Mental Health Care – Original Research Article

SAGE Open Nursing

Volume 9: 1–8
Enhancing Medication Adherence Among © The Author(s) 2023
Article reuse guidelines:
Patients With Schizophrenia and sagepub.com/journals-permissions
DOI: 10.1177/23779608231197269
Schizoaffective Disorder: Mobile App journals.sagepub.com/home/son

Intervention Study

Khloud Al Dameery, MSc, RN1 , Blessy Prabha Valsaraj, PhD, RN1,

Mohammad Qutishat, MSc, RN1, Arwa Obeidat, MSc, RN1,
Abdullah Alkhawaldeh, PhD, RN2 , Sulaiman Al Sabei, PhD, RN1,
Omar Al Omari, PhD, RN1 , Mohammed ALBashtawy, PhD, RN2
and Mohammad Al Qadire, PhD, RN1,2

Abstract
Introduction: Technology has permeated every aspect of our existence and the mental health sector is not exempt from
this.
Objectives: The aim of this study was to test the impact of using a mobile phone app (MyTherapy pill reminder and med-
ication tracker) on medication adherence in patients with schizophrenia and/or schizoaffective disorder.
Methods: Time series design was used. Fifty-one participants were recruited from tertiary hospitals in Oman. The
Medication Adherence Rating Scale was used for assessing medication adherence. The data related to medication adherence
were collected at baseline, 3 months later and 3 months after installing the program on participants’ smartphones. SPSS data
set used to analyze the data.
Results: A repeated-measures ANOVA found no significant change in the level of adherence among patients with schizophre-
nia and schizoaffective disorders at the start and 12 weeks later when the mobile app was installed (p = .371). However,
adherence scores improved significantly 12 weeks after installation of mobile app compared with the same group at the base-
line and 12 weeks before the installation of mobile app (p < .001).
Conclusion: The mobile phone app was effective in improving the adherence level among patients. Installation of the pro-
gram and teaching patients how to use it to improve their level of adherence is recommended.

Keywords
adherence, schizophrenia, schizoaffective disorder, Oman, medication adherence
Received 20 April 2023; Revised 16 July 2023; accepted 5 August 2023

Introduction/Background medication is a major challenge for patients with schizophre-

Twenty-one million people are diagnosed with schizophrenia
globally (World Health Organization [WHO], 2018).
Schizophrenia and schizoaffective disorder are chronic
mental health conditions characterized by significant impair-
ments in cognition, emotions, and overall functioning, and it
is common for individuals with schizophrenia to undergo
extended treatment with antipsychotic medication, which
plays a crucial role in symptom control and relapse preven-
tion (King et al., 2014). However, adherence to antipsychotic
nia and schizoaffective disorder (Tarutani et al., 2016) as
only 50% adhere to their antipsychotic medication (Al
1
College of Nursing, Sultan Qaboos University, Muscat, Oman
2
Princess Salma Faculty of Nursing, Al Al-Bayt University, Mafraq, Jordan
Corresponding Author:
Khloud Al Dameery, College of Nursing, Sultan Qaboos University, P.O. Box
66, Al-Khoudh 123, Muscat, Oman.
Email: k.aldameery@squ.edu.om

