Is There a Good App for That? Evaluating m-Health Apps for Strategies That Promote Pediatric Medication Adherence

Abstract

Background: Mobile health medication reminder apps may be a useful supplement to traditional adherence-promotion interventions for pediatric chronic illness populations because they can give real-time reminders and provide education and promote behavior modification (components known to enhance adherence in traditional interventions) in an engaging and developmentally acceptable way. Moreover, apps have the potential to be used by youth and parents, an important consideration given that shared involvement in condition management is associated with better adherence. Introduction: This study evaluated the content and usability of existing medication reminder apps operating on the Apple platform. Materials and Methods: Two researchers coded 101 apps on 15 desirable reminder, educational, and behavioral modification features. Usability testing was conducted with the subset of apps (n = 8) that had the greatest number of content features using a validated measure. Results: Apps contained an average of 4.21 of 15 content features, with medication reminder features being more common than either educational or behavioral modification features. Apps most commonly included a medication name storage feature (95%), a time-based reminder feature (87%), and a medication dosage storage feature (68%). Of the eight apps that had the highest number of content features, Mango Health, myRX Planner, and MediSafe evidenced the highest usability ratings. No apps identified were specifically designed for pediatric use. Discussion: Most apps lacked content known to be useful in traditional pediatric adherence-promotion interventions. Greater attention to educational and behavioral modification features may enhance the usefulness of medication reminder apps for pediatric groups. Conclusion: Collaborations between behavioral medicine providers and app developers may improve the quality of medication reminder apps for use in pediatric populations.

Introduction

As many as half of all youth may be diagnosed with a chronic medical condition at some point during childhood or adolescence.¹ Although some diversity exists with respect to the required treatment management tasks across conditions, following one's prescribed medication regimen is a critical task for families of children with chronic medical conditions that generalizes across illness groups.² Unfortunately, only about half of youth follow their medication regimen as prescribed by their physician,^3,4 and pediatric nonadherence is associated with numerous negative consequences, including poorer physical and mental health outcomes as well as greater healthcare utilization.^5

–8

Interventions to enhance medication adherence among youth with chronic medical conditions exist.^9

–12 Traditionally, these pediatric interventions have involved both youth and parents and have been delivered through an average of nine in-person sessions scheduled over several months.¹⁰ Past research suggests that pediatric adherence-promotion interventions that incorporate behavioral modification or multicomponent approaches (i.e., those that incorporate both behavioral and educational methods of intervention) are more effective in enhancing adherence than are other standalone interventions.^10,11,13

Behavioral modification focuses on increasing monitoring of medication taking, providing positive reinforcement for medication taking, and assisting patients and families in developing solutions to address barriers to adherence.¹⁴ Educational approaches aim to improve adherence by educating the patient and family about the rationale for treatment, benefits of adherence, and costs associated with nonadherence.¹⁴ Existing behavioral and multicomponent interventions are promising when delivered to patients and families with respect to improving pediatric medication adherence; however, they are also resource intensive and can become burdensome to families.¹⁰ Furthermore, it can be difficult for families to practice and maintain the skills learned between intervention sessions when interventions are delivered intermittently.

Prior efforts have provided support for the feasibility and efficacy of text-messaging reminders for adherence promotion in pediatric patients.^15,16 However, despite a rapid rise in popularity of mobile devices (i.e., smartphones and tablet computers), less attention has focused on the use of available mobile health (m-health) apps as a method to deliver pediatric adherence promotions.

Apps possess several unique advantages that make them well suited for pediatric adherence promotion. First, smartphone apps are a platform that both youth and parents use for educational and health promotion purposes. For example, 73% of youth own a smartphone,¹⁷ and more than half report using apps for educational purposes. Similarly, more than 70% of adults of ages 18–49 are smartphone users, and nearly half use apps for health tracking purposes.¹⁸ Among the younger subset of adults, about three-quarters of 18–29-year-old adults use their smartphone to get information about a health condition.¹⁸

Given that both youth and adults are frequent smartphone and app consumers, the use of m-health apps to promote medication adherence has the flexibility to accommodate different patterns of family-based condition management. For example, among families of young children, parents can use apps as a strategy to assist them in remembering to administer their child's medication. Among families of older adolescents, youth can use apps on their own smartphone as an adherence-promotion strategy. Finally, among families in which both youth and parents share condition management responsibilities, apps can be used by both parties to facilitate medication taking.^18

–21

Second, apps are designed to be interactive, intuitively navigated, and can be personalized. Consequently, apps have the potential to be more engaging and to increase pediatric patient participation more than other forms of m-health interventions.²² Third, apps hold the potential to provide real-time medication reminders and reinforcement of adherence-promotion principles and, as such, they have the potential to be a useful adjunct to traditional adherence-promotion strategies.²³ Finally, the ability of many apps to track medication-taking patterns over time and to share medication history with another user can facilitate collaboration between parents, youth, and providers, and allows for a family-based approach to condition management, which is important for successful chronic illness management in pediatric populations.²⁴

