Dual Antiplatelet Therapy Adherence With Reminder App Usage
Phase: NA
Conditions: Aneurysm Cerebral (Unruptured)
Sponsor: Montefiore Medical Center

Dual Antiplatelet Therapy Adherence With Reminder 
App Usage
ID: 2021-13195
NCT05071027
10/27/2021

Protocol Version 1.4 10-21-2021
Study Protocol
A.
Study Title and Investigators
Dual Antiplatelet Therapy Adherence With Reminder App Usage
INVESTIGATOR’S QUALIFICATIONS AND EXPERIENCE
□ A copy of C.V./resume for each attending/faculty investigator, HIPAA and Human 
subjects protection training for all research team members are included with this 
protocol, if not in IRB files. (Please ensure that all research personnel included above 
have completed training in the protection of human subjects as per iRIS requirements.)
CONFLICTS OF INTEREST STATEMENT
□ A statement of financial disclosure and other conflicts of interest of all investigators 
and research personnel is included in the iRIS initial review application form for chart 
reviews.
Principal Investigator
David Altschul, MD
Department of Neurosurgery
3316 Rochambeau Ave, Bronx, NY 10467-2841
Phone #: 718-820-3243
Email: daltschu@montefiore.org
Co-Investigator
Samuel Ahmad
Research Staff
Erida Castro-Rivas, Wenzhu Mowrey, PhD
Title
Dual Antiplatelet Therapy Adherence With Reminder App 
Usage
Study Design /Methodology
Randomized Control Trial
Study Duration
6 months 
Objectives
To examine the level of compliance with DAPT of patients 
assigned to a medication reminder app compared to that of 
patients not using the app receiving the same standard of care.
Number of Subjects
68
Eligibility Criteria and main 
objective
See pertinent sections below 
Study Site 
Single Center
Study Funded
No
IRB NUMBER: 2021-13195
IRB APPROVAL DATE: 10/27/2021

Protocol Version 1.4 10-21-2021
(Please verify if any members of the research team have any conflict of interest related 
to this study. Please ascertain this prior to submission- contact iRIS for guidance)
B. Research Proposal:
1. Introduction
Medication compliance adherence is of the utmost importance in medicine and has 
significant impact on clinical outcomes. New technologies, such as smart phones, are 
currently utilized for a plethora of purposes. By developing an app-based 
medication reminder system for patients undergoing procedural treatment of 
aneurysms, the study authors hope to significantly enhance medication adherence 
as well as clinical outcomes. This study compares dual antiplatelet therapy [DAPT] 
adherence of the patients using this app and the patients receiving only the standard 
of care. Questions from the Adherence Barriers Questionnaire [ABQ] will be utilized 
to assess adherence and relevant clinical outcomes will be used as well.
2.
Background
Flow-diverter devices (FDDs) such as the Pipeline Embolization Device (PED) are 
next-generation stents that are placed at neck of the aneurysm in order to 
significantly diminish blood flow into the aneurysm, which ultimately results in 
aneurysm thrombosis. Another method used to treat aneurysms is stent-assisted 
coiling. These procedures, however, bring with them risk of stroke and 
thrombosis/stenosis and thus require antiplatelet medications both prior to and 
post treatment. 
Dual antiplatelet therapy [DAPT] in the form of aspirin and clopidogrel, a 
thienopyridine, is most common. A survey by Faught et al. found that among 
neurointerventionalists practicing in America, the most commonly prescribed 
antiplatelet therapy was aspirin 325 mg and clopidogrel 75 mg daily for seven days or 
five days prior to the procedure. Maintenance therapy following FDD placement is 
commonplace, with only 15.6% and 30.2% of practitioners refraining following 
intracranial and cervical stent placement, respectively. Aspirin 325 mg daily for life and 
clopidogrel 75 mg daily for three months was the most common maintenance therapy 
aside from the choice “other” [2].
Discontinuation of antiplatelet medication has been found to be associated with 
thrombotic events. A review article by Briganti et al. reported a mean incidence of 
3.8% for parent artery thrombosis or 50 percent or greater stenosis during the FDD 
IRB NUMBER: 2021-13195
IRB APPROVAL DATE: 10/27/2021

