INTRODUCTION:

Medication adherence plays a crucial role for patients with chronic diseases in achieving optimal therapeutic outcomes. However, adherence is often compromised due to the long duration of treatment¹. Patients with coronary heart disease (CHD) are among those frequently experiencing adherence issues. A study conducted in Brazil in 2022 found that 57% of CHD patients were non-adherent to pharmacological therapy. The most commonly cited reasons for non-adherence included forgetting to take medications on time, completely forgetting doses, stopping medication when feeling better, and deliberately skipping doses^2,3. Adherence among CHD patients extends beyond pharmacological therapy to include non-pharmacological recommendations such as lifestyle modifications—dietary changes, physical activity, and smoking cessation—which are equally important in achieving favorable clinical outcomes. Both medication adherence and adherence to lifestyle modifications can influence the severity of recurrent vascular events, stroke, and mortality. In India, the average lifestyle modification adherence score among CHD patients following percutaneous transluminal coronary angioplasty (PTCA) declined from 4.2 in the first month to 3.8 in the sixth month and 3.2 in the twelfth month. This score was measured using the Manipal Lifestyle Modification Score (MLSMS), which evaluates five lifestyle factors: diet, smoking, blood pressure monitoring, blood glucose monitoring, and physical activity⁴.

Self-management in chronic disease patients is defined as the ability to manage one's health condition, including treatment adherence, self-care, and symptom control. Based on this definition, both medication adherence and lifestyle modification fall under self-management behaviors for CHD patients. Several instruments have been developed to assess self-management in CHD populations. A study in China found that CHD patients two years after undergoing percutaneous coronary intervention (PCI) had low levels of self-management, with an average score of 69.5 on the Coronary Heart Disease Self-Management Scale (CSMS). The lowest-scoring domain was disease management, with an average score of 57.5^5,6.

In Indonesia, the prevalence of CHD diagnosed by physicians was reported at 1.5%. The majority of patients are over 40 years old, with more females affected than males, and most residing in urban areas⁷ Medication adherence and self-management remain critical issues among Indonesian CHD patients. Research conducted in South Kalimantan Province revealed that 94% of CHD patients had low levels of medication adherence, primarily due to drug side effects such as dizziness, coughing, bloating, and nausea⁸.

In recent years, the rapid advancement of information and communication technology has opened new opportunities in healthcare, including the pharmaceutical sector. One such innovation is the application of mobile health (mHealth) technologies. mHealth interventions offer a promising solution to improve medication adherence and health outcomes in CHD patients^9,10. A randomized controlled trial (RCT) conducted in China demonstrated that mHealth interventions significantly improved medication adherence and clinical outcomes, including reductions in both systolic and diastolic blood pressure. These findings suggest that mHealth can enhance treatment adherence and therapeutic results¹¹. Furthermore, a previous systematic review indicated that digital health technologies, particularly web-based mHealth applications, effectively improve medication adherence and self-management in CHD patients¹². However, the implementation of web-based mHealth applications for CHD patients has not yet been explored in Indonesia, highlighting the novelty and urgency of conducting such research in the Indonesian context. Given that, in 2021, smartphone ownership in Indonesia had reached 65.87%, and internet access was available to 62.1% of the population, the use of mHealth presents a feasible and timely solution¹³. This study aims to develop a suitable and ready-to-use mHealth model to enhance medication adherence and self-management among CHD patients in Indonesia.

MATERIALS AND METHODS:

Study Design and Participant:

This study employed agile design consisting of six main phases as a cycle: requirement, design, development, testing, deployment, and review. Agile design is a method of making software that is organized with continuous improvement in a short cycle. The use of agile design involves prioritizing user needs and being able to respond quickly to changes so that it can increase user satisfaction with the software^14,15. The cycle of the research phase can be seen in (Figure 1).

Figure 1. Research phase based on agile design

The design and development phases were part of alpha testing, while the functionality testing and review phases were included in beta testing. Alpha testing was internal testing from the website team developer side before the product launch to end users. This is followed by external testing involving users during the beta testing¹⁶.