Thus, m-health apps have the potential to enhance existing pediatric adherence-promotion strategies by providing a structure for delivering medication reminders to youth and parents, reinforcing behavioral modification principles necessary for pediatric medication adherence promotion, and providing educational information about the importance of adherence to families. Since youth involvement in condition management varies as a function of developmental level and because parents play an important role in promoting pediatric medication adherence across childhood and adolescence, considering the ways in which apps meet these unique needs of children with chronic illnesses and families is important.

Recent reviews of m-health apps for promoting medication adherence for disease-specific groups (e.g., asthma, diabetes, and pediatric obesity) have found that the content of apps often did not correspond to evidence-based adherence-promotion strategies.^25

–28 Two broader reviews of adherence apps and medical apps suggested that few apps provide the ability to track adherence (track missed and taken doses) and few allow for sharing of data with another individual, a critical feature for pediatric population given the family involvement.^25,29 Although informative, these reviews have not examined the extent to which apps incorporate behavioral and educational features critical to promoting pediatric medication adherence.^10,11,14

Attention to whether or not apps contain behavioral and educational features known to promote pediatric adherence can assist medical providers in making informed decisions about what apps might be most useful to patients and their families. Currently, patients, parents, and providers must rely largely on user reviews and app rankings on the app marketplace. However, user reviews are known to be subjective and unreliable and app popularity is not strongly associated with app quality.^30,31 Therefore, there is little information beyond the star rating system and user reviews, which do not serve as reliable indicators of the evidence base for the strategies suggested within the app.

In addition, previous reviews have not systematically evaluated the usability of the apps for adherence promotion using a validated measure of usability. Given that pediatric adherence promotion involves both youth and parents, ratings of app usability should incorporate components important to the full range of users. Ease of use is an important area of analysis given that apps with features that are easy to access, fluent, and more automatic have yielded higher acceptability and satisfaction ratings across several reviews focused on adult groups.^32

–35 Moreover, the extent to which the app is easy to navigate, engaging, and aesthetically pleasing may promote continued use over time among pediatric users.^36,37 The Mobile App Rating Scale (MARS)³⁸ is a recently developed system for evaluating several components of app usability such as aesthetics and engagement. The MARS has demonstrated good psychometric properties in a validation study focused on review of various types of health-promotion apps.³⁸

This study sought to extend the m-health literature through a systematic analysis of both the content and usability of medication reminder apps for assisting with adherence to medication regimens among families of youth with pediatric chronic illnesses. The study examined the characteristics of m-health medication reminder apps available in the Apple App Store along several dimensions that are of high relevance for pediatric adherence promotion.

Aim 1 sought to evaluate the nature of the medication reminder features included in these apps, with specific emphasis on features that would be appealing and necessary for pediatric users. Aim 2 sought to examine the frequency with which existing apps included key features of traditional pediatric adherence-promotion trials, including behavioral modification features, educational features, and a multicomponent set of features (i.e., both behavioral modification and educational features). Aim 3 sought to examine the usability of a subset of apps containing the highest proportion of key features. Usability was evaluated across three key domains: engagement, functionality, and aesthetics using the MARS rating system.³⁸

Materials and Methods

Among youth in the United States, Apple's iOS³⁹ is the most popular mobile platform. Therefore, our review focused on free and for-purchase m-health medication reminder apps found on the Apple App Store. The review was conducted in May and June of 2015. In Phase 1, we identified apps through the following search terms: “adherence,” “compliance,” “medication reminder,” “prescription reminder,” “pill reminder,” and “medicine reminder.” Search terms were chosen based on review of terms used in previous medication reminder app reviews and based on discussion among research team members. Search results were sorted by popularity.

A total of 165 apps were identified using the search criteria. Descriptions for each app were reviewed based on the following inclusion criteria: (1) app included a medication reminder feature; (2) app was available in the English language; and (3) app was designed for use with human medications. Apps designed for sole use by medical professionals and those targeted to a specific medical condition or health issue (e.g., an acne-only medication tracking system) were excluded. The latter exclusion criterion was implemented given our interest in identifying a set of apps that could be widely recommended to pediatric patients with various chronic medical conditions. Of the 165 apps screened, 64 were ineligible for failure to meet all three inclusion criteria. The remaining 101 apps were reviewed during Phase 2. Seventy-four of the apps reviewed were available at no cost and the remainder required purchase. Purchase prices ranged from $0.99 to $3.99.