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-
NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution
of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-
us/nam/open-access-at-sage).
2 SAGE Open Nursing
Qasem et al., 2011; Chaudhari et al., 2017). Previous
research reported that medication nonadherence rates
ranged from 25% to 80%, with an average of 40% to 50%
across various studies (Basit et al., 2020). These highlight
the need for interventions aimed at improving medication
adherence among individuals with schizophrenia.
Review of Literature
Poor medication adherence is a common issue among schizo-
phrenia patients, leading to poor clinical outcomes, including
increased distress, relapse, rehospitalization, and increased
rates of mortality and morbidity, as well as increased health-
care costs (Chan et al., 2021; Cristarella et al., 2022).
Studies have shown that individuals who do not adhere to
their prescribed medication regimens are more likely to expe-
rience psychotic episodes, worsening symptoms, and func-
tional impairment (Llorca et al., 2018; Yang et al., 2021).
Contrary to this, medication adherence decreases the odds of
rehospitalization (Jiang & Ni, 2015) and improves patients’
physical health outcomes (Hayhurst et al., 2014), which
reflects positively on patients’ quality of life.
Several predictors for nonadherence among people with
schizophrenia have been identified, including a lack of
insight into the illness (Chaudhari et al., 2017), medication
side effects, stigma (Abdisa et al., 2020), and limited
access to healthcare resources (Shuler, 2014). Additionally,
complex dosing regimens (Ljungdalh, 2017), a lack of
support from family and friends (Chaudhari et al., 2017),
and negative beliefs about medication can also contribute
to this issue (Eticha et al., 2015).
Many evidence-based approaches by researchers and clini-
cians are believed to improve patients’ medication adherence,
including family psychoeducation (McFarlane, 2016), motiva-
tional interviewing (Barkhof et al., 2013), social skills training
(Costa et al., 2015), tailored environmental support and
weekly home visits (Velligan et al., 2013), web-based infor-
mation (Van der Krieke et al., 2013), and computer apps
(Treskes et al., 2018). Despite the potential benefits of psycho-
social interventions, they are rarely implemented in clinical
settings due to a scarcity of trained clinicians, inadequate
funding and the failure of patients to take advantage of treat-
ment options or to stay engaged (Drake et al., 2009).
With respect to the aforementioned limitations, using
smartphone apps to deliver health interventions shows
promise as a means of overcoming the current constraints
of healthcare services (PEW Research Center, 2015). That
is, smartphones are popular, people keep their smartphones
with them all the time and they are connected to the internet,
which makes them a practical and convenient way to deliver
interventions in any location and at any time (Pennou et al.,
2019). Despite their difficult circumstances, one study found
that homeless people also use smartphones (Post et al., 2013).
Furthermore, people with mental disorders use smartphones
in the same way as their healthy counterparts. A study of
1,592 individuals with serious mental disorders revealed
that mobile phone usage among this group is comparable
with that of the general population (Ben-Zeev et al., 2013).
Additionally, a significant number of individuals expressed
interest in receiving mobile interventions, such as reminders,
psychoeducation, and communication with clinicians, via
their mobile device (Ben-Zeev et al., 2013).
The early use of smartphones in health interventions was
through sending text messages (Granholm et al., 2012).
However, the results were not always statistically significant
(Granholm et al., 2012). In contrast to smartphones used in
previous studies, current smartphones have greater capabili-
ties and apps, which could enhance medication adherence.
Furthermore, all prior studies have been carried out in devel-
oped nations, and it is necessary to assess such apps in devel-
oping nations, such as Oman.
Purpose of the Study
The aim of this study was to use a mobile phone app
(MyTherapy—pill reminder and medication tracker) and
test the impact of its use on medication adherence among
adults with schizophrenia and schizoaffective disorders.
Methods
Design
Quasi-experimental design, particularly time series design,
was used to evaluate the effect of a smartphone app on med-
ication adherence among adults with schizophrenia
(Figure 1). The time series design was specifically used to
assess the adherence behavior of the sample accurately and
clearly before and after using the mobile app. The memory
biases of the patients were avoided by measuring adherence
at specific intervals (Kaplan et al., 1995)—at the start, at 12
