JMIR FORMATIVE RESEARCH

Park et al

Original Paper

Implications for Training on Smartphone Medication Reminder
App Use by Adults With Chronic Conditions: Pilot Study Applying
the Technology Acceptance Model
Daniel Y Park1*, MA; Elizabeth M Goering1*, PhD; Katharine J Head1*, PhD; Rebecca J Bartlett Ellis2*, RN, ACNS-BC,
PhD
1

Department of Communication Studies, Indiana University-Purdue University Indianapolis, Indianapolis, IN, United States

2

Indiana University School of Nursing, Indiana University-Purdue University Indianapolis, Indianapolis, IN, United States*

all authors contributed equally

Corresponding Author:
Elizabeth M Goering, PhD
Department of Communication Studies
Indiana University-Purdue University Indianapolis
425 University BoulevardIndianapolis, IN, 46202
United States
Phone: 1 317 278 3136
Fax: 1 317 278 1025
Email: bgoering@iupui.edu

Abstract
Background: The majority of middle-aged to older patients with chronic conditions report forgetting to take medications asprescribed. The promotion of patients’ smartphone medication reminder app (SMRA) use shows promise as a feasible andcost-effective way to support their medication adherence. Providing training on SMRA use, guided by the technology acceptancemodel (TAM), could be a promising intervention to promote patients’ app use.
Objective: The aim of this pilot study was to (1) assess the feasibility of an SMRA training session designed to increase patients’intention to use the app through targeting perceived usefulness of app, perceived ease of app use, and positive subjective norm
regarding app use and (2) understand the ways to improve the design and implementation of the training session in a hospitalsetting.
Methods: A two-group design was employed. A total of 11 patients older than 40 years (median=58, SD=9.55) and taking 3
or more prescribed medications took part in the study on one of two different dates as participants in either the training group(n=5) or nontraining group (n=6). The training group received an approximately 2-hour intervention training session designed
to target TAM variables regarding one popular SMRA, the Medisafe app. The nontraining group received an approximately
2-hour control training session where the participants individually explored Medisafe app features. Each training session was
concluded with a one-time survey and a one-time focus group.
Results: Mann-Whitney U tests revealed that the level of perceived ease of use (P=.13) and the level of intention to use an
SMRA (P=.33) were higher in the training group (median=7.00, median=6.67, respectively) than in the nontraining group(median=6.25, median=5.83). However, the level of perceived usefulness (U=4.50, Z=−1.99, P=.05) and the level of positive
subjective norm (P=.25) were lower in the training group (median=6.50, median=4.29) than in the nontraining group (median=6.92,
median=4.50). Focus groups revealed the following participants’ perceptions of SMRA use in the real-world setting that theintervention training session would need to emphasize in targeting perceived usefulness and positive subjective norm: (1) the
participants would find an SMRA to be useful if they thought the app could help address specific struggles in medication adherencein their lives and (2) the participants think that their family members (or health care providers) might view positively the participants’
SMRA use in primary care settings (or during routine medical checkups).
Conclusions: Intervention training session, guided by TAM, appeared feasible in targeting patients’ perceived ease of use and,
thereby, increasing intention to use an SMRA. Emphasizing the real-world utility of SMRA, the training session could bettertarget patients’ perceived usefulness and positive subjective norm that are also important in increasing their intention to use theapp.
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Park et al(JMIR Formativ Res 2017;1(1):e5) doi: 10.2196/formative.8027
KEYWORDS
chronic disease; education of patients; medication adherence; mHealth; mobile apps; smartphone

Introduction
Background
Approximately 87.5 million middle-aged to older adults in the
United States report having one or more chronic conditions [1],and 68% report not taking or filling medications as prescribed[2]. Medication adherence is critical to reducing negative
health-related outcomes such as increased hospitalization,
morbidity, and mortality [3-5].
Poor medication adherence among middle-aged to older patientswith chronic conditions often stems from forgetting [2].
Complex medication schedules for chronic condition
management (ie, polypharmacy) [6] might lead these patientsto struggle with remembering medication schedules and, thereby,
lead them to poorly adhere to medications [7,8].
Smartphone medication reminder apps (SMRAs) that enable
users to (1) record prescribed medication information (eg,medication type and dosing schedule) in the app, (2) receive
reminders (eg, alarm and message) from the app at the time totake medications, and (3) monitor medication adherence levels
via the app [9], show promise as a way to enhance adherence
for middle-aged to older patients with chronic conditions. In an
experimental setting, a randomized control trial revealed thatthe patients with a 3-month SMRA use reported higher levelsof medication adherence compared with those without app use[9]. In the real-world setting, an SMRA is available tosmartphone owners at little to no cost [10], and there is a highrate of smartphone ownership within the middle-aged to older
population. For example, 74% of US adults aged between 50
and 64 years report having smartphones [11], which indicatesthat an SMRA could be utilized with little to no cost by the
majority of these adults. In this regard, the promotion of SMRA
use among middle-aged to older patients with chronic conditions
could be a feasible and cost-effective way to support their
medication adherence.