During Phase 2, two raters independently downloaded and evaluated the presence or absence of 15 content features for each app by using each app over the course of a day. In addition, app-written descriptions were reviewed for any mention of the app being designed for use by children, adolescents, or families. Content features of focus were those known to be useful in pediatric adherence-promotion trials^10,11 including medication reminder features (five features; e.g., able to set time-based medication reminder), behavioral modification features (five features; e.g., app provides reinforcement for logging medication as taken), and educational features (five features; e.g., app provides information about the benefits of adherence). See Table 1 for a list of all 15 content features reviewed.

Table 1.

Proportion of Apps Possessing Key Medication Reminder, Behavioral Modification, or Educational Content Features

FEATURE	NO. OF APPS WITH FEATURE (%)
Medication reminder
1. Can store medication names	96 (95)
2. Can set time-based medication reminder	88 (87)
3. Can store medication dosages	69 (68)
4. Can record if medication was taken or skipped	57 (56)
5. Can record reason for skipping medication	10 (9)
Behavioral modification
1. Can track medication-taking progress over time	52 (51)
2. Allows user to set a medication-taking goal	6 (6)
3. Provides reinforcement for logging medication as taken	7 (7)
4. Includes a feature to promote problem solving related to adherence barriers	0 (0)
5. Provides a mechanism for sharing user medication-taking history	14 (14)
Educational
1. Provides educational information about medication	11 (11)
2. Provides information about medication side effects	10 (10)
3. Provides disease-specific information	8 (8)
4. Provides information on benefits of adherence	1 (1)
5. Provides information on the risks of nonadherence	0 (0)

To ensure uniformity of coding, a coding schematic was created and each rater underwent app coding training before reviewing apps for this study. Training involved having raters code sample apps using the procedure identified previously. Raters were required to evidence 90% agreement or higher before beginning Phase 2 coding. During Phase 2, content features were independently rated by two individuals and discrepancies were resolved through rater discussion until a consensus was achieved. When consensus could not be achieved between the two raters, a third rater examined the app to resolve the disagreement. This method of assessing app feature content has been used in other app reviews.^40,41 In this study, inter-rater agreement (before discussion) for Phase 2 was very high (96%). Rater agreement improved to 100% after resolution of discrepancies.

Phase 3 of coding involved examining the usability of a subset of apps that had the highest proportion of content features (defined as apps scoring >1 SD above the mean on number of content features). App usability was evaluated using the engagement, functionality, and aesthetics subscales of the MARS.³⁸ The MARS is a simple and reliable app-quality assessment tool developed for use with m-health apps. It has shown excellent internal consistency and inter-rater reliability.³⁸

Each MARS item is rated on a 5-point scale (1, inadequate; 2, poor; 3, acceptable; 4, good; 5, excellent). Subscale scores were calculated through averaging ratings across each item. In this investigation, the functionality, engagement, and aesthetics scores were calculated and a total usability score was calculated by averaging item ratings across each of these subscales. MARS assessments were completed independently by two raters who completed the recommended MARS training before coding apps.⁴² Any rater disagreements were resolved through discussion until consensus could be reached. Inter-rater agreement for MARS ratings (before discussion) was 98%. Rater agreement improved to 100% after resolution of discrepancies.

Data Analysis

To evaluate Aims 1 and 2, we examined the percentage of apps that included each of the 15 features of interest. In addition, we computed a summary score of the total number of content features (out of 15) each app possessed, and we examined the proportion of apps that included multicomponent (i.e., educational and behavioral) adherence-promotion features. Third, we examined whether there were differences in the mean number of content features between free and for-purchase apps. Finally, we examined the percentage of apps that mentioned being designed for children, adolescents, or families in their written description.

To evaluate Aim 3, descriptive analyses were conducted to examine mean MARS total usability and subscale scores for the subset of apps with the highest number of content features (defined as scoring at least 1 SD above the mean for number of content features). We limited the usability analyses to this subset of apps in an effort to identify the combination of apps with the most content features and best usability ratings, as the presence of both would be indicative of higher quality for use in pediatric adherence promotion. Analyses were conducted using SPSS, version 22.

Results

Content of Apps

The 101 apps reviewed contained an average of 4.21 of 15 (SD = 1.86, range = 1–10) possible content features. Only 3% (n = 3) of these 101 apps included at least half of the content features known to be important in promoting youth medication adherence. Apps with 50% or more of desired features were GenieMD, Cardio Smart Med Reminder, and Mango Health. Apps that had a cost associated with purchase [M(SD) = 4.07 (1.59)] did not differ from free apps [M(SD) = 4.26 (1.96)] in the number of overall features [t(99) = 0.48, p = 0.634]. None of the apps reviewed mentioned being designed specifically for use by children, adolescents, or families in the written app description.