This study was conducted from January to July 2024 at an outpatient heart disease polyclinic in Yogyakarta, Indonesia. The inclusion criteria were patients diagnosed with coronary heart disease defined as when the heart arteries cannot distribute blood normally due to atherosclerosis, ≥18 years, and with or without comorbidities. Patients with cognitive impairment were excluded.

The sampling technique used was purposive sampling according to the inclusion and exclusion criteria. The sample size used the saturation concept, with a minimum of five patients as recommended in this type of research¹⁷. During patient recruitment, researchers provided a comprehensive explanation of the study’s objectives, procedures, potential benefits, associated risks, and assurances regarding data privacy and confidentiality. Participation was voluntary, and patients were informed of their right to withdraw at any time without penalty. Data confidentiality was maintained through coded identifiers, with data access limited exclusively to the research team. Informed consent was obtained from each patient through a signed consent form prepared by the researchers. Ethical approval for this study was granted by the Ethics Committee of Panti Rapih Hospital, Yogyakarta (Approval No. 45/SKEPK-KKE/VI/2023).

Requirement:

The requirement phase was conducted through in-depth interviews with the CHD patients that aimed at identifying essential features for the mHealth application. Two questions served as the topic guide during the interview: "What are the obstacles during your CHD treatment?", and "What feature do you need in a website to support your treatment?". The themes obtained from the interview were then generated in the form of appropriate features.

Alpha Testing:

The design of the mHealth application employed a patient-centered approach, using wireframes to visualize the structure and features of the app. Additionally, the design incorporated the principles of Persuasive System Design (PSD), which aims to influence behavior change without coercion. PSD features were organized into four categories: primary task support, dialogue support, system credibility support, and social support. Primary task support included elements such as personalization, self-monitoring, simulation, content creation, reduction, and training to help users engage with their health data and therapy. Dialogue support focused on user feedback features like reminders, rewards, and suggestions to encourage continued use and behavior modification. System credibility support ensured that the app appeared trustworthy through features such as expert endorsements, third-party validation, and system verification. Lastly, social support mechanisms such as social comparison, cooperation, recognition, and social learning were integrated to enhance user motivation and foster a sense of community. These features were strategically categorized to align with the app's goal of encouraging long-term engagement and adherence. Detail of the PSD model can be seen in (Figure 2)¹⁸.

Figure 2. Persuasive design system model

The development process focused on both user interface/user experience (UI/UX). The application was developed using Visual Studio Code. The website developer team included one IT expert, one cardiologist specialist, and two pharmacists. Two versions of the prototype were developed in this phase.

Beta Testing:

Functionality testing employed the black box testing method, in which users were instructed to log into the app using a username and password, navigate the contents, complete required forms, and log out. Afterward, users provided feedback on the app’s visual design, language clarity, and ease of use through short interviews. This testing phase involved a multidisciplinary team consisting of an information technology (IT) staff, a physician, a pharmacist, and a CHD patient.

The final phase in this research phase was the launch of the web-based mHealth app prototype. The sustainability of web-based mHealth is carried out by reviewing and monitoring when the application was used by users so that ensuing changes can be quickly responded to.

RESULT:

Requirement:

Eleven patients with a 100% response rate participated in the interview for the requirement phase of this study. The majority were male (64%), with most being over 60 years old (73%). Several themes emerged: education, discussion forums, medication reminders, health condition tracking, and healthcare provider location services. Other themes that emerged related to the treatment barrier: patients unable to recognize CHD symptoms, polypharmacy, patients forgetting to take their medication, and side effects of medication in CHD patients. Detailed descriptions of these features can be found in (Table 1).

Table 1. Description of mHealth app features

Feature	Description
Education	Education topics about coronary heart disease, percutaneous coronary intervention, pharmacological therapy, and lifestyle modification
Medication reminder	Patient schedule and a reminder to take the medicine
Health condition	Records of the patient's blood pressure, weight and height, body mass index, lipid profile, and other laboratory tests
Discussion forum	Patient sharing forum and consultation with doctor and pharmacist
Healthcare and hospital location	Provide the location of the nearest healthcare or hospital

Alpha Testing:

In the initial stage of the application design, the researcher created an application flow represented in a flowchart, which was subsequently used to develop a storyboard and a wireframe table. Each feature was categorized according to the principles of the persuasive design system. The features in the application were aligned with all categories of the persuasive design system model. The educational feature was primary task support. Medication reminder was dialogue support. The discussion forum was social support. System credibility support comprised of health conditions, and healthcare/hospital location.