Intervention and the Aims of Pilot Study
Patients’ electronic health (eHealth) technology use is likely to
be challenged by age-related declines in eHealth literacy [12-14]
or ability to incorporate eHealth technology use into health care[15]. As an intervention strategy to promote middle-aged toolder adults’ eHealth technology use, existing studies havehelped these adults to be capable of using the technologies
through training sessions [16,17].
In the same vein, providing training on SMRA use shows
promise as an intervention strategy to promote middle-aged toolder patients’ app use. Existing studies have indicated the utilityof training sessions (eg, demonstrating SMRA features tohttp://formative.jmir.org/2017/1/e5/

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patients, having patients complete app-related tasks, andproviding patients with app-related education materials) inenabling patients to use an SMRA [9,18,19]. However, little
attention has been paid to how to design an SMRA training
session to be more effective in promoting the patients’ app use,such as which theoretical determinants of app use the training
session should focus on to ensure the patients will adopt the useof the app.
The technology acceptance model (TAM) [20,21] provides auseful theoretical framework for informing the design of an
SMRA training session, given its focus on the determinants oftechnology use [20]. Specifically, TAM describes that users’
positive perceptions of technology, such as perceived usefulness
and perceived ease of use, might lead to intention to use thetechnology that might, in turn, lead to actual technology use[22]. Furthermore, TAM describes that technology training
might lead users to adopt the use of technology when the training
first increases users’ levels of positive perceptions of technology[22]. Although the more recent unified theory of acceptanceand use of technology (UTAUT) [23,24] that TAM isincorporated into also describes technology training (ie,facilitating condition) as the determinant of technology use, the
UTAUT describes that the training, independently of users’
positive perceptions of technology, might lead users to adopt
the use of technology [23,24]. Considering this, when comparedwith UTAUT, TAM may provide a clearer framework fordesigning an SMRA training session that aims to ensure thepatients’ app use by serving as a blueprint for tracking patients’progress from receiving an SMRA training session to increasing
the levels of positive perceptions of app to adopting the use of
the app.
Among the positive perceptions of technology within TAM,
perceived usefulness is defined as the degree to which people
think their performance could be improved using a technology[20]. In the case of medication adherence, performance in taking
medications as prescribed would be improved using the SMRA.
Furthermore, existing studies have shown that perceived
usefulness is positively related to intention to use a technology[25-27]. On the basis of this prior research, it is likely thattraining sessions designed to elicit perceived usefulness would
also affect intention to use an SMRA.
Another TAM variable related to positive perceptions, perceived
ease of use, is defined as the degree to which people think they
can use a technology with little effort [20]. Existing studies
have shown that perceived ease of use is positively related tointention to use a technology [28-30], and the research showsthat an SMRA training session that affects patients’ perceptionsof ease at using the app is likely to lead them to use the app.

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Figure 1. Technology acceptance model (TAM) framework for a smartphone medication reminder app (SMRA) training session.

Existing studies [22,25,31,32] have extended TAM by adding
subjective norms or people’s perceptions of how others wouldview the subject engaging in specific behaviors [33] such astechnology use [22]. These studies have shown that subjective
norms are positively related to intention to use a technology,
which implies that an SMRA training session that helps patientsto think that their family members or health care providers
would positively view the patients’ app use is likely to lead thepatients to use the app. In sum, TAM could be a usefultheoretical framework guiding the design of an SMRA training
session that aims to ensure the patients’ app use focusing on
the determinants of app use.
In addition to the guiding theoretical framework for the designof the SMRA training session, addressing how to conduct thetraining session in ways suitable to middle-aged to older patientsis important for an appropriate delivery of the training session.
Existing studies have indicated that middle-aged to older adults
might feel comfortable learning about new technology when
(1) training them in small peer groups in a supportive location,(2) providing them with instructions on technology use on alarge screen, and (3) providing them with hands-on experience
with technology [16,17,34]. In addition, existing studies haveindicated that an SMRA training session of approximately 2hours might be sufficient to help patients become familiar withapp use [9,18]. Following these principles, such as conducting
an approximately 2-hour small-group SMRA training session
at a hospital, the location that advocates patients’ need for healthcare education [35], and where patients visit for chronic
condition management, the training session could be delivered
to patients in ways that would help them feel comfortablelearning about the app.
The study reported here, guided by TAM, aimed to (1) assess
the feasibility of an SMRA training session designed to target
patients’ perceived usefulness of app, perceived ease of appuse, and positive subjective norm regarding app use that mightlead to their intention to use the app (Figure 1) and (2) gain
insight into how to refine the training session in preparation fora larger main study focusing on these theoretical determinants,
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as well as the practical implications of designing andimplementing the training session in a hospital setting.