Protocol Version 1.4 10-21-2021
implantation procedure in 12 studies. An occlusion or stenosis rate of 6.8% by the 
time of angiographic follow-up was found in 16 studies. Mean angiographic follow-
up was nine months, with a range of three to thirty months. The authors note that 
these later findings were frequently incidental and were associated with 
termination of clopidogrel [1]. This association has also been found in the case of 
stent-assisted coiling. Mocco et al. found that seven out of 213 patients who received 
stent-assisted coiling of aneurysms developed delayed thrombotic events. 
Furthermore, the authors reported that prior to these events, the patients were not 
taking DAPT, which consisted of aspirin and clopidogrel [6]. 
Thromboelastography [TEG] is commonly used to assess the clotting ability of 
blood. In neuroendovascular procedures such as PED implantation, TEG evaluates 
the effectiveness of antiplatelet therapy. The hepatic CYP450 system is responsible 
for converting clopidogrel and prasugrel, two thienopyridines, into their active 
forms [4]. As reported by Norgard et al., whereas clopidogrel metabolism is reduced 
in patient’s carrying a reduced-function CYP2C19 allele, prasugrel metabolism does 
not appear to be affected to any clinically significant degree. Cosequently 
hyporesponders to clopidogrel are at elevated risk of thrombosis [8]. McTaggart et 
al. found that among the eight patients out of 31 who had suffered thromboembolic 
events/TIA following PED placement, six were hyporesponders to clopidogrel on 
TEG [5].
Noncompliance with DAPT may have clinically significant consequences. The CDC 
states that several factors influence medication compliance. These factors include 
the severity of the health condition and the patient’s beliefs about his or her 
condition, busy schedules that make it difficult to remember to take medicines, out-
of-pocket cost of medications, and possessing an understanding of when to take 
medications [10]. Prasugrel, for example, can be prohibitively expensive for some 
patients due to higher out-of-pocket costs. Fortunately, smart phone app-generated 
reminders to take medications may enhance compliance by providing patients with 
clear instructions wherever they happen to be. 
Text-based reminders have been shown to decrease medication noncompliance. 
Park et al. explored the impact of text messaging on antiplatelet and statin 
adherence among patients who had suffered an MI or received percutaneous 
coronary intervention [PCI]. The mean age was 59.2 years. Text medication 
reminders required acknowledgement of receipt. Patients who received text 
messages took a significantly greater percentage of correct doses taken [p= 0.02] 
and percentage of prescribed doses taken [p=0.01] compared to those who did not 
receive such reminders. No significant difference in percentages of doses of statins 
taken was found [9]. Foreman et al. found that patients who received text message 
reminders regarding chronic oral medications were significantly more likely to take 
the appropriate dosages. Regarding antidiabetes medications, the text message 
cohort had a mean compliance rate of 0.91 compared to a rate of 0.82 for the control 
group (p=0.029). A significant increase in β-blocker compliance was also found, 
IRB NUMBER: 2021-13195
IRB APPROVAL DATE: 10/27/2021

Protocol Version 1.4 10-21-2021
with a mean compliance rate of 0.88 for the text message cohort opposed to a 0.71 
rate for the control group (p=0.006) [3]. 
The advent of an antiplatelet reminder app for FDDs and stent-assisted coiling holds 
the possibility of not only improving medication compliance but also of decreasing 
the incidence of thrombotic events following said procedures. The effectiveness of 
this app may be assessed via a prospective cohort study. We would like to develop a 
tailored standardized intervention for endovascular patients receiving DAPT that 
extends beyond the traditional teach-back method and follow-up evaluation.
3. Research Question:
To test the efficacy of a medication reminder app regarding DAPT compliance, with 
compliance estimated by patients’ ABQ scores. The free app is called Endovascular 
Neurosurgery and is available on the Apple App Store. It was developed by Dr. Jonathan 
Nakhla and does not collect user data. The only data inputted into the app are the 
patient’s procedure date and the antiplatelet medications the patient has been 
prescribed. The app does not possess patient data. Montefiore IT stated that it does not 
monitor apps that patients download onto their own devices. Both groups will receive 
the same standard of care, including any information on the risks of DAPT 
nonadherence. 
C. Research Population or Study Sample Selection
1. Study Setting:
The target population will be adult aneurysm patients from Montefiore’s 
cerebrovascular neurosurgery clinic. All consultations and introductions to the study will 
take place in the 3316 Rochambeau Ave, and participants will be selected based on their 
willingness to participate in the study and possession of an iphone. 
2. Source of subject selection: 
A qualified research staff member will approach potential participants. They will be 
recruited in the waiting room area by face-to-face meetings. A screening questionnaire 
(APPENDIX 1-Attached Eligibility Form) will be utilized to identify subjects for inclusion in 
the study.
3. Sampling Strategies: 
We plan to enroll 68 patients undergoing either FDD placement or stent-assisted coiling 
at baseline. Upon consent, the patients will be randomized with 1:1 ratio into one of the 
2 arms: the intervention arm (standard of care + medication compliance app) and the 
comparison arm (standard of care).
IRB NUMBER: 2021-13195
IRB APPROVAL DATE: 10/27/2021