weeks when the mobile app was installed and 12 weeks after
installation.
Research Question
What is the impact of using MyTherapy mobile phone app on
the medication adherence among adults with schizophrenia
and schizoaffective disorders?
Sample
A convenience sampling technique was used. Sample size
was calculated using G*Power 3.1.9.7, and the statistical
test employed was a repeated-measures ANOVA. A
medium effect size of r = .25, a statistical power of 80%
and a probability level of .05 were assumed for the calcula-
tion. The estimated sample size was 43 participants to be suf-
ficient for this study. However, the sample size was increased
to 51 participants (the experimental group acted as their own
Al Dameery et al.
Figure 1. Research design on the effect of using a mobile app on medication adherence among Omani patients with schizophrenia and
schizoaffective disorder.
control group in this study) due to higher attrition rates
among patients with schizophrenia, as reported in previous
studies (Ainsworth et al., 2013; Ben-Zeev et al., 2014).
Inclusion/Exclusion Criteria
The inclusion criteria were (a) diagnosed with schizophrenia
or schizoaffective disorder for a minimum period of 1 year;
(b) visiting the outpatient clinics; (c) aged 18 years and
older; (d) able to read and speak Arabic; (e) having a smart-
phone supporting Android apps; and (f) able to give informed
consent. Participants were excluded if they had (a) any cog-
nitive impairment based on the reports or initial screening;
and (b) any visual or auditory impairment that prevented
them from using the mobile app. A psychiatric nursing spe-
cialist with a master’s degree in mental health nursing
assessed participants’ eligibility.
Ethical Considerations
Ethical approval was obtained from the Sultan Qaboos
University, Sultan Qaboos University Hospital and the
Ministry of Health, all in Oman. Prior to data collection, par-
ticipants were given an information sheet that explained data
confidentiality and, that participants, had the right to with-
draw from the study at any stage. The consent form was
signed by the patients before participating in the study. No
personal identification information was collected. All data
were stored in encrypted files on a password-protected com-
puter, and the surveys were kept in a locked cupboard.
Overall, the researchers adhered to the Belmont principles.
Data Collection Procedures
After obtaining ethical permission for the study, a registered
nurse who was familiar with the hospital setting and the data
collection and entry process was recruited as a research assis-
tant (RA). The RA was further trained by the researchers in
3
the specific data collection procedure for this study and the
use of the mobile app. The RA visited the outpatient depart-
ments of the setting and collected the list of patients visiting
the outpatient departments for appointments.
The RA contacted potential patients and explained the
purpose and procedure of the study, answered their queries
(if there were any), and provided them with an information
sheet and the consent form. Fifty-one patients were recruited
in total, all of whom provided consent to participate in the
study.
In the first visit, participants were asked to sign the
consent form. The RA then arranged a meeting with the par-
ticipants at a mutually convenient place and time, during
which they were requested to complete the Medication
Adherence Rating Scale (MARS) along with demographic
sheet. To ensure confidentiality, each participant received a
code number linked to their name, which was kept in a pro-
tected place. This helped the researchers to track the patients
over the next two visits and assisted in conducting appropri-
ate statistical tests.
Following the initial visit, patients continued their normal
routine for a period of 12 weeks until the second visit. During
the second visit, the RA then arranged a meeting with the par-
ticipants at a mutually convenient place and time, during
which they were requested to complete the MARS. In the
same meeting, the RA installed the mobile phone app
(MyTherapy), which served as a medication reminder for
the participants, on their smartphones immediately after com-
pleting the MARS. The RA provided the participants with all
the necessary information about the app and trained them on
how to use it. Throughout the 12-week period, the partici-
pants were instructed to use the app as a tool to assist them
in adhering to their medication regimen. The MyTherapy
app provided features such as reminders to take medications
at specific times, and dosage tracking. Participants were edu-
cated about the functionalities of the app and trained on how
to utilize it effectively. The app was tailored to individual
medication schedules, allowing participants to set reminders
4 SAGE Open Nursing