Methods
Pilot Study Design
To meet the first aim of this pilot study, the researchers decided
to employ a two-group design with a survey method to (1) have
one group receive an SMRA training session designed to target
TAM variables (intervention training session) and have anothergroup receive the training session without targeting TAM
variables (control training session) and (2) assess the differencesin outcome measures (eg, perceived usefulness of SMRA)
between the groups [36] so that precisely quantifying whether
or not the intervention training session is feasible in targeting
TAM variables could be possible [37]. To meet the second aimof the study, the researchers decided to conduct a focus group,
which is an appropriate method for exploring shared experiencesamong a similar group of people [38], to assess why theintervention training session is (or is not) feasible in targeting
TAM variables (eg, whether the training session content
adequately helped participants perceive the usefulness of
SMRA) by exploring participants’ communal perceptions of
the SMRA in relation to TAM variables at the end of eachtraining session.
Therefore, in this study, one group, as training group, received
an intervention training session that was concluded with a
one-time survey and a one-time focus group on one of two
different study dates. Another group, as nontraining group,
received a control training session that was concluded with a
one-time survey and a one-time focus group on another date.
The details of intervention and control training sessions aredescribed in the following sections.

Development of an SMRA Training Session
The researchers selected the Medisafe app (Figure 2) developedby Medisafe Inc for SMRA training sessions. This app wasselected because it is available as a free app for both iPhone
operating system (iOS, Apple Inc) and Android devices, making
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it cost-effective and accessible to most smartphone users.
Additionally, this app has existing evidence of success withmiddle-aged to older patients with chronic conditions who used
the Medisafe app for 6 months, reporting higher levels of
medication adherence compared with those without app use[39].
The training sessions for both the training and nontraining
groups were developed following the principles deemed suitable

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for training middle-aged to older patients to use newtechnologies in general [16,17,34] and SMRA in particular[9,18]. Specifically, the researchers decided to (1) train
participants in small groups at their local hospital, (2) use
Microsoft PowerPoint slides to provide them with instructions
on Medisafe app use, (3) provide them with hands-on experience
with the app, and (4) schedule each training session to beapproximately 2 hours.

Figure 2. Screenshots of the Medisafe app: virtual pill box (left) and reminder (right) features.

Figure 3. Screenshot of the intervention training session PowerPoint slide.

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Regarding intervention training session content for the training
group, based on middle-aged to older patients’ perceptions andexperiences of SMRA use that previous studies have reported[9,18,19], the researchers developed the content to increase
participants’ levels of perceived usefulness of Medisafe app,
perceived ease of app use, and positive subjective norm
regarding app use. In addition, as iPhone and Android phones
differ in the layout of Medisafe app, the researchers developed
the content for iPhone users and for Android phone users
separately to prevent participants from being confused byinstructions on app use that do not correspond with theirsmartphone version of app (eg, different location of app feature
buttons; Figure 3). Regarding control training session content

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for the nontraining group, the researchers developed content
designed to lead participants to explore Medisafe app featureson their own (Table 1).

Sample and Procedures
In fall 2016, this pilot study was conducted at a rural midwesterncommunity hospital after approval was obtained from theuniversity’s institutional review board (IRB) and the hospital’s
IRB. To recruit participants, a designated hospital staff member
distributed recruitment materials (ie, study description andcontact information to pass on to interested patients) via email
to health care providers and staff members throughout thehospital.

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Table 1. Descriptions of intervention training session and control training session.
Training session schedule

Training session content and activity

Intervention training session for the training group (up to 2 hours)
Introduction of SMRAa (10 min)Content: introduction of what an SMRA is in general and what the Medisafe app is in particular (eg, who the developer is, where and at what cost and in which languages the app isavailable to use)

Targeting TAM b variables (20 min)
Perceived usefulness

Rationale for content: patients reported satisfaction with SMRA that visually (eg, medication
pictures) supports correct medication taking [9]; patients described SMRA as useful as it
reminds of and helps set up medication routines [19]Content: (to increase participants’ levels of perceived usefulness of SMRA) introduction ofvirtual pill box (ie, feature for visually keeping track of medication list) and reminder (ie,feature for being reminded of taking and refilling medications in a timely fashion) featuresof the Medisafe app

Positive subjective norm

Rationale for content: patients’ perceptions of others who support patients’ medication adherence matter to patients’ continuous SMRA use [19]Content: (to increase participants’ levels of positive subjective norm regarding SMRA use)
introduction of the Medfriend feature (ie, feature for notifying co-app users such as family
members if a patient missed a reminder from the app so that they could call or text the patientto additionally remind of medication taking) of the Medisafe app

Perceived ease of use (hands-on experience
with SMRA)

Rationale for content: patients often struggled with navigating SMRA features by missingor misinterpreting app feature buttons [18]Content: provision of step-by-step instructions on how to use virtual pill box (eg, adding
either prescribed or hypothetical medications to the app) and reminder (eg, scheduling reminders and receiving them from the app) features of the Medisafe app
Activity: (to increase participants’ levels of perceived ease of SMRA use) participants
practice the above features following step-by-step instructions; participants repeat the practiceon their own to ensure their competency in app use

Survey (10 min)

Activity: participants complete a survey measuring TAM variables

Focus group (1 hour)

Activity: participants describe their perceptions of the Medisafe app in relation to TAM
variables

Control training session for the nontraining group (up to 2 hours)
Introduction of SMRA (10 min)Content: introduction of what an SMRA is in general and what the Medisafe app is in particular

Hands-on experience with SMRA

Activity: participants explore any Medisafe app features on their own(20 min)a

Survey (10 min)

Activity: participants complete a survey measuring TAM variables

Focus group (1 hour)

Activity: participants describe their perceptions of the Medisafe app in relation to TAM
variables

SMRA: smartphone medication reminder app.

b

TAM: technology acceptance model.