Medication reminder features

Apps contained an average of 3.14 of five (SD = 1.06; range = 1–5) medication reminder features. All (n = 101) apps contained at least one medication reminder feature (Table 1). Ninety-five percent (n = 96) allowed the user to store medication names and 87% (n = 88) permitted the user to set time-based medication reminders. In addition, more than half of apps allowed for the storage of medication dosages (68%; n = 69) or provided a way for the user to record if medications had been taken or skipped (56%; n = 57). Few apps (9%; n = 10) allowed the user to record a reason for skipping medication. Of note, 37% (n = 37) of apps contained only medication reminder features. Apps that had a cost associated with purchase [M(SD) = 3.22 (1.01)] did not differ from free apps [M(SD) = 3.11 (1.08) [t(99) = −0.48, p = 0.634] in their number of medication reminder features.

Behavioral modification features

Apps contained an average of 0.77 of five (SD = 0.82; range = 0–3) behavioral modification features (Table 1). Fifty-six apps (55%) contained at least one behavioral modification feature. Roughly half of the apps reviewed (51%; n = 52) allowed the user to track medication-taking progress over time. Fewer apps (14%; n = 14) provided a mechanism for sharing user medication-taking history (e.g., through e-mail), provided reinforcement (e.g., encouraging statements and earning points) for logging medication as having been taken (7%; n = 7), or allowed the user to set a medication-taking goal (6%; n = 6). None of the apps included features to promote problem solving related to adherence barriers (e.g., goal setting or identifying potential barriers to taking one's medications). Apps that had a cost associated with purchase [M(SD) = 0.74 (0.76)] did not differ from free apps [M(SD) = 0.78 (0.83)] in their number of behavioral modification features [t(99) = −0.24, p = 0.815].

Educational features

Apps contained an average of 0.30 of five (SD = 0.82; range = 0–4) educational features (Table 2). Fourteen apps (14%) contained at least one educational feature. Only a small subset of apps provided educational information about the medication (11%; n = 11), medication side effects (10%; n = 10), or disease-specific information (8%; n = 8). Only one app (1%) provided information on the benefits of adherence and no apps provided information on the risks of nonadherence. Apps that had a cost associated with purchase [M(SD) = 0.11 (0.58)] did not differ from free apps [M(SD) = 0.36 (0.89)] in the number of educational features [t(99) = 1.38, p = 0.169].

Table 2.

Features Possessed by Top Tier of Medication Reminder Apps

FEATURE	GenieMD^a	CARDIO SMART MED REMINDER^a	MANGO HEALTH^a	MedMemo ^a	myRX PLANNER^a	CareZone ^a	MEDISAFE MEDS AND PILL REMINDER	PILLJOGGER LITE
Medication reminder
Can store medication names	X	X	X	X	X	X	X	X
Can set time-based medication reminder	X	X	X	X		X	X	X
Can store medication dosages	X	X	X	X	X	X	X	X
Can record if medication was taken or skipped	X	X	X	X	X	X	X	X
Can record reason for skipping medication	X	X			X		X
Behavioral modification
Can track medication-taking progress over time	X	X	X	X	X	X	X	X
Allows user to set a medication-taking goal
Provides reinforcement for logging medication as taken			X					X
Includes a feature to promote problem solving related to adherence barriers
Provides a mechanism for sharing user medication-taking history						X	X	X
Educational
Provides educational information about medication	X	X	X	X	X
Provides information about medication side effects	X	X	X	X	X
Provides disease-specific information	X					X
Provides information on benefits of adherence	X
Provides information on the risks of nonadherence

Multicomponent app.

Multicomponent apps

Six apps (6%) used a multicomponent approach that incorporated features from both the behavioral modification and educational domains. All apps that were considered to use a multicomponent approach were free. Among the multicomponent apps, Genie MD had the highest total number of features (five features) across both behavioral and educational domains, followed by Mango Health (four features). Each of the four remaining multicomponent apps had three behavioral or educational features (Table 2).

Usability Analyses

Apps that scored more than 1 SD above the mean on the number of content features (i.e., those with seven or more content features) were considered to be in the top tier of apps, and these apps were coded for usability (Table 3). Mean total usability scores for these eight apps were 3.93 of five features (SD = 0.88, range = 3.26–4.83). Mean engagement scores were 3.49 (SD = 0.55, range 3.0–4.6), mean functionality scores were 4.16 (SD = 0.45, range 3.63–4.88), and mean aesthetics scores were 3.88 (SD = 0.63, range 3.17–5.0). Mango Health had the highest mean MARS total usability score (M = 4.83), as well as the highest usability ratings in each of the three domains. myRX Planner had the second highest total usability score (M = 4.11), followed by MediSafe Meds (M = 4.01).