During the development phase, the app design was applied to create the user interface and experience, making the mHealth app visually accessible to users. This stage involved incorporating text, colors, and images into the app. The resulting user interface design of the web-based mHealth app can be viewed in (Figure 3).

Figure 3. Screenshot of website interface design, including (a) login page; (b) main page; (c) health condition page; (d) list of education topics; (e) medication schedule or reminder page.

Beta testing:

Prototype testing of the web-based mHealth app was conducted using the black box method to assess the functionality of each feature. A total of 10 users were involved in this testing stage, which included 1 IT staff, 1 physician, 3 pharmacists, and 5 CHD patients. The majority were female (60%), between 20-45 years (50%). The functionality testing results indicated that all features of the mHealth app were valid and functioned properly when used by the users. Detailed information on the functionality testing results is provided in (Table 2).

Revisions were made based on the prototype testing feedback from several users. These revisions included improving the login process and allowing users to log in using either a mobile phone number or email. Additionally, features that had encountered issues during functionality testing were fixed. The method of delivering educational content was also revised, switching from pictorial narratives to audiovisual videos to enhance patient understanding. The font size was increased to improve readability. Once these revisions were completed, the final stage involved launching the web-based mHealth app prototype for CHD patients.

DISCUSSION:

Medication adherence plays a crucial role in patient treatment, helping achieve optimal outcomes. The results of medication adherence assessments can serve as a foundation for healthcare providers to develop educational and consultation programs, ultimately improving patient adherence and satisfaction. High level of medication adherence are associated with improved quality of life among patients^19,20. Non-adherence was observed in 31% of myocardial infarction patients, who discontinued their medication after six months, increasing the risk of recurrent vascular events and mortality. Medication adherence is a key component of self-management behavior that coronary heart disease (CHD) patients must adopt for therapeutic success. Along with medication adherence, self-management also includes physical activity and diet. Similar to medication adherence, patients with strong self-management behaviors can reduce the risk of vascular events and mortality in CHD patients^21,22.

A lack of patient knowledge concerning coronary heart disease, prescribed therapies and healthy lifestyle, coupled with limited access to healthcare services, has a significant impact on medication adherence and self-management among CHD patients. Identifying the factors that hinder adherence is essential for developing intervention programs aimed at improving medication adherence and self-management behaviors in CHD patients^23,24. Recent advancements in healthcare services have led to the digitalization of care, particularly through the use of information technology. Therefore, this study aimed to design and develop a web-based mHealth app capable of providing education and fostering medication adherence and self-management behaviors in CHD patients.

The mHealth app can enhance health services by offering screening, disease diagnosis, and therapy monitoring. The increasing number of smartphone users in developing countries is one of the factors supporting the use of mHealth in these regions. The adoption of mHealth can bridge gaps in healthcare services, such as ensuring equal access and reducing healthcare costs²⁵. The development of mHealth focuses on several aspects, including the intervention's objectives, the creation of guidelines, features and functions, and evaluation. The intervention's goal plays a critical role in the design stage, where each feature must be integrated effectively to achieve the desired outcomes. Researchers must establish design guidelines that align with the intervention's goals and ensure that the app's features support the intended impact. The evaluation of mHealth use provides valuable feedback to assess its usefulness, ease of use, and contribution to users, while also ensuring the long-term sustainability of mHealth technology implementation²⁶.

The development of the web-based mHealth app in this study followed a patient-centered design approach to ensure that its features were aligned with the conditions and needs of coronary heart disease (CHD) patients. A common issue leading to the ineffectiveness of many mHealth interventions is the lack of user involvement in the design and development process, which can hinder the app from achieving its intended goals. The patient-centered design method facilitated collaboration among multidisciplinary development teams, incorporating patient feedback to address usability challenges and ensure the app’s effectiveness. This approach not only encouraged interdisciplinary collaboration but also prioritized patient needs^27,28. This method has been successfully used in several interventions employing mHealth apps for managing mental illnesses, monitoring therapy in elderly patients, promoting lifestyle changes, and supporting self-management in chronic diseases^29,30.