Eligible participants for the study were patients who had been
managing a chronic condition for at least 3 months preceding
the study, were taking at least 3 prescribed medications, wereaged 40 years or older, use a smartphone, and had no experienceof SMRA use. Hospitalized patients, patients with limited
English proficiency, and patients unable to travel to the study
location during the study period were excluded.
Interested patients contacted 2 researchers (DP and KH) to
participate in the study, and 11 participants were recruited as
the final sample. The researchers (DP and KH) asked
participants to take part in the study on either of two different
study dates at their convenience; they were invited to a private
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room at the hospital on the date they had chosen. One date wasfor the intervention training session (for training group) andanother date was for the control training session (for nontraining
group); participants were not informed which date was for theintervention or control training session.
Participants arrived for their group training session, and after
obtaining informed consent, the researchers asked participants
to download the Medisafe app to their smartphones. After theparticipants successfully downloaded the Medisafe app to theirsmartphones, they either participated in the intervention training
session (led by researchers DP and EG on one study date) or
the control training session (led by researchers DP and KH on
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another study date). There was no incentive for the completionof training sessions.

Data Collection
SurveyFollowing the first part of training sessions (hands-on experience
with SMRA), the participants completed a survey questionnaire
related to demographics and TAM variables (Multimedia
Appendix 1). The following TAM variables were measured on
a 7-point Likert-type scale ranging from “strongly disagree”(score 1) to “strongly agree” (score 7), and item scores for eachvariable were summated and averaged to create variable scales(eg, perceived usefulness scale) for data analysis: perceived
usefulness (6 items adapted from Davis’s [20] study; mean=6.73,
median=6.83, SD=0.35), perceived ease of use (6 items adaptedfrom Davis’s [20] study; mean=6.05, median=6.33, SD=1.51),
subjective norm (7 items adapted from Charng et al’s [40] study;
mean=4.55, median=4.43, SD=1.17), and intention to use an
SMRA (3 items adapted from Venkatesh et al’s [23] study;
mean=6.03, median=6.00, SD=0.81). Cronbach alpha wascalculated to assess an internal consistency of each variable
scale, and scores on perceived usefulness (Cronbach alpha=.79),
perceived ease of use (Cronbach alpha=.99), subjective norm
(Cronbach alpha=.88), and intention to use an SMRA (Cronbachalpha=.97) were deemed acceptable.

Focus Groups
A focus group followed the survey. Participants were asked todescribe their perceptions of the SMRA in relation to TAM
variables in depth; a semistructured interview guide focused on(1) participants’ general struggles related to medication
adherence, (2) past strategies to address these struggles, and (3)perceptions about using the SMRA both during the study, as
well as how they might use it in their real lives. The focus
groups were audio-recorded and then transcribed using atranscription service; after transcription was completed, 2researchers (DP and EG) checked the accuracy of transcripts.
The researchers removed any identifying information from thetranscripts and replaced participants’ names with pseudonyms.

Data Analysis
Quantitative data was analyzed using SPSS 16.0 (SPSS Inc).
As the assumption for normal distribution of the data was unmet(eg, histogram), a Mann-Whitney U test was conducted to assess
whether the training group and nontraining group differ in TAM
variables.

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The transcripts were analyzed using a first- and second-level
coding method [38] to identify the themes reflecting
participants’ perceptions of the SMRA in relation to TAM
variables. Two researchers coded the transcripts independently
and compared and combined codes. Following the consolidated
criteria for reporting qualitative research guidelines [41], theother two researchers reviewed the codes to minimize bias incoding. In addition, the researchers discussed whether andconcluded that saturation had been reached.

Results
Participant Characteristics
Of the 11 participants, 45% (5/11) were part of the training
group and 55% (6/11) were a part of the nontraining group. All
participants were white, and the majority of them were female(73%, 8/11). Participants’ ages ranged from 45 to 70 years(median=58, SD=9.55). The majority of participants reported
education levels of bachelor’s degree or higher (64%, 7/11) andannual household income levels of US $90,000 or greater (73%,8/11). All but one participant reported they had never used an
SMRA before. Chi-square tests and Mann-Whitney U tests
revealed that there were no significant differences indemographics between training group and nontraining group(Table 2).

Differences in TAM Variables Between Training
Group and Nontraining Group
Mann-Whitney U tests revealed differences in TAM variables
between the training group and nontraining group (Table 3).
Although there was no significant difference between the groups(P=.33), the training group (median=6.67) reported higher levels
of intention to use an SMRA than the nontraining group(median=5.83). In addition, although there was no significant
difference between the groups (P=.13), the training group(median=7.00) reported higher levels of perceived ease of use
than the nontraining group (median=6.25).
The training group (median=6.50) reported lower levels ofperceived usefulness than the nontraining group (median=6.92)
at the marginally significant level (U=4.50, Z=−1.99, P=.05).
In addition, although there was no significant difference between
the groups (P=.25), the training group (median=4.29) reported
lower levels of positive subjective norm than the nontraining
group (median=4.50).

