global Health Equity, Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA

cMbarara University of Science and Technology, Mbarara, Uganda

dCenter for Global Health, Massachusetts General Hospital

eDepartment of Medicine, Harvard Medical School, Boston, Massachusetts, USA.

Correspondence to Norma C. Ware, Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA. Tel: +1 617 432 2554; e-mail:

Received 4 November, 2015

Revised 22 December, 2015

Accepted 4 January, 2016

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