for each specific medication and dosage. Over the course of used to describe demographics. Means, percentages, and
the 12 weeks, participants were encouraged to engage with SDs were used to describe the distribution over the stages
the app regularly, record their medication intake, and of study (pretest I, pretest II, and posttest I). A
utilize the reminder system to ensure timely and accurate repeated-measures ANOVA was used to determine the dif-
medication adherence. At the end of the 12-week period, ference between the means over the stages of the study. A
the participants’ usage of the MyTherapy app and their med- p-value of ≤.05 was considered statistically significant.
ication adherence were evaluated and assessed using the
MARS for the final time. The researchers selected these
periods because the follow-up visits and medication reassess- Results
ment are usually scheduled every three months by the psychi-
atrist. Please see Figure 1 for more information Sample Characteristics
A total of 51 participants with schizophrenia or schizoaffective
Description of the Mobile Health App disorders completed the study. Participants’ mean age was 33.9
years, with a median of 35 and a range of 18 to 58 years.
The researchers used a free, open-source app—MyTherapy Two-thirds of the participants were unemployed (n = 33),
pill and medication reminder. This app is developed by while 35.3% were employed (n = 18). More than half the par-
“smart patient.” This app is available in Arabic and English ticipants were male (n = 28), while 45.1% were female (n =
languages in the Google Play and App stores. The app is 23). Almost half the participants were single (n = 26), 94.1%
easy to use and reminds the patients of the time their medica- lived with family (n = 48), 78.4% of the sample reported
tion is due. It also helps patients report when they forget their taking medication alone (n = 40), and 41.2% had secondary
medication and reminds them that not taking medication on education (n = 21). For more details see Table 1.
time is harmful to their health. Although no previous
studies have used the same app, globally almost 200,000
users have used the app and rated it as 4.6 out of 5, Research Question Results
making it one of the most highly rated apps on the market.
A one-way repeated-measures ANOVA was performed to
Participants do not need to insert personal information to
evaluate the impact of the smartphone app on the level of
download and register with the app.
adherence before and after installation of the app among
patients with schizophrenia and/or schizoaffective disorders.
Instrument for Data Collection Mauchly’s test of sphericity revealed that the assumption of a
spherical shape was not upheld X2 (2) = 7.932, p < .01.
The researchers used the MARS and completed a demo-
graphic form. The MARS was developed by Thompson
et al. (2000) to assess adherence to medication among Table 1. Sample Characteristics.
patients with mental illnesses. The main sample was patients
Variable n % M SD
diagnosed with schizophrenia. The scale was originally avail-
able in English language, and validity and reliability were Age 33.9 9.3
established, with an internal reliability (Cronbach’s alpha) Occupation
of .75. The MARS was translated to Arabic and Unemployed 33 64.7
Cronbach’s alpha was >.70 (Alsous et al., 2017). The Employed 18 35.3
MARS includes 10 items. The 10 questions could be Gender
answered as “No = 0” and “Yes = 1.” Adherence level is Female 23 45.1
determined by summating scores of items ranging from 0 Male 28 54.9
Marital status
(poor adherence) to 10 (good adherence). A higher score
Single 26 51.0
indicates better adherence. Permission to use the survey Married 25 49.0
was obtained from the originator of the tool. The demo- Living status
graphic form consists of questions about gender, age, Living with the family 48 94.1
marital status, and employment status. Living alone 3 5.9
Support for medication
Support available 11 21.6
Statistical Analysis Taking alone 40 78.4
The statistical package SPSS version 24.0 for Windows was Level of education
used to analyze the data (IBM Corp, 2016). An initial explor- Illiterate 1 2.0
atory analysis was conducted to identify any outliers or Primary 9 17.6
Secondary 21 41.2
missing data. No outliers or missing information were iden-
BSc 20 39.2
tified. Means, standard deviation (SD), and frequency were
Al Dameery et al. 5