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Table 2. Demographic profile of the participants.
Demographics

Training group (n=5)

Nontraining group (n=6)

P valuea,b

Age in years, median (SD)58 (9.33)

60 (10.57)

>.99a
.06b

Gender, n (%)
Female5 (100)3 (50)

Male

0 (0)

3 (50).34b

Ethnicity, n (%)
Non-Hispanic or Latino

5 (100)5 (83)

Unknown

0 (0)1 (17)

Race, n (%)
White–
5 (100)6 (100)>.99a

Education, n (%)
Some college, no degree

1 (20)0 (0)Associate degree (eg, occupational)

0 (0)1 (17)

Associate degree (academic)

1 (20)0 (0)Bachelor’s degree

1 (20)

3 (50)

Master’s degree

1 (20)

1 (17)

Professional school degree

1 (20)0 (0).76aIncome (USD), n (%)$70,000-$79,999

0 (0)1 (17)$80,000-$89,999

0 (0)1 (17)$90,000-$99,999

2 (40)

1 (17)

Greater than $100,000

2 (40)

3 (50)

Experience of SMRA c use, n (%)

.25b

Yes

1d (20)0 (0)No4 (80)

6 (100)Acid reflux

0 (0)1 (17).34b

Anxiety0 (0)1 (17).34b

Arthritis

2 (40)

4 (67).38b

Asthma1 (20)

0 (0)

.25b

Back pain

1 (20)

2 (33).62b

Diabetes

1 (20)

2 (33).62b

Epilepsy

1 (20)

0 (0)

.29b

Heart disease

1 (20)

1 (17).89b

High blood pressure

2 (40)

4 (67).38b

High cholesterol

0 (0)1 (17).34b

Ulcer or stomach disease

1 (20)

0 (0)

.25b

Chronic condition, n (%).18a

Number of chronic condition, n (%)
1

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Demographics

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Training group (n=5)

Nontraining group (n=6)

2

5 (100)1 (17)30 (0)3 (50)40 (0)1 (17)

P valuea,b.69a

Number of prescribed medication, n (%)
3

2 (40)

2 (33)

4

1 (20)0 (0)5

1 (20)

1 (17)

6

1 (20)

0 (0)

8

0 (0)

1 (17).75b

Presence of a caregiver, n (%)

aYes

1 (20)

1 (17)

No

3 (60)

5 (83)

P values calculated using Mann-Whitney U tests.

b

P values calculated using chi-square tests.

c

SMRA: smartphone medication reminder app.

d

All participants reported having no experience of SMRA use during the participant recruitment but one of them reported she previously tried andstopped using another SMRA (different from the Medisafe app) during the focus group.
Table 3. Differences in technology acceptance model (TAM) variables between training group and nontraining group.
VariablesaInterquartile range

Training group (n=5)

Nontraining group (n=6)

MedianMean (SD)MedianMean (SD)P value

Intention to use an SMRAa

5.00-7.00

6.67

6.33 (0.85)

5.83

5.78 (0.75).33

Perceived usefulness

6.50-7.00

6.50

6.50 (0.42)

6.92

6.92 (0.09).05

Perceived ease of use

6.00-7.00

7.00

6.73 (0.43)

6.25

5.47 (1.88).13

Positive subjective norm

4.14-5.29

4.29

4.09 (1.34)

4.50

4.93 (0.96).25

SMRA: smartphone medication reminder app.

Participants’ Perceptions of the SMRA in Relation to
TAM Variables
Throughout the focus groups, participants described theirperceptions of the SMRA in relation to TAM variables including
perceived usefulness, perceived ease of use, positive subjective
norm, and intention to use the app.

Perceived Usefulness
Participants described the real-world utility of the SMRA in
addressing specific struggles in medication adherence in theirlives. Furthermore, participants’ intention to use an SMRA wasbased upon the degree to which their perceived usefulness was
positively rated.
Real-World Utility of SMRA in Medication Adherence
Participants described the utility of the SMRA in medication
adherence in terms of struggles encountered in the real-world
setting. For example, one of participants described her struggle
in remembering to take her medications in the evening, saying:

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My bedtime one I forget a lot, just because it’s, youknow, it’s later in the evening or whatever and I getbusy and I forget that one.
Regarding this struggle, she described the fact that SMRA users
would receive reminders from the app as helpful for
remembering medication taking, noting:
You always have your phone with you...so, the fact
that, you know, it would...vibrate [to remind of
medication taking] or do whatever you set it to, I
mean, I think that would be very helpful.
Another of the participants described struggles in remembering
to take medications when traveling, particularly to places witha different time zone. As Susanna said:
If you’re travelling, you know, and you’re in [nameof place] where the time changes sodrastically...Should I take it at, what I would havetaken in [name of place] or do I switch it?
Regarding this struggle, she noted that an SMRA feature that
reminds of medication taking based on local time would be
helpful as she continued:
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Then the app would go off [to remind of medication
taking].
Yet another participant described her struggle to remember torefill her prescriptions in a timely fashion:
I thought I had some left but I didn’t have any left.
So then it’s like, ok, you gotta call your friends overat the pharmacy, and say, help!
This participant found the Medisafe app feature that reminds
users of their medication refilling schedule to be particularly
helpful:
The fact that it’s gonna remind me is a, is a big help
to me, especially when you get 3 months out it’s, youknow, your mind kind of goes, so.
Some of participants described struggling to manage changing
medications. For example, William said:[I] can identify some of them, but, every few years
they change...in the last, 3or 4 months I’ve, noticed
that, there have been a time or two I forgot them.
He went on to acknowledge the potential value of the SMRA
in helping him overcome this struggle:
If me and this phone can become friends we might beable to set up where it could remind me pretty good.
In addition, Emily described an SMRA feature that enables
recording medications in the app in visually precise ways (ie,virtual pill box) as helpful for managing varying medications,as she said:
I did like how that had, um, the pills you could put
the color and the shape...I thought that was nice.
Especially because they do change so often.
A final medication adherence struggle participants identified
was managing temporary medications. Although participants
described using specific tools (eg, Pill box and Outlook
calendar) or setting up rules or habits (eg, brushing teeth after
medication taking) as ways to support medication adherence,
they agreed that managing temporary medications could beparticularly challenging. For example, Avery noted:
One of those things that I don’t normally take, I’ll
write right on the bottle...all the dates [for medication
taking]...it works but if you have a lot of them it
doesn’t.
She perceived the potential value of the app as a convenient
way to manage temporary medications, noting:It’d be a lot more convenient to have it set up in there
as a temporary, you know, a temporary dosage.
Intention to Use an SMRA
Some of participants described their intention to use an SMRA
in relation to perceived usefulness, as William said, when asked
if the participants would be willing to use the app in future:
Oh, I think it would be helpful.
More specifically, Grace described her intention to use thereminder feature because it seems helpful for remembering
medication taking on weekends when she often ended up second
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Park et al
guessing (eg, “Did I take those before we left the house, I don’t
remember”). She explained:
Because weekends are hard for me and busy with kids
and doing things and so...I think I’ll get in the routineof clicking those reminders...it will be a big help.
In sum, the focus groups revealed the utility of SMRA in
real-world medication adherence and indicated a potential
positive link between perceived usefulness and intention to use
the app.

Perceived Ease of Use
The nontraining group described more struggles in SMRA use
than the training group. Furthermore, participants’ intention touse an SMRA was based upon the degree to which theirperceived ease of use was positively rated.
Challenge in SMRA Use by Nontraining GroupThe nontraining group, which was given 20 min to explore
Medisafe features on their own, described difficulty in using
SMRA features that the training group was able to use after 20
min of training that involved step-by-step instruction on app
features. Nontraining group participant Emma said:
You can’t sit here in 10,15 minutes and understandwhat’s going on with that app.
Michael agreed:
I think I’d need more than 20 minutes to really get afeel for it.
Olivia observed:
I had a little trouble navigating...one of the pills [Irecorded in the app] was the wrong shape so I had
to go in and change...and it didn’t change for me rightaway.
William said:
I tried to program it [reminder schedule] to 3 a day,but, uh, the milligrams of it [regarding dosing
schedule] or whatever, um, never would let me put
those in.
In addition, the nontraining group was unaware of SMRA
features that were introduced to the training group. Emily said:
I clicked on that [Medfriend feature] but didn’t-didn’tknow what it was so I just got out of it.
Michael observed:
I didn’t pay attention to that [virtual pill box].
Nontraining group members also had several unansweredquestions for the researchers. Emma, for instance, wanted toknow:
What kind of sound does it make when you miss yourpill?
Andrew asked:
Can you set the reminders for different days of the
week? The times?

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JMIR FORMATIVE RESEARCH
Intention to Use an SMRA
Some of participants described that their intention to use an
SMRA depends on perceived ease of use, as Avery said:
Well, [if] it’s not easy then I’m not gonna deal with
it. Forget it.
In addition, Hannah described that she previously tried another
SMRA (different from the Medisafe app) and stopped using it
because “it wasn’t as user friendly.”In sum, focus groups indicated the challenges in SMRA use by
the nontraining group and a potential positive link between
perceived ease of use and intention to use the app.

Park et alNo, I don’t think I would need anybody to call me
because...they would get, uh, tired of saying, hey, takeyour medicine. I’m gonna take my medicine, I haveto take my medicine.
In sum, focus groups indicated specific health care settings (eg,primary care and routine medical checkups) in which theparticipants think their family members or health care providers
would find value in the participants’ SMRA use. Furthermore,
focus groups indicated a potential positive link between positive
subjective norm and intention to use an SMRA.

Discussion

Positive Subjective Norm

Feasibility of the Intervention Training Session

Participants described their perceptions of others who mightview positively the participants’ SMRA use in the real-world
setting, such as family members or health care providers.
Furthermore, participants’ intention to use an SMRA was based
upon the degree to which their subjective norm was positively
rated.

