Dr. Melanie Murray is one of this year’s MSFHR Health Professional-Investigator Award recipients. Her study, Individual disposition and mHealth: Personalized care to improve outcomes, is looking at dispositional traits that might identify which patients are more likely to benefit from antiretroviral adherence support provided by the WelTel program.
How did you become interested in the WelTel intervention?
At Oak Tree Clinic approximately a third of our patients experience barriers to accessing care, to being able to take their antiretrovirals, and to being well. A lot of those barriers focus around the social determinants of health, and so in looking for ways to engage our patients I started talking with Dr. Richard Lester who designed the WelTel intervention. He did a WelTel study in Kenya which was effective there, and he wanted to bring it out of Africa and try it here to see what we could do to improve care for our patients. We started with a pilot study looking at feasibility here at Oak Tree Clinic, and then did a second study with some of our most vulnerable patients to see if WelTel works. The study found that WelTel does work – especially for those who use it – and so that led to the current question which is ‘How do we know ahead of time who might use the program and who might benefit most from it?’
What inspired you to consider personalizing antiretroviral adherence support in persons living with HIV?
It was the results from our second study that show that WelTel works for those who actively engage with the program. When we talked to health care providers at the clinic and those who are directly interacting with participants of the study there was really nothing obvious about an individual that would give us a hint as to whether the WelTel program was going to work for them. But this finding led us to thinking that although we think this program is great it is not for everyone – and everyone who needs support should have the type of support that is suited to their needs.
Why did you choose to focus on dispositional traits?
When we looked at the results of our effectiveness study (the WelTel Oak Tree study) we found that people who responded to the text messages were more likely to take their antiretroviral and suppress their HIV viral loads. Then we looked at the demographic information we have about participants to see if there was a clear type of person who responded or didn’t –and there wasn’t. So then we considered that some people just prefer to text, and it could be more about disposition – whether someone is the type of person who likes to communicate that way – and that whether an adherence support works is just about what works for them as an individual. My colleagues Patrick Hill and Grant Edmonds look at big population studies in the US looking at personality and sense of purpose and health outcomes. There are short, easy questionnaires that can be done and tell a lot about a person and what programs might be suited to them, and so we thought perhaps this is a way we could look at the disposition of a person and see if that disposition would give us information about whether they would participate in and use this type of program.
The MSFHR Health Professional-Investigator Research Award is focused on implementation and using research to improve patient outcomes. How do you intend to mobilize the results of your study?
We would like to be able to roll out WelTel clinically to all of our patients who would benefit from the program. However, resources are limited and it would be nice to have a quick and easy way to determine if the WelTel program would be the right fit for an individual, so as to offer the program to those most likely to benefit from it. In addition, we aim to go back to those individuals for whom text messaging isn’t really a fit and see if we can come up with other programs or strategies for engaging them in their care.
How do you think that these findings will benefit patients?
A lot of the issues that prevent individuals from taking antiretrovirals are the social determinants of health. Housing, stable food sources, or physical safety, for example, all stand in the way of adherence to medications because these things are of higher priority. If you don’t know where you’re going to get your next meal you’re hardly going to be worrying about taking pills, particularly if those pills require you to eat. What WelTel does is it enables participants to ask for help when a problem arises, rather than at their next clinical appointment which could be months away. It allows us to help deal with smaller problems as they arise, and before they become big crises. If we could potentially roll WelTel out clinically with those individuals most likely to use it, then we could help those persons to engage in care, be well, and address the social determinants of health that stand in the way of their being able to attain adherence to their HIV medications.
Dr. Murray and team have recently conducted Sharing Circles to receive input from Indigenous members of the community on the language and feasibility of their questionnaires, and has been fortunate to receive mentorship from Elders Valerie Nicholson and Sandy Lambert. This process is intended to ensure that survey questions and the WelTel program are culturally safe for the individuals receiving them, and to get feedback on how to make it better. In addition, Dr. Murray and her team are in the process of validating the questionnaires with the Indigenous community so that results of these surveys may be meaningful to the population being studied. .
Looking forward, if her team is awarded CIHR funding for the proposed study they will begin work to enrol approximately 300 participants in the next phase of the study, with a focus on enrolling participants from groups that struggle most often with adherence to antiretrovirals (including Youth, Women, and First Nations individuals). The study will be a partnership between Vancouver Native Health, the Portland Hotel Society, and Oak Tree Clinic.