Protocol Version 1.4 10-21-2021
3.1 Randomization: Participants will be randomized at the cerebrovascular 
neurosurgery clinic prior to the start of the intervention. Randomization will be 
performed using a random number generator. 
Equitable Selection of Subjects
i)
Gender of Subjects:  No exclusion by gender. Women and men 
are included in this research.
ii)
Age of Subjects: By the nature of the study all subjects to be 
included in the study are adults ≥ 18 years of age.
4. Potential Issues/Problems with Specific Sub-Groups 
No specific issues related to study procedures are expected given the minimal risk 
nature of these procedures. However, language barriers to understanding the 
questionnaires will be overcome by utilizing appropriate translations of questionnaires, 
study material and through study personnel who are bilingual.
D. Study Criteria
1. Inclusion Criteria: 
i)
Over 18 years old
ii)
Must speak either English or Spanish fluently
iii)
Physically able to come to the research site location.
iv)
Elective stent-based procedures for unruptured cervical, and intracranial, 
intradural aneurysms
v)
Endovascular therapy must be deemed appropriate by clinical team. 
2.  Exclusion Criteria
i) Presence of basilar, cavernous, or ruptured aneurysms. Presence of 
comorbidities that preclude the possibility of treatment. Presence of 
contraindications to DAPT. Presence of certain vessel anatomical characteristics. 
Lack of iphone.
E. Methods and Procedures
1. Materials and Methods
i. Objectives:
To examine the level of DAPT adherence between patients who receive medication 
reminder notifications vs those who only receive the standard of care.
IRB NUMBER: 2021-13195
IRB APPROVAL DATE: 10/27/2021

Protocol Version 1.4 10-21-2021
ii. Study Design:
This will be a randomized control trial, with patients undergoing stent-based 
endovascular treatment for unruptured cervical and intradural, intracranial 
aneurysms. Informed consent will be obtained from participating patients and 
the study will be conducted after being approved by local ethics committees. 
Patients will be assigned to either the app group or the control group. 
The particular stent-based therapy, either FDD placement or stent-assisted 
coiling, will be chosen for each patient by the clinical team. During the study 
consultation, the app group will have the app installed on their smart phones 
and will be trained in its usage. TEG and Aspirin inhibition percentage will be 
determined for each patient following the procedure. Patients with TEG less than 
60% will have DAPT changed from 81 mg aspirin and 75 mg clopidogrel to 81 
mg aspirin and 10 mg prasugrel. Patients with aspirin inhibition percentages of 
less than 20% will have their aspirin doses increased to 325 mg. Medication 
compliance of all participants will be assessed on the day of the procedure via a 
medication compliance questionnaire. The same questionnaire will be 
administered during follow-up appointments 2-4 weeks and 6 months post-
procedure. 
2. Study Procedures
 
i. Recruitment and Enrollment
Participants will be recruited in Montefiore’s cerebrovascular neurosurgery clinic. The 
initial recruitment plan is that research staff will use standardized scripts to describe the 
study and its purpose highlighting eligibility criteria, including both gender and English 
and/or Spanish speaking. Interested individuals will be asked to indicate their interest in 
the study to the research staff who will invite them to complete the informed consent 
process and an eligibility questionnaire. Both the app and questionnaire will be available 
in Spanish. As part of the consent process, patients will be shown and taught how to use 
the app.
ii. Intake Process
Study staff will conduct all intake processes (i.e., informed consent and screening) at the 
site. In instances where participants are not comfortable proceeding with the study, 
they will be withdrawn by research staff.  Staff will meet in an alternative private setting 
in the clinic.
3. Data Collection and Management
Patient data will be stored on a document accessible only with a password. We will use 
codes for each patient and said codes will be stored in a separate database to match 
with the names of the patients. We will not publish any identifying patient data.
i. Survey Data Management
IRB NUMBER: 2021-13195
IRB APPROVAL DATE: 10/27/2021

