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Member Spotlight: Richard Lester

By K. Rivet Amico, PhD | 12 Nov, 2012

Please join us for this member spotlight on Dr. Richard Lester and his experiences with use of mobile technologies to promote adherence.



K. Rivet Amico, PhD Replied at 5:59 AM, 12 Nov 2012

We are very excited to announce that Dr. Richard Lester will lead a discussion on a number of issues many of us are dealing with, in both practive and research contexts, on WEDNESDAY and THURSDAY of THIS WEEK (Nov 14th and 15th). A brief description of Dr. Lester and his work is provided below.

We asked Dr. Lester to think about the following questions and are looking forward to his commentary on these to be posted on Wednesday. Please think about your own experiences with these and join the discussion!

1. Where do you see technology helping or hindering in the adoption of health behaviors?

2. There are different ideas for how texting can be used for health behaviors- reminders, sending motivational messages, or more like outreach- what do you think is the best strategy for using text messaging?

3. What are your thoughts on the generalizability of research study supported text-based approaches? Is it too expensive? Is it reasonable?

4. What are the next steps in your program of research?

Dr. Richard Lester is an assistant clinical professor in the Division of Infectious Diseases at the University of British Columbia and the Medical Head of STI/HIV control at the BC Centre for Disease Control in Vancouver, Canada. He founded WelTel, a program designed to improve patient engagement (adherence and retention) in care for HIV and other conditions, after living for five years in Kenya doing his HIV research fellowship with the University of Manitoba and University of Nairobi. While there, he was the principal investigator of WelTel Kenya1, a randomized clinical trial among HIV/AIDS patients in Kenya that provided some of the first evidence that using mobile phones and text messaging via SMS to support patient care could significantly improve health outcomes. These findings, published in the Lancet in 2010, have been widely discussed in global venues and have contributed to HIV care and treatment guidelines. He is principal investigator or collaborator on a number of ongoing studies in Africa, Canada, and the US regarding use of text messaging and mobile health (mHealth) to improve patient engagement in HIV care and care of other health conditions.

Looking forward to a great discussion!

Warm regards,
K. Rivet Amico

K. Rivet Amico, PhD Replied at 7:56 AM, 14 Nov 2012

Richard Lester provided some really thoughtful responses to our 'interview' questions. Our questions are in CAPS below, followed by Dr. Lester's response. Please read on and reply with your thoughts, feelings, reactions or questions for Dr Lester.
Warm regards,


Mobile phones already positively influence people’s lives and behaviors in many areas of life; health behaviors will be no exception. In many ways, it’s comparable to the introduction of automobiles into society: vehicles were quickly adopted as transport tools for health purposes on an individual level (e.g. being driven to the hospital quickly while in labour) and by the health system (e.g. ambulances). Like vehicles, mobile phones cannot replace health services, but they can substantially improve their effectiveness and efficiency. Mobile phones are a monumental advance in increasingly widely accessible state-of-the-art communications technology globally, with much further reach than land based telecommunications technology. Personal mobile phones are already used by patients (and health providers) to conveniently schedule appointments or access health information, even while on the move. The question is, are we able to structure mobile communication technology in purposeful ways to improve individual and population health outcomes? This is where I believe mobile technology will have its greatest impact: in conveniently, effectively and efficiently transferring data and support between patients and their health providers or the health system.

In terms of hindering the adoption of health behaviors, the risk lies in that not all technology will be successfully adopted, and that which is adopted may not be evidence-based. Technology that is not truly valued by health providers or patients can actually disengage patients from the health system (technology that doesn’t work well or meet an individual’s needs is perceived as a nuisance). Patients use the health system to in order to improve their health, so they must perceive that the technology is helping them achieve this (i.e. is patient-centered). Finally, the technology must also be proven to improve important health outcomes before it can be deemed useful, and not just ‘be used’. Usage is not an indicator of success, unless health outcomes have been demonstrated o be improved. Ineffective technology interventions, regardless of how well intended or popular, may be detrimental by diverting resources from programs that have been proven to work.


The best strategy for using text messaging to improve healthy behaviors will be to create and follow the evidence. Randomized controlled trials (RCTs) have already answered some important questions on what works and what doesn’t, and more studies are needed to better understand what works best and in what contexts. For example, for efficacy in improving patient adherence to antiretroviral therapy (ART) for HIV/AIDS it appears that both the content of a text message sent to patients (what is being communicated), and the frequency and timing of text messages (when it is communicated) are critically important. Two RCTs in Kenya, including one we conducted (WelTel Kenya1, Lancet 2010) and one led by Pop-Eleches and Thirumurthy in Western Kenya (AIDS 2011), demonstrated that weekly text messages were efficacious at improving ART adherence. But equally important, the latter trial showed that daily text messaging (with reminders or motivational messages) had no effect on adherence behavior. Similarly, a separate RCT in Kenya, led by Chung and colleagues (PLoS Med 2011) demonstrated that targeted adherence counselling improved ART adherence, but that a digital alarm device (timed to alert when medications were supposed to be taken) had no effect. These trials were well designed and had sufficient power to suggest these differences in influencing adherence behaviors were real.