One of the primary aims of this pilot study was to assess thefeasibility of an SMRA training session designed to increase
patients’ intention to use the app through targeting TAM
variables. The findings from this pilot study indicated that theintervention training session was feasible in increasing an
intention to use an SMRA through targeting perceived ease ofuse.

Family Members and Health Care Providers
Participants described several situations in which they thought
others would positively view participants’ SMRA use. Someof participants described that doctors could find patients’ SMRA
use to be positive. For example, Emily explained:
When you go to a doctor, they want to know, youknow, what all medicines are you on. I can neverremember...that [SMRA feature helping findmedication names] will be a very, very nice feature
to have.
Furthermore, some participants described that family members
could find patients’ SMRA use to be positive. Emily said:
For loved ones too, if anything ever happens to me,
they could take my phone...if I end up in theemergency room...they’ll know everything that I take,will be right there on my phone.
In addition, Andrew described that his daughters could findusing the Medfriend feature with him to be positive, admitting:I think my 2 daughters would appreciate knowing thatI’m taking my medication.
Intention to Use an SMRA
Some of participants described their intention to use an SMRA
in relation to subjective norm. For example, Grace described
her intention to use an SMRA feature that enables recording a
medication list in the app because she thought her doctor would
perceive it to be helpful. She said:
I would use it...if I go to an appointment or something,
you know, what are you on? I-I can never remember
the dosages and things like that so to have it on myphone, it’ll be nice.
In contrast, Chloe described her intention to not use theMedfriend feature because others might feel bothered by using
the feature with her, as she said:

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Results revealed that the level of perceived ease of use and thelevel of intention to use an SMRA were higher in the training
group than in the nontraining group, and the focus groups
indicated that perceived ease of use might lead to intention to
use the app. These findings are consistent with existing studies
that have ascertained the path from technology training toperceived ease of use to intention to use the technology [28,42].
In addition, these findings expand existing studies on
middle-aged to older patients’ SMRA use [9,18,19] by indicating
not only the utility of a training session in promoting patients’app use but the type and focus of a training session that could
be a promising intervention to promote patients’ app use: ascheduled small-group training session in a hospital setting
focused on helping patients feel at ease navigating and using
the app by providing them with step-by-step instructions on andhands-on experience with app features.

Limitations and Plans for the Future Study
The second aim of this pilot study was to understand how tobetter design and implement the training session in a hospitalsetting for the larger main study. There are a couple oflimitations of this pilot study that will be addressed in designing
the main study.
As the first limitation of this pilot study, the findings indicatedthat the intervention training session was not feasible inincreasing intention to use an SMRA through targeting perceived
usefulness and positive subjective norm. Participants indicatedin the focus groups that, not surprisingly, the perceived
usefulness and positive subjective norm might lead to intention
to use an SMRA, consistent with findings from existing TAM
literature [22,25,26,28,31,32,43]. However, quantitative results
revealed that the level of perceived usefulness and the level ofpositive subjective norm in the training group did not surpass
those in the nontraining group. Understanding the reasons forthese findings is important in moving forward to the main study.

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JMIR FORMATIVE RESEARCHFirst, it may be that the intervention training session did notadequately address perceived usefulness and positive subjective
norm, suggesting a need to refine the content of the training
session. Beyond the nonsignificant quantitative results related
to perceived usefulness and positive subjective norm, the focus
group findings may provide some insight. The focus groups
revealed that the intervention training session did not include
content that would help target perceived usefulness and positive
subjective norm.
Regarding perceived usefulness, whereas the intervention
training session focused on introducing participants to thetechnical utility of SMRA in medication adherence (eg, thevirtual pill box as a visual aid for correct medication
management), throughout the focus groups, the participants
described the real-world or practical utility of an SMRA in
relation to perceived usefulness. Regarding positive subjective
norm, whereas the intervention training session focused on
introducing participants to the technical utility of SMRA thatenables their family members or health care providers to monitor
and support participants’ medication adherence (ie, Medfriend
feature), many participants described the real-world reasons
behind why their family members or health care providers might
have positive views on participants’ app use in relation topositive subjective norm. In other words, participants indicatedthat family members or health care providers might view
participants’ SMRA use more positively because they perceive
it to be useful in helping participants stay healthy, both in a
day-to-day sense, as well as during an emergency. In sum, it
was indicated that introducing participants to the utility of
SMRA in medication adherence without applying it to thereal-world setting might lead the intervention training session
to not adequately target perceived usefulness and positive
subjective norm. In this regard, the researchers will plan torefine the content of the intervention training session in waysthat (1) emphasize the real-world application of SMRA toaddressing patients’ specific struggles in medication adherencein their lives (to better target perceived usefulness) and (2) help
the patients to see how their family members or health careproviders might benefit from the patients’ app use (to bettertarget positive subjective norm).
In addition, the intervention training session time allocated totargeting TAM variables (approximately 20 min) might beinsufficient to target perceived usefulness and positive subjective
norm. For example, within 20 min, the training group
participants might feel pressed for time for digesting instructions
on SMRA features and might pay more attention to how to use
app features than whether and how app features could support
them and their family members in (participant) medication
adherence in the real-world setting. For this pilot study, theresearchers allocated more time to quantitative and qualitative
assessments (more than an hour) than targeting TAM variables,
given that the primary aims of this study were assessing thefeasibility of the intervention training session. For future work,
the researchers will plan to increase the time for targeting TAM
variables to up to 2 hours, following what the existing studies[9,18] have done (eg, allocating up to 2 hours to the completionof app-related tasks) [18], so that the abovementioned potential