Protocol Version 1.4 10-21-2021
All local staff will be trained in maintaining participant confidentiality and rigorous data 
management based on standard operating procedures. All electronic files will be 
reviewed for completeness and accuracy.
ii. Qualitative Data Management
All interview guides will be translated to Spanish and confirmed by a second qualified 
translator to ensure accuracy prior to conducting the interviews. 
iii. Data Storage and Confidentiality:
The principal investigator and research team will be responsible for ensuring the 
physical privacy of participants and that data are stored in a secure area accessible only 
to study staff. All efforts will be made to protect subject personal information.  Medical 
information of research study subjects will be stored and kept in a designated research 
office according to requirements and they will not be identified personally in any 
reports or publications resulting from this study. 
iv. Screening: The screening time will start at the time of the consultation. After 
patients agree that they will be part of the study, eligibility verification will take 
place. Randomization will take place and patients will be assigned to either the 
app or control group. We plan to enroll 68 patients undergoing either FDD 
placement or stent-assisted coiling at baseline. Upon consent, the patients will 
be randomized with 1:1 ratio into one of the 2 arms: the intervention arm 
(standard of care + medication compliance app) and the comparison arm 
(standard of care). Block randomization with the block size of 10 will be used to 
generate the randomization scheme using the SAS procedure called proc plan. 
            
Patients in the app group will have the app installed on their devices and will be     
trained in using the app. Demographic data will also be harvested from all patients.
Once the app is installed, patients may input their procedure type and date. Patients 
then will select the antiplatelet medications that have been prescribed and schedule a 
time to receive medication reminders. The medication(s) and time of usage will be 
selected following the shared-decision making process between the attending physician 
and patient. These medication reminders may be turned off at any time on the app. 
Upon receiving a medication reminder, the patient must only unlock his or her phone to 
end the reminder message.
v. Procedure: Approximately 1 week post-screening patients will undergo their 
procedures. The ABQ will be administered to all patients.
vi. Follow-up plan: 
IRB NUMBER: 2021-13195
IRB APPROVAL DATE: 10/27/2021

Protocol Version 1.4 10-21-2021
1. 2-4 weeks post-procedure: This will serve as standard follow-up for all patients. 
The ABQ will be administered to all patients for a second time. 
2. 6 months post-procedure: Standard follow-up will occur for all patients. The ABQ 
will be administered a third and final time.
3. Outcomes related to morbidity and mortality will be collected for all patients at 2 
to 4 weeks and 6 months post-procedure.
4. Closure or termination of study: Once data collection and analysis are complete, 
the study will be closed.
5. Sample Size
We plan to enroll 68 patients undergoing stent-based aneurysm procedures (25 in the 
app group and 25 in the control group) at baseline.
vii. Data Safety and Monitoring: Given that the intervention is non-harmful [an app], we 
do not believe that a Data Safety Monitoring Plan will be necessary. The trial will go to 
completion.
F. Analysis
i.
Statistical plan:
All analyses will be performed according to intention to treat, where patients 
are analyzed as randomized. Baseline characteristics will be compared between 
arms using Pearson’s Chi-square or Fisher’s exact test for categorical variables 
and using 2-sample t-test or Wilcoxon rank sum test for continuous variables. 
The primary end point is ABQ medication compliance score. Within-arm 
analysis: Paired t-tests will compare ABQ scores between pre-procedure and 6 
months within each arm. Primary analysis will use the 2-sample t-test to 
compare the ABQ score at 6 months between the two arms. These analyses will 
be repeated for the pre-procedure and the intermediate time point (2-4 weeks) 
to assess whether ABQ scores are improved with a shorter intervention period. 
Linear regression models will compare ABQ scores at 6 months between the 2 
arms while adjusting for potential confounders such as age, sex, race/ethnicity, 
potential out-of-pocket expenses, and cigarette smoking status. Linear mixed 
models accounting for repeated measures from the same patient will be used to 
compare the effects of the arms (App vs. usual care) and time points while 
adjusting for potential confounders.
IRB NUMBER: 2021-13195
IRB APPROVAL DATE: 10/27/2021

