48 Chapter 2 2 Our study is unique as it targets multiple drivers for non-adherence, serving as a foundation for the design of Ademgenoot, a six-week challenge-based game designed to increase medication adherence. Ademgenoot aims to motivate users, employ goaloriented strategies, and provide visual feedback on adherence behaviour to raise awareness of the effect of adherence on asthma control. Ademgenoot incorporates various behavioural change strategies, such as personal goal setting and continuous direct feedback, along with persuasive game design elements, including a narrative and rewards. These combined elements are intended to increase patients’ motivation to adhere to their maintenance inhaler regimen. Self-determination theory and motivation Increasing motivation to adhere to the maintenance inhaler and sustain the behaviour is an important design strategy and in accordance with the Self-Determination Theory’s motivational underpinnings. According to this theory, there are three essential psychological needs – autonomy, relatedness, and competence – that are critical in forming motivation (49, 50). In the context of asthma medication adherence, Self-Determination Theory suggests that patients are more likely to adhere to their medication regimen when they have a sense of autonomy in decision-making, feel competent in managing their asthma, and have a supportive relationship with their healthcare provider. To promote autonomy, the six-week challenge of Ademgenoot, along with personal goal setting, contributes to patients’ sense of control. Competence is targeted through patient education on inhaler differences and fostering a sense of accomplishment through being adherent. Generally, patients experience better well-being and a greater sense of being in control over their asthma when they comply with their medication regimen. Relatedness, another vital aspect, can be achieved by integrating Ademgenoot into a blended-care setting, as suggested by the patient advocates, and by incorporating evaluation moments that focus on successes, thereby providing support for competence. Ademgenoot could facilitate conversations between patients and healthcare providers on adherence behaviour, asthma control and decisions regarding therapy step-up. Ademgenoot employs a combination of internal motivation (e.g., personal goal setting), external motivation (such as motivating screens featuring Brad’s progression), additional rewards (e.g., the environment becoming richer) and intrinsic motivation by fostering engagement and enjoyment with the app itself (instead of using the inhaler itself having to be enjoyable). While short-term motivation is achieved through these fun and rewarding elements, long-term adherence requires the internalization of extrinsic motivation according to the Self-Determination Theory (51). The six-week challenge stimulates long-term engagement, allowing users to experience the benefits of using a maintenance inhaler and facilitating the process of internalizing extrinsic motivation, thereby increasing the chances of maintaining desired behaviour in the long run.
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