Table 3.

Mobile App Rating Scale Usability Ratings for Apps Possessing the Most Content Features

APP NAME	ENGAGEMENT, M	AESTHETICS, M	FUNCTIONALITY, M	Total
Mango Health^a	4.60	5.00	4.88	4.83
myRX Planner^a	3.80	4.17	4.38	4.11
MediSafe Meds and Pill Reminder	3.20	4.33	4.50	4.01
GenieMD^a	3.20	4.00	4.25	3.82
PillJogger Lite	3.80	3.67	3.63	3.70
Cardio Smart Med Reminder^a	3.30	3.50	4.25	3.68
MedMemo^a	3.00	3.17	3.75	3.31
CareZone^a	3.00	3.17	3.63	3.27

Multicomponent app.

Discussion

Medication adherence is suboptimal among pediatric patients with chronic medical conditions, and m-health interventions offer unique potential to enhance adherence. Since smartphone apps are frequently used by youth and adults, they provide an optimal platform for improving medication adherence because they are low burden, developmentally acceptable, and can accommodate various patterns of family involvement in condition management. This study examined the extent to which the content of medication reminder apps included domains known to be important in in-person, family-based pediatric adherence-promotion interventions.

Furthermore, this study evaluated which apps, from among those with the highest number of content features, had the highest usability. This study focused on app usability broadly for children, adolescents, and parents, given that pediatric condition management is characterized by shared youth and parent involvement. Examination of both the extent to which apps include appropriate adherence-promotion content and have high usability for youth and parent users has not been previously evaluated with respect to pediatric adherence promotion. However, examining both content and usability simultaneously is important to identify apps that are most beneficial for use by families of youth with chronic medical conditions.

Consistent with pediatric and adult literature reviews of disease-specific apps, (e.g., pediatric obesity²⁷), our analysis found that most apps fail to incorporate a large number of features that are based on research evidence or recommended by experts for adherence promotion. Our findings revealed that medication reminder features were the most commonly included content domain than either behavioral modification or educational content domains. In fact, four of five medication reminder features identified as important were present in more than 50% of the apps reviewed.

In contrast, only one behavioral modification feature (i.e., the ability to track medication adherence over time) and no educational features were present in more than half of the apps reviewed. Moreover, few apps were multicomponent in nature (i.e., incorporated both behavioral modification and educational features). These findings are noteworthy insofar as pediatric adherence-promotion interventions that are behavioral or multicomponent are associated with larger improvements in pediatric adherence, relative to other forms of intervention.^10,11

Our analysis of the specific content features present within the apps also yielded information about several noteworthy gaps of high relevance for family-based pediatric adherence promotion. First, although medication reminder features as a whole were well represented among the apps reviewed, a feature allowing the user to record a reason for missing medication was absent in the majority of apps. This is notable given that most youth with chronic medical conditions experience barriers to adherence,^13,43
–45 and having parents and youth systematically track such barriers is the first step in identifying viable solutions to improve medication taking.⁴⁶

Second, few apps included a system to provide positive reinforcement for logging medication as taken. For pediatric samples, behavioral modification principles rely heavily on concrete forms of positive reinforcement as a behavior change strategy.⁴⁶ A lack of framework within the apps for providing such reinforcement may reduce the likelihood that a given pediatric patient would habitualize his or her medication-taking routine or persist in app use over time.⁴⁷

Finally, few apps included in this review included a mechanism for sharing medication-taking behavior with another user. For youth with chronic medical conditions, this is a major area of concern, given a large body of research to suggest that high levels of both youth involvement and parent involvement in condition management are associated with the most optimal adherence outcomes.^48,49 Taken together, the current results suggest that medication adherence apps could be improved by the inclusion of more behavioral modification and educational features. Inclusion of such features would enhance app viability as both a supplemental and potentially a stand-alone method of pediatric adherence promotion.

This study also examined app usability, or the extent to which apps are engaging, aesthetically pleasing, and function with ease. Usability has been established as an important priority by app users of all ages,⁵⁰ and it is especially critical for pediatric populations. Youth have a shorter attention span than adults,⁵¹ and as a result, youth may be more easily distracted and more quick to disengage from the app if barriers to functionality are present. Our review indicated that usability ratings ranged across the subset of apps containing the most relevant adherence-promotion content. Although one app (Mango Health) demonstrated very high usability ratings across all three of the domains assessed, ratings of usability for the remaining apps were more variable.

This review was characterized by several strengths. First, our app review involved an in-depth examination of each app's features by having two researchers independently download and evaluate the apps by using them over the course of a day. Previous reviews of disease-specific apps assessed the quality of apps by reviewing the written descriptions or only analyzing a small subset of apps.^{22,25,29,52

–55} Notably, we found that app descriptions do not necessarily reflect actual app content, and as such, relying solely on written descriptions of apps may yield inaccurate information about an app's content.