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Park et al
effects of the training session time on the training session
outcomes could be mitigated.
The second limitation of this pilot study is associated withsampling issues. Specifically, small sample size (n=11) might
result in underpowered and nonsignificant findings (ie, type IIerrors) [44] and might be insufficient to ensure internalconsistencies of variable scales [45]. In addition, a power
analysis for the main study was not feasible because of thesample size [45]. Following Hertzog’s [45] suggestions for apilot study sample size for the power analysis, the researchers
first planned to recruit at least 20 participants in an attempt tohave at least 10 in the training group and 10 in the nontraining
group. However, meeting this aim was challenging, and it isattributable to a couple of issues.
Recruitment in a hospital setting may have been more successful
except for the time constraints of the hospital staff member who
assisted with recruiting (ie, the 2 weeks leading up to the study
dates she was unavailable). Addressing time constraint issues
with health care professionals is imperative to meet the aims ofhealth care education [35], and the researchers will plan toaddress this in the future by cooperating with multiple healthcare providers and staff members, who differ in the time
availability of recruitment support, to better meet the aim ofparticipant recruitment for the future study. For health careproviders with limited time availability of direct recruitment
support, following Lorig’s [46] suggestions, the researchers
will plan to ask them to (1) permit researchers to place a
recruitment poster and sign-up sheet in their waiting room and(2) refer their patients interested in the study to researchers formore information about an SMRA training session.
Furthermore, following what existing studies have done,
utilizing more varied recruitment strategies such as (1) placing
recruitment flyers in community centers [17,18] or on social
media (given the increasing use of social media within the
middle-aged to older population) [47], (2) recruiting potential
participants at hospital events [24], (3) using the snowball
sampling method [48], and (4) using participant incentives (eg,a gift card) [16,18,19] might facilitate meeting the aim ofparticipant recruitment for this pilot study that the researchers
will plan to do for the future study.
Utilizing the above recruitment strategies, in addition toincreasing participant number, the researchers will plan toincrease participant diversity for the future study, given that all
participants in this pilot study were white and the majority ofthem were female and with higher education and income levels.
Existing studies have indicated the impact that demographic
variables have on patients’ medication adherence behaviors[8,49] and might have on their SMRA use. In this regard,
recruiting a larger and more diverse sample, the researchers willplan to assess the feasibility of an SMRA training session intargeting TAM variables for patients across demographics.

Conclusions
The findings from this pilot study confirm that an SMRA
training session for middle-aged to older patients with chronic
conditions is important in promoting their app use. Specifically,
the value in designing a TAM-based training session was
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JMIR FORMATIVE RESEARCH
indicated, such that the intervention training session appeared
feasible in leading patients to adopt the use of an SMRA by
first targeting perceived ease of use, guided by TAM. The
findings also provide practical implications that will inform thedesign of the larger main study. Refining intervention training
session content (ie, focusing on the utility of an SMRA in thereal-world setting) informed by this study and providing patientswith sufficient time for digesting instructions on SMRA features,

Park et al
the training session might better help increase patients’ levelsof perceived usefulness and positive subjective norm that mightalso lead them to adopt the use of an SMRA. In addition,
cooperating with multiple health care professionals in participant
recruitment could help secure a sufficient and continuous
recruitment support for meeting the aim of participant
recruitment in a hospital setting.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Measurement items for perceived usefulness, perceived ease of use, subjective norm, and intention to use an SMRA.
[PDF File (Adobe PDF File), 17 KB-Multimedia Appendix 1]

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Abbreviations
IRB: institutional review board
SMRA: smartphone medication reminder app
TAM: technology acceptance model
UTAUT: unified theory of acceptance and use of technology

Edited by G Eysenbach; submitted 11.05.17; peer-reviewed by K Grindrod, B Xie, K Blondon, J Apolinário-Hagen; comments toauthor 04.07.17; revised version received 25.08.17; accepted 23.09.17; published 10.11.17
Please cite as:
Park DY, Goering EM, Head KJ, Bartlett Ellis RJ
Implications for Training on Smartphone Medication Reminder App Use by Adults With Chronic Conditions: Pilot Study Applying
the Technology Acceptance Model
JMIR Formativ Res 2017;1(1):e5
URL: http://formative.jmir.org/2017/1/e5/
doi: 10.2196/formative.8027
PMID: 30684397©Daniel Y Park, Elizabeth M Goering, Katharine J Head, Rebecca J Bartlett Ellis. Originally published in JMIR Formative
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JMIR Formativ Res 2017 | vol. 1 | iss. 1 | e5 | p. 15(page number not for citation purposes)