The ‘negative’ trials may have been surprising to some who expected that simple reminders would be effective, or that somehow ‘more is better’. However, as we know, health behaviours, such as medication adherence, are complex and can be difficult to modify on an individual or population basis. In our WelTel studies, qualitative assessments of participants’ experiences suggest that the two-way communications via text messaging, with follow-up phone calls from nurses when problems were identified, was both comforting to patients and perceived as helpful in promoting adherence behaviors. One way text-messaging in the Western Kenya trial also appeared effective at weekly intervals, but it is less clear what role the motivational content played, since longer and more motivational wording in the texts did not appear to provide additional adherence benefit.

Motivational text messaging likely holds promise, but is really a black box at this point and requires much more research to understand and determine what will actually lead to positive health behaviors. My opinion is that mobile phones are two way communication devices, and therein lies their greatest power to be helpful. Patients are generally already motivated to improve their health, that’s why they sought help in the first place. Access to care and professional advice is what patients primarily seek from health providers, so using mobile technology to provide health access and information more effectively, efficiently (and in an attractive, non-intrusive way) will be of most value and ultimately most effective. There is a lot of genuine excitement around mobile technology’s potential; however, only well-designed studies that minimize bias can or should effectively guide program level investment. One cannot assume, however exciting or apparently intuitive, that a new idea or specific intervention will automatically be effective until it is tested.


Generalizability of research studies for mHealth behavioural interventions is perhaps even a more important consideration than for other types of therapeutic interventions. Health behaviors are very contextual, and thus a trial’s context must be carefully considered. We should seek common threads of behavioral influences with study populations and in our own patient populations, and use those concepts as starting points in determining what interventions or services to consider adopting. Infrastructure and logistical context are also important. For instance, although higher-resource settings with well developed health systems may often have more resources overall, we’ve found additional challenges in some Canadian and US settings compared with Africa related to ensuring patients consistently receive text messages (receiving SMS and phone calls in Africa is usually free, and in North America individuals are completely ‘cut-off’ when they run out of credit). Also, in more developed settings, text messaging competes more with other legacy technology such as landlines and fixed internet or email, and multi-modal approaches may be required. Finally, harnessing existing infrastructure can be very inexpensive, while introducing new infrastructure or devices can have considerable costs. But again, only that which is effective, can be cost effective, so effectiveness studies are the essential start to cost-effectiveness. Overall, I recommend that when considering adopting a new health promotion technology, that the patient-centered context, the health-provider context, and the logistical context be carefully assessed and piloted before introducing broadly.


We are conducting studies to advance our initially proven WelTel model involving weekly text message interactive check-ins to patients, in order to improve medication adherence and health outcomes in different settings, and to determine factors important to scaling up those services. In an AMREF clinic in Kibera Kenya, we are conducting a new RCT to determine if the WelTel service can improve pre-ART retention in care among patients newly diagnosed with HIV. We are also further developing our automated SMS clinical management platforms for implementation and sustainable scale-up services (with support from Grand Challenges Canada and the Kenyan Ministry of Health). In Vancouver, Canada, we have conducted two pilot studies aimed at informing the adoption the WelTel model in the Canadian context of HIV and TB care, and we are conducting an RCT to test whether WelTel improves adherence to medications for latent TB infection. We have also partnered with colleagues in San Francisco to develop and test a program based on the WelTel model to improve adherence to HIV pre-exposure prophylaxis (PrEP) in the US and South America (Dr. Al Liu et al.). We are open to partnering with others. In these programs, we are focusing on a combination of informative preliminary work, comparative effectiveness trials, qualitative assessment among system users and stakeholders, and cost-effectiveness and implementation science. Our vision and mission is to use the best scientific methods to guide and improve the way forward for best practices and highest impact. I look forward to any discussion on this forum.

K. Rivet Amico, PhD Replied at 5:02 AM, 15 Nov 2012

I was wondering....among those reading/receiving this post, does anyone currently use text-based technologies for retention or adherence promotion? And if so, where (Country. Practice or Research related) and what has the experience been? If not, what has prevented use of text or internet technologies (costs, poor coverage, low cell phone use, poor internet access)? I think this community could provide a great amount of guidance in terms of uptake and use of technology in practice.

Richard Lester Replied at 11:33 AM, 15 Nov 2012

Thanks Rivet. I know that a lot of work is being done in other areas of infectious and non-communicable chronic diseases and I was wondering if anyone from the community has evidence or experiences to highlight or discuss in this context as well.

This Community is Archived.

This community is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.