Second, our analysis of app content was guided by the existing pediatric adherence-promotion literature. Specifically, we chose to examine content domains that are known to be associated with better adherence outcomes in family-based pediatric adherence-promotion trials (i.e., behavioral modification features or a multicomponent set of behavioral modification and educational features). Attention to whether apps contain features that are associated with better adherence outcomes in research trials provides information about the extent to which apps could be used in combination with traditional pediatric adherence-promotion interventions or whether apps may have value as a stand-alone intervention modality.

Third, to our knowledge, this is one of few analyses of medication reminder apps for pediatric adherence promotion that is not limited to a review of disease-specific apps. Attention to general medication reminder apps provides information on a wider scope of apps and can yield a set of recommendations for pediatricians, pediatric subspecialists, or allied health professionals that applies to their full patient population, rather than just a small subset of individuals they treat. Fourth, evaluation of usability using a validated measure³² (i.e., the MARS) is a notable strength as doing so provides an objective and reliable method to quantitatively compare usability across different apps.

Although informative, this study has several limitations. First, because rankings of apps in the Apple Store are based on popularity, the top 100 apps generated from each search term do not necessarily reflect the highest quality apps. Thus, it is possible that other high-quality apps exist that were not reviewed in this study. However, this procedure for identifying apps for inclusion in systematic reviews is consistent with the procedures of other authors.^29,40 Second, we used just a subset of all possible search terms in attempting to identify relevant apps. Thus, it is possible that with different search terms, we may have identified apps not included in this review. However, given that many of our search term combinations yielded fewer than 100 apps and because many of the same apps were identified across the different search terms, we feel confident that we captured the majority of relevant apps in our review.

Finally, our review was limited to one operating system (Apple iOS), and as such, apps from other mobile app markets (e.g., Android and Windows) were not included. However, the Apple platform is the most popular mobile platform among youth in the United States,³⁹ so our focus on this platform is likely to have greater generalizability than had we focused on other app markets.

Conclusion

In conclusion, although existing medication reminder apps contain some useful content domain, there is still significant room for improvement, particularly with respect to inclusion of more behavioral modification and educational content. Moreover, greater attention to the usability of apps with high-quality content may be useful in promoting their use for pediatric patients with chronic medical conditions and their parents. Currently, medication reminder apps seem most appropriate for use as a supplement to other adherence-promotion interventions for youth with chronic medical conditions and their families. Given the limitations of existing medication reminder apps, greater collaboration between pediatric adherence-promotion scientists and app developers is needed.

Footnotes

Acknowledgment

We gratefully acknowledge the assistance of Amanda Morais with initial screening and data entry.

Disclosure Statement

No competing financial interests exist.

References

Van Cleave

, Gortmaker

, Perrin

. Dynamics of obesity and chronic health conditions among children and youth. JAMA, 2010; 303:623–630.

Modi

, Pai

, Hommel

, et al. Pediatric self-management: A framework for research, practice, and policy. Pediatrics, 2012; 129:e473–e485.

Rapoff

, Barnard

. Compliance with pediatric medical regimens. In: Cramer

, Spiler

, eds. Patient Compliance in Medical Practice and Clinical Trials. New York NY: Raven Press, 1991: 73.

Schwartz

, Axelrad

. Healthcare partnerships for pediatric adherence. Switzerland: Springer, 2015.

Dobbels

, Ruppar

, De Geest

, Decorte

, Van Damme Lombaerts

, Fine

. Adherence to the immunosuppressive regimen in pediatric kidney transplant recipients: A systematic review. Pediatr Transplantat, 2010; 14:603–613.

Oliva

, Singh

, Gauvreau

, VanderPluym

, Bastardi

, Almond

. Impact of medication non-adherence on survival after pediatric heart transplantation in the USA. J Heart Lung Transplant, 2013; 32:881–888.

Drotar

, Rohan

. Pediatric adherence and health behavior change. In: Martin

, DiMatteo

, eds. New York NY: Oxford University Press, 2013: 1–26. doi:10.1093/oxfordhb/9780199795833.013.012.

Wolfsdorf

, Craig

, Daneman

, et al. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes, 2009; 10 Suppl 12:118–133.

Cushing

, Brannon

, Suorsa

, Wilson

. Systematic review and meta-analysis of health promotion interventions for children and adolescents using an ecological framework. J Pediatr Psychol, 2014; 39:949–962.

10.

Kahana

, Drotar

, Frazier

. Meta-analysis of psychological interventions to promote adherence to treatment in pediatric chronic health conditions. J Pediatr Psychol, 2008; 33:590–611.