Protocol Version 1.4 10-21-2021
ii.
Power analysis: 
The study sample sizes of 25 in the App arm and 25 in the usual care arm will 
achieve 80% power to detect a minimum group difference of 0.80 SD between 
the two arms in the ABQ scores at 6 months for medication compliance with a 
significance level (alpha) of 0.05 using a 2-sided 2-sample t-test.
iii.
Outcome measures: 
Primary endpoint: medication compliance score from the Adherence Barrier 
Questionnaire [ABQ]. The ABQ score ranges from 14-52 and a higher score 
indicates that a patient faces greater barriers to adherence [7].
Assessment time points: App usage will commence when medication use is 
initiated 7 days prior to the procedure. The ABQ will be given 3 times: on the 
day of the procedure, 2-4 weeks post-procedure and 6 months post-procedure. 
6-month is the primary time point.
Safety endpoints: incidence of stroke/thrombotic events/TIAs at 6 months post-
treatment, as well as all-cause mortality, all-cause morbidity, rehospitalization for 
cerebrovascular events, peri-treatment hospitalization lasting more than 15 days, 
and delayed discharge from hospital.
G. Risk/Benefit Assessment
i. Risk
One possible risk is that participants may feel uncomfortable in sharing their health 
information with investigators and or research staff regarding their healthcare and 
demographic information. However, participation in this study is strictly voluntary and 
participants may leave the study at any point or refuse to answer any question.  
Participants also have the option to report to the project administrators any event 
during the study that causes any discomfort.  It is important that participants know that 
they will not be penalized nor will their care or benefits at Montefiore be at risk if 
participants choose to share withhold this information.  
ii. Protection against Risks
All necessary precautions will be taken to ensure that the information collected during 
the study is safe-guarded. Additionally, as part of the process involved in obtaining 
written informed consent, all participants will be reminded that their responses are 
confidential and that they may refuse to participate in the project or withdraw at any 
time without explanation, and further, that such action will in no way affect their 
IRB NUMBER: 2021-13195
IRB APPROVAL DATE: 10/27/2021

Protocol Version 1.4 10-21-2021
employment, treatment or future interactions with their supervisors or health care 
providers. To ensure confidentiality, all patient data will be stored in a repository 
accessible only with a password. We will use codes for each patient and said codes will 
be stored in a separate database to match with the names of the patients. We will not 
publish any identifying patient data.
iii. Potential Benefits to the Subjects. 
We cannot and do not guarantee that participants will receive any benefits from this 
study.  The benefit for the community at large is that the collected data will be used to 
establish a standard medication adherence intervention, tailor-made for 
cerebrovascular neurosurgery patients. 
iv. Alternate procedures.
Instead of being in this study, participants have these options:  They do not have to 
participate in this study to receive ongoing care for their current conditions.  
Additionally this is not a study that will diagnose or treat a disease or condition in 
subjects.  Participants are free to choose not to participate in the study.
H. Subject Identification, Recruitment and Consent
i. Process of Consent
All eligible participants will be required to review and sign an informed consent form in 
their preferred language before participating in the pilot test. The research coordinator 
will be present to explain the consent form in its entirety. This research coordinator will 
answer any questions or concerns raised by any participant during the consent form 
review and the consent process will be documented by the research coordinator. All 
participants will receive a copy of their signed consent form after assuring that they 
have understood what was said and can repeat to the proctor specific security/rights 
procedures. (IE: the participant knows that he or she does not risk the care they receive 
at Montefiore by not committing to the study.) The PI is responsible for ensuring that 
valid consent is obtained and documented for all subjects.
These consent forms will be created utilizing the IRB templates at iRIS Center in both 
English and Spanish and will be approved by the IRB.  
ii. Subject Capacity
All the potential participants will be asked if they have decisional capacity.
iii. Subject/Representative Comprehension 
The study staff (PI or research coordinator) will explain the consenting process in detail 
including all required elements of the consent process in participant’s language. A read 
back of the essential items of the consent will be conducted by the staff to ensure 
adequate understanding by the participant of the consent and study procedures, risk, 
benefits and alternatives.
All assessment materials will be created in both English and Spanish by qualified 
individuals to safeguard each participant’s autonomy. Materials will first be created in 
IRB NUMBER: 2021-13195
IRB APPROVAL DATE: 10/27/2021

