Phone call or text?: New study explores youth’s “Supportive Accountability” preferences

Sayegh, C., Iverson, E., MacDonell, K., Wu, S., & Belzer, M. (2023). Youth perspectives on mobile health adherence interventions: A qualitative study guided by the supportive accountability model. Patient Education and Counseling.


Medication nonadherence is a significant issue among youth with chronic health conditions (CHCs), with over 50% not adhering to prescribed regimens. This can lead to medical complications, reduced quality of life, and increased healthcare utilization. Mobile health (mHealth) interventions integrating human support have shown promise in improving medication adherence among youth. The Supportive Accountability Model posits that human support creates a bond and sense of accountability, increasing engagement in desired health behaviors.

This interesting new qualitative study explored youth perspectives on an mHealth adherence intervention pilot trial comparing: 1) coaching phone calls, 2) coaching text messages, and 3) automated text reminders. The aim was to understand how youth viewed human coaching versus automated support and their experiences with different communication modalities.


The study included 22 youth aged 15-20 with sickle cell disease, solid organ transplants, or type 2 diabetes, taking daily oral medication. Participants had <80% medication adherence and were randomized to one of the three 12-week interventions in the parent trial.

Semi-structured interviews were conducted via videoconference every 2 months after intervention completion. Interviews used a guide piloted with a mock participant and were audio-recorded and transcribed.

Reflexive thematic analysis methods were used . The research team reviewed transcripts, developed a codebook through an iterative process, and coded data in pairs. Coded excerpts were synthesized into themes through team discussions. A youth advisory board assisted with interpretation.

Eight themes and five subthemes emerged regarding youths’ experiences

1. Coaching helped develop routines and strategies: Youth reported coaches helped them establish habits and plans to improve adherence, sustaining benefits after the intervention.

2. Coaching via calls vs texts was experienced differently:
– Phone calls allow personal connection: Call recipients described deeper bonds with coaches than text recipients.
– Calls motivated avoiding disappointing coaches: Call recipients felt obligated not to let coaches down.
– Texts conveyed coaches cared: Text recipients felt cared for by coaches, improving adherence.
– Texts are easy and flexible: Texts fit easily into daily life compared to calls.
– Calls interrupt daily life: Calls were disruptive but helped focus engagement.

3. Ending coaching was emotionally difficult: Many felt disappointed when the coaching relationship ended.

4. Both coaching and reminders prompted adherence: All interventions served as reminders to take medication.

5. Automated reminders can be motivational: Some found automated reminders motivating beyond just reminding.

6. Automated support demands less engagement: Automated interventions required less active participation than coaching.

7. Automated support sounds uncomfortable: Some viewed automated coaching as impersonal.

8.  It depends:” Preferences differ: Youth had varying preferences for human vs automated support and communication modalities based on individual differences.


This study provides insights into how the Supportive Accountability Model mechanisms may operate in mHealth adherence interventions for youth. Participants viewed coaching as more potent and engaging than automated reminders, consistent with the model’s emphasis on human support. However, individual preferences varied.

Coaching helped develop routines/strategies and served as an adherence prompt.  The personal bonds with coaches resonated with youth and made them feel obligated to avoid disappointing coaches, suggested an uncomfortable interpersonal emotion like guilt may motivate adherence .

Communication modality impacted experiences). Calls enhanced personal connection and accountability, but texts were easier to integrate, highlighting person-medium fit . Automated support required less engagement  and felt impersonal to some, consistent with the model’s premise that social presence increases supportive accountability

The authors provided practice implications like recommending automated reminders as a starting point, but ideally offering human coaching adapted to individuals’ modality preferences and needs.