Therefore, degrees of freedom were corrected using the MONEO platform to improve the adherence and clinical con-
Huynh–Feldt estimate of sphericity (.875). There was a stat- dition of patients with schizophrenia (Krzystanek et al.,
istically significant difference in the level of adherence 2019). The study found a significant improvement in medica-
between at least two groups p < .01. tion adherence, accompanied by a significant reduction in
Three paired-sample t tests were used to make post hoc schizophrenic symptoms among the participating patients
comparisons between pretest I, pretest II, and posttest (Krzystanek et al., 2019). Overall, mobile technology has
I. Post hoc pairwise comparisons were then conducted. The become more sophisticated and user-friendly, and it is now
first paired-sample t test between pretest I and pretest II the responsibility of mental healthcare teams to promote its
found no significant difference in average adherence at use to maximize the benefits for the success of treatment
the baseline (M = 5.1, SD = 1.5) and 12 weeks later on a regular basis.
(M = 4.9, SD = 1.3; t [45] = .904, p = .37). A second The results of this study are in contrast with the results of a
paired-sample t test between pretest I and posttest I of the Canadian study on a schizophrenia-focused mobile app—
mobile phone app found a significant difference in average App4Independence (A4i)—that revealed small–medium
adherence from pretest II (M = 5.3, SD = 1.5) to posttest I improvements in certain psychiatric symptoms, but no signif-
(M = 6.45, SD = 1.6; t [39] = 7.98, p < .01). A third paired- icant changes in recovery engagement or medication (Kidd
sample t test found a significant difference in average adher- et al., 2019). In the study, while participants expressed satis-
ence between pretest II (M = 5.0, SD = 1.3) and posttest I faction with the use of the app, those who interacted with the
(M = 6.4, SD = 1.6; t [39] = 6.8, p < .01). For further app more frequently were found to have higher levels of
details see Table 2 and Figure 2. depression, hostility, and interpersonal sensitivity at baseline
(Kidd et al., 2019). This focuses our attention on the previous
researchers, who were skeptical about the excessive “digital
Discussion engagement” of the patients (Ben-Zeev et al., 2019). At the
The aim of the study was to evaluate the impact of mobile same time, many studies have supported the use of mobile
phone app usage on medication adherence among patients apps in managing schizophrenia patients (Hilty et al., 2018;
with schizophrenia and schizoaffective disorders. Results Stubbe, 2020).
showed that the average adherence score increased signifi- As the world moves towards digitalization and embraces
cantly after installation of the mobile phone app on the par- technology, we must explore the possibilities that can
ticipants’ smartphones. This supports results from another benefit patients. Schizophrenia patients are in great need of
study, which identified the acceptability and usability of the rehabilitation and independent living that enhances their rein-
mobile app among schizophrenia patients (Kreyenbuhl tegration back into the community. Mobile technology paves
et al., 2019). The aim of Kreyenbuhl et al. (2019) was to the way for self-monitoring of adherence and the improve-
assess the effectiveness of the MedActive smart phone app ment of symptoms, which, in turn, enhances self-confidence
on the adherence to antipsychotic medication duration over and satisfaction. Sound clinical trials are needed to test the
2 weeks. Participants rated the MedActive to be highly growing body of research into digital health approaches for
acceptable and practical, and they expressed positive feed- severe mental illness populations, especially for patients
back and satisfaction with their experience using the app. diagnosed with schizophrenia.
This is in line with a recent review conducted on 28 studies These study results contradict those of a randomized con-
by Simões de Almeida and Marques (2023), which conclude trolled trial in which the effect of weekly telephone interven-
that mobile app effectively enhances adherence to medication tion on self-reported medication adherence, self-efficacy, and
among patients with mental illnesses. This suggests that symptom levels was investigated in 140 stable outpatients
mobile apps may be an effective strategy to tackle many of with serious persistent mental illness (Beebe et al., 2016).
the issues of chronic mental illnesses. Our findings are also Although the experimental group had fewer symptoms and
in alignment with the results of another study used higher self-reported medication adherence in the immediate
results compared with the control group, the differences
Table 2. Change in Adherence Among Participants. were not statistically significant, which means that the
observed effects could have been due to chance.
ANOVA Additionally, medication adherence and self-efficacy were
Obs. Mean Std. Dev. t Df p-Value unchanged over the 3-month follow-up period. This con-
firmed that the telephone intervention did not have a signifi-
Pair 1 Pretest I 46 5.1 1.5 .90 45 .371 cant effect on participants’ confidence in their ability to
Pretest II 46 4.9 1.3 adhere to their medication regimen (Beebe et al., 2016).
Pair 2 Pretest I 40 5.3 1.5 7.98 39 <.01 However, the difference between these interventions should
Posttest I 40 6.4 1.6 be noted, and further rigorous, multicentric studies should
Pair 3 Pretest II 40 5.0 1.3 6.79 39 <.01
be carried out to examine the effect of mobile apps on
Posttest I 40 6.4 1.6
chronic mental disorders to establish generalizability.
6 SAGE Open Nursing
Figure 2. Changes in the adherence scores before, 12 weeks after and postintervention.
There is a dearth of methodologically sound studies testing the
effect of mobile apps directly on patients with schizophrenia in the
Middle East. This could be due to the feasibility of conducting
such studies among these populations itself. Mental health profes-
sionals should be encouraged to use mobile technology to enhance
autonomy and treatment adherence, with the aim of better thera-
peutic outcomes. Further studies in the field should also be
carried out to enable evidence-based practice with the use of
mobile technology in the management of schizophrenia patients.
Strengths and Limitations
With respect to the significant results, this study was limited to
self-report data, which may have impacted on the results as
some patients might have deliberately tried to show that they
adhered to their medication. Furthermore, the potential for con-
founding variables to influence the observed changes in the
study could also be considered a limitation as there was no
control group involved in the study. For example, changes in
the dependent variable may be due to other factors such as
changes in the environment, rather than the independent vari-
able of interest. The study could not afford to have a control
group; thus, the research results may not be generalized in
other settings and require further testing to establish the same.
Implications for Practice
As the first study testing the usage of mobile apps among
patients diagnosed with schizophrenia or schizoaffective dis-
order in Oman, this research significantly contributes to the
field of clinical practice, administration, and research. The
findings of this study will increase the awareness of govern-
ment and healthcare providers of the significance of smart-
phone apps for enhancing medication adherence among
patients with schizophrenia or schizoaffective disorder.
The findings suggest that using mobile apps can be an
effective tool for improving medication adherence among
Omani patients with schizophrenia and schizoaffective disor-
der. Healthcare providers should consider incorporating
mobile apps into their treatment plans for patients with schiz-
ophrenia as a means of enhancing medication adherence,
improving clinical outcomes, and reducing healthcare costs.
There is a real dearth of studies at national and international
levels that have tested the Mobile apps among patients with
Schizophrenia or Schizoaffective disorder, hence we recom-
mend more methodologically sound, multicenter randomized
clinical trials for testing the effect of mobile app on adher-
ence. Future research should examine the impact of mobile
apps on medication adherence among different populations
and across different cultural and socioeconomic contexts.
Conclusions
The use of mobile apps has the potential to improve medica-
tion adherence among Omani adults with schizophrenia and/
or schizoaffective disorders. However, larger, and more com-
prehensive studies are needed to fully understand the impact
of mobile apps on medication adherence.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Al Dameery et al.
Funding
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This work
was supported by the Sultan Qaboos University.
ORCID iDs
Khloud Al Dameery https://orcid.org/0000-0002-3687-9606
Abdullah Alkhawaldeh https://orcid.org/0000-0002-1146-0972
Omar Al Omari https://orcid.org/0000-0002-7614-1729
Mohammed ALBashtawy https://orcid.org/0000-0002-6107-
7605
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