Protocol Version 1.4 10-21-2021
English and upon IRB approval be translated into Spanish by qualified personnel. These 
new materials will then be subjected to IRB amendment approval before formal use. All 
translation of project materials will be performed by qualified individuals and certified in 
writing as per IRB requirement. All procedures will be executed according to participant 
disposition and be further divided and executed based on each participant’s most 
convenient language; in either Spanish or English. None of the materials will be formally 
administered until review boards from the participating site - Einstein IRB - approve 
their use and language.
iv. Consent Forms
Written informed consent will be obtained and will be made available in English and 
Spanish. (See APPENDIX #2: (Informed Consent Document)
v. Documentation of Consent
The study staff will review the consent form, explain the critical components and obtain 
written documentation through signatures from each participant prior to enrollment 
into the study. 
vi. Costs to the Subject
There will be no cost for participation. 
vii. Payment for Participation
There will be no payment for participation.
I– Conflicts of Interest
There is no conflict of interest for any authors in this study.
J– Reporting Results 
All results will be analyzed and manuscripts will be prepared for submission to an 
academic medical journal for publication. We are also aiming to present these findings 
in regional or national conferences. 
Work Cited
1. Briganti, Francesco, et al. “Endovascular Treatment of Cerebral Aneurysms Using Flow-Diverter 
Devices: A Systematic Review.” The Neuroradiology Journal, vol. 28, no. 4, 2015, pp. 365–375., 
doi:10.1177/1971400915602803. 
2. Faught, Ryan W, et al. “Heterogeneous Practice Patterns Regarding Antiplatelet Medications for 
Neuroendovascular Stenting in the USA: a Multicenter Survey.” Journal of NeuroInterventional 
Surgery, vol. 6, no. 10, 2014, pp. 774–779., doi:10.1136/neurintsurg-2013-010954. 
IRB NUMBER: 2021-13195
IRB APPROVAL DATE: 10/27/2021

Protocol Version 1.4 10-21-2021
3. Foreman, Kalee F., et al. “Impact of a Text Messaging Pilot Program on Patient Medication Adherence.” 
Clinical Therapeutics, vol. 34, no. 5, 2012, pp. 1084–1091., doi:10.1016/j.clinthera.2012.04.007. 
4. Iqbal AM, Lopez RA, Hai O. Antiplatelet Medications. [Updated 2020 Dec 7]. In: StatPearls [Internet]. 
Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: 
https://www.ncbi.nlm.nih.gov/books/NBK537062/
5. McTaggart, Ryan A, et al. “Use of Thromboelastography to Tailor Dual-Antiplatelet Therapy in Patients 
Undergoing Treatment of Intracranial Aneurysms with the Pipeline Embolization Device.” Journal 
of NeuroInterventional Surgery, vol. 7, no. 6, 2014, pp. 425–430., doi:10.1136/neurintsurg-2013-
011089. 
6. Mocco, J, et al. “Delayed Thrombosis or Stenosis Following Enterprise-Assisted Stent-Coiling: Is It 
Safe? Midterm Results of the Interstate Collaboration of Enterprise Stent Coiling.” Neurosurgery, 
vol. 69, no. 4, 2011, pp. 908–914., doi:10.1227/neu.0b013e318228490c. 
7. Müller S, Kohlmann T, Wilke T. Validation of the Adherence Barriers Questionnaire - an instrument for 
identifying potential risk factors associated with medication-related non-adherence. BMC Health 
Serv Res. 2015;15:153. Published 2015 Apr 10. doi:10.1186/s12913-015-0809-0
 
8. Norgard, Nicholas, and Mazen Abu-Fadel. “Comparison of Prasugrel and Clopidogrel in Patients with 
Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention.” Vascular Health and 
Risk Management, 2009, p. 873., doi:10.2147/vhrm.s5699. 
9. Park, Linda G., et al. “A Text Messaging Intervention to Promote Medication Adherence for Patients 
with Coronary Heart Disease: A Randomized Controlled Trial.” Patient Education and Counseling, 
vol. 94, no. 2, 2014, pp. 261–268., doi:10.1016/j.pec.2013.10.027. 
10. “Strategies and Emerging Interventions for Improving Medication Adherence.” Cdc.gov, Aug. 2017, 
www.cdc.gov/dhdsp/pubs/docs/SIB_feature_Aug2017.pdf. 
IRB NUMBER: 2021-13195
IRB APPROVAL DATE: 10/27/2021