11.

Pai

ALH

, McGrady

. Systematic review and meta-analysis of psychological interventions to promote treatment adherence in children, adolescents, and young adults with chronic illness. J Pediatr Psychol, 2014; 39:918–931.

12.

Stice

, Shaw

, Marti

. A meta-analytic review of obesity prevention programs for children and adolescents: The skinny on interventions that work. Psychol Bull, 2006; 132:667–691.

13.

Graves

, Roberts

, Rapoff

, Boyer

. The efficacy of adherence interventions for chronically ill children: A meta-analytic review. J Pediatr Psychol, 2010; 35:368–382.

14.

Dean

, Walters

, Hall

. A systematic review of interventions to enhance medication adherence in children and adolescents with chronic illness. Arch Dis Child, 2010; 95:717–723.

15.

Miloh

, Annunziato

, Arnon

, et al. Improved adherence and outcomes for pediatric liver transplant recipients by using text messaging. Pediatrics, 2009; 124:e844–e850.

16.

Woolford

, Clark

, Strecher

, Resnicow

. Tailored mobile phone text messages as an adjunct to obesity treatment for adolescents. J Telemed Telecare, 2010; 16:458–461.

17.

Lenhart

, Duggan

, Perrin

, Stepler

, Rainie

, Parker

. Teens, Social Media & Technology Overview. 2015. 2015. Available at http://books.google.com/books?id=8zZvrgEACAAJ&dq=intitle:Teens+Social+Media+and+Technology+Overview +2015&hl = &cd = 1&source = gbs_api (last accessed September 29, 2015 ).

18.

Smith

. U.S. Smartphone Use in. 2015. April 2015. Available at www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015 (last accessed January 31, 2016 ).

19.

Lenhart

. Downloading Apps for Children. May 14, 2012. Available at www.pewinternet.org/2012/05/15/downloading-apps-for-children (last accessed January 31, 2016 ).

20.

Fox

, Duggan

. Mobile Health. 2012. November 8, 2012. Available at http://pewinternet.org/Reports/2012/Mobile-Health.aspx (last accessed January 31, 2016 ).

21.

Purcell

. Half of adult cell phone owners have apps on their phones. November 2, 2011. Available at http://pewinternet.org/Reports/2011/Apps-update.aspx (last accessed January 31, 2016 ).

22.

Sama

, Eapen

, Weinfurt

, Shah

, Schulman

. An evaluation of mobile health application tools. JMIR Mhealth Uhealth, 2014; 2:e19.

23.

Hale

, Capra

, Bauer

. A Framework to Assist health professionals in recommending high-quality apps for supporting chronic disease self-management: Illustrative assessment of type 2 diabetes apps. JMIR Mhealth Uhealth, 2015; 3:e87.

24.

, Hommel

. Using technology to assess and promote adherence to medical regimens in pediatric chronic illness. J Pediatr, 2014; 164:922–927.

25.

Obiodu

, Obiodu

. An empirical review of the top 500 medical apps in a European Android market. J Mob Technol Med, 2012; 1:22–37.

26.

Huckvale

, Car

, Morrison

, Car

. Apps for asthma self-management: A systematic assessment of content and tools. BMC Med, 2012; 10:144.

27.

Schoffman

, Turner-McGrievy

, Jones

, Wilcox

. Mobile apps for pediatric obesity prevention and treatment, healthy eating, and physical activity promotion: Just fun and games?. Transl Behav Med, 2013; 3:320–325.

28.

Breland

, Yeh

, Yu

. Adherence to evidence-based guidelines among diabetes self-management apps. Transl Behav Med, 2013; 3:277–286.

29.

Dayer

, Heldenbrand

, Anderson

, Gubbins

, Martin

. Smartphone medication adherence apps: Potential benefits to patients and providers. J Am Pharm Assoc (2003), 2013; 53:172–181.

30.

Girardello

, Michahelles

. AppAware: Which mobile applications are hot? In: Proceedings of the 12th International Conference on Human Computer Interaction with Mobile Devices and Services Sep 7, 2010 (pp. 431–434). ACM.

31.

Kuehnhausen

, Frost

. Trusting smartphone apps? To install or not to install, that is the question. In: Cognitive Methods in Situation Awareness and Decision Support (CogSIMA), 2013 IEEE International Multi-Disciplinary Conference on Feb 25, 2013 (pp. 30–37). IEEE.

32.

King

, Hekler

, Grieco

, et al. Harnessing different motivational frames via mobile phones to promote daily physical activity and reduce sedentary behavior in aging adults. PLoS One, 2013; 8:e62613.

33.

Mattila

, Orsama

A-L

, Ahtinen

, Hopsu

, Leino

, Korhonen

. Personal health technologies in employee health promotion: Usage activity, usefulness, and health-related outcomes in a 1-year randomized controlled trial. JMIR Mhealth and Uhealth, 2013; 1:e16.

34.

Robinson

, Higgs

, Daley

, et al. Development and feasibility testing of a smart phone based attentive eating intervention. BMC Public Health, 2013; 13:639.

35.

Kirwan

, Vandelanotte

, Fenning

, Duncan

. Diabetes self-management smartphone application for adults with type 1 diabetes: Randomized controlled trial. J Med Internet Res, 2013; 15:e235.

36.

Turner

, Metz

, Wen

. Prevention and treatment of pediatric obesity using mobile and wireless technologies: A systematic review. Pediatr Obes, 2015; 10:403–409.

37.

Kenny

, Dooley

, Fitzgerald

. Developing mental health mobile apps: Exploring adolescents' perspectives. Health Informatics J, 2014 [Epub ahead of print]; DOI: 10.1177/1460458214555041.

38.

Stoyanov

, Hides

, Kavanagh

, Zelenko

, Tjondronegoro

, Mani

. Mobile app rating scale: A new tool for assessing the quality of health mobile apps. JMIR Mhealth and Uhealth, 2015; 3:e27.

39.

Taking Stock with Teens—Fall 2014. October 8, 2014. Available at www.piperjaffray.com/3col.aspx?id=3268 (last accessed September 29, 2015 ).

40.

Pagoto

, Schneider

, Jojic

, DeBiasse

, Mann

. Evidence-based strategies in weight-loss mobile apps. Am J Prev Med, 2013; 45:576–582.

41.

Conroy

, Yang

C-H

, Maher

. Behavior change techniques in top-ranked mobile apps for physical activity. Am J Prev Med, 2014; 46:649–652.

42.

Hides

et al. 2014, Mobile Application Rating Scale (MARS): A new tool for assessing the quality of health mobile applications, Young and Well Cooperative Research Centre, Melbourne.

43.

Rapoff

. Measurement issues: Assessing adherence and disease and health outcomes. In: Adherence to Pediatric Medical Regimens. Issues in Clinical Child Psychology. Boston, MA: Springer US, 2010:69–113.

44.

Drotar

, Bonner

. Influences on adherence to pediatric asthma treatment: A review of correlates and predictors. J Dev Behav Pediatr, 2009; 30:574–582.

45.

Quittner

, Modi

, Lemanek

, Ievers-Landis

, Rapoff

. Evidence-based assessment of adherence to medical treatments in pediatric psychology. J Pediatr Psychol, 2008; 33:916–936, discussion 937–938.

46.

Rapoff

. Strategies for Improving Adherence to Pediatric Medical Regimens. In: Adherence to Pediatric Medical Regimens. Issues in Clinical Child Psychology. Boston, MA: Springer US; 2010:115–145.

47.

Stawarz

, Cox

, Blandford

. Don't forget your pill!: Designing effective medication reminder apps that support users' daily routines. In: Proceedings of the SIGCHI Conference on Human Factors in Computing Systems

Apr 2014

26 (pp. 2269–2278). ACM.

48.

Modi

, Guilfoyle

, Rausch

. Preliminary feasibility, acceptability, and efficacy of an innovative adherence intervention for children with newly diagnosed epilepsy. J Pediatr Psychol, 2013; 38:jst021–jst616.

49.

Rapoff

. Review of adherence intervention studies and top ten ways to advance research on adherence to pediatric medical regimens. In: Adherence to Pediatric Medical Regimens. Issues in Clinical Child Psychology. Boston, MA: Springer US; 2010:147–185.

50.

Payne

, Lister

, West

, Bernhardt

. Behavioral functionality of mobile apps in health interventions: A systematic review of the literature. JMIR Mhealth Uhealth, 2015; 3:e20.

51.

Niksch

. mHealth in pediatrics finding healthcare solutions for the next generation. mHealth, 2015; 1:7 doi: 10.3978/j.issn.2306-9740.2015.03.09.

52.

Rosser

, Eccleston

. Smartphone applications for pain management. J Telemed Telecare, 2011; 17:308–312.

53.

Azar

KMJ

, Lesser

, Laing

, et al. Mobile applications for weight management: Theory-based content analysis. Am J Prev Med, 2013; 45:583–589.

54.

West

, Hall

, Hanson

, Barnes

, Giraud-Carrier

, Barrett

. There's an app for that: Content analysis of paid health and fitness apps. J Med Internet Res, 2012; 14:e72.

55.

Shen

, Levitan

M-J

, Johnson

, et al. Finding a depression app: A review and content analysis of the depression app marketplace. JMIR m-Health and uHealth, 2015; 3:e16.