The features derived from the patient needs assessment included education, tracking patient health conditions, discussion forums, medication reminders, and maps of health service centers and hospitals. Educational content was provided in the form of videos covering topics related to the treatment of coronary heart disease and healthy lifestyle modifications for CHD patients. The sources for educational materials came from resources by the Ministry of Health of the Republic of Indonesia and therapy guidelines from the Indonesian Association of Cardiologists. Education was the most common feature in nearly all mHealth apps, aimed at enhancing patient self-management knowledge and behavior³¹. The feature for tracking patient health conditions stored records of clinical conditions and disease examination history, enabling health progress monitoring and the improvement of clinical outcomes. Communication between patients and healthcare providers was not limited to direct contact, as the discussion forum feature allowed for ongoing interactions. Additionally, the discussion forum served as a platform for patients to share information and experiences, motivating each other to follow through with treatment. This feature represented a form of health promotion, fostering patient engagement and support³². One of the factors that could enhance the effectiveness of the mHealth app was the inclusion of user-friendly features that focused on managing treatment and symptoms. Features such as education, discussions, and symptom tracking could all contribute to the app’s success. The implementation of these features in a web-based mHealth app for CHD patients aimed to modify risk factors such as obesity and to prevent recurrent vascular events and mortality^33,34.

Self-management is significantly influenced by an individual’s belief in their ability to perform actions. A person is unlikely to adopt new behaviors if they do not align with their beliefs and expectations. One of the models commonly used to predict changes in health behavior is the Health Belief Model (HBM), which consists of five domains: perceived susceptibility, perceived severity, perceived benefit, perceived barriers, and perceived cue to action. In this study, the improvement of medication adherence and self-management through the use of mHealth in CHD patients in Indonesia can be explained by the HBM model. The perceived susceptibility aspect relates to the patient’s acceptance of their disease condition, while the perceived severity aspect involves the patient’s perception of the seriousness of the disease. CHD, being a chronic disease with multiple risks for complications, exemplifies aspects of perceived susceptibility and perceived severity. This underpins the Health Conditions feature in the app, which helps patients consistently monitor their clinical condition and the risk associated with CHD. Furthermore, features such as Education, Medication Reminders, Discussion Forums, and Health Service Location Maps relate to the perceived benefits and barriers domains. By utilizing these features, patients can enhance their knowledge, improve medication adherence, and engage in better self-management, thus realizing the benefits of using the app to improve their health. These features also address communication barriers between CHD patients and healthcare providers. With these advantages, patients are more likely to be motivated to change their behavior, adopting the use of the web-based mHealth app^35,36.

To ensure the reliability of each feature’s performance in the web-based mHealth app, functionality testing was conducted using the black box method. This method was chosen based on references from several previous studies³⁷. Performance reliability testing is a critical phase in application development, as it identifies any issues or obstacles in performance, enabling prompt resolution. This process ensures the development of a high-quality app that meets user satisfaction. The black box method focused on testing the functionality of the application based on the tester’s interactions and behavior, without requiring knowledge of the internal code. The test results indicated whether inputs were valid or invalid according to user interactions with the feature functions^38,39. All features in the web-based mHealth app performed validly and functioned effectively for users. After successfully passing the design, development, and functionality testing stages, the final prototype of the web-based mHealth app for medication adherence and self-management of CHD patients could be implemented. Feedback and evaluations will be gathered to ensure the application’s optimal sustainability and benefits.

CONCLUSION:

The use of information technology, specifically a web-based mHealth app, presents significant opportunities for improving medication adherence and self-management in CHD patients. The app's features align with patient needs and demonstrate valid functionality. The prototype developed in this study can be implemented in a pilot setting as part of a broader evaluation of the mHealth app's effectiveness. This study lays a scientific groundwork for subsequent randomized controlled trials on mHealth in CHD management in Indonesia. Future research should focus on assessing user experience, clinical outcomes, and long-term engagement through usability testing and feasibility studies in clinical settings.

CONFLICT OF INTEREST:

The authors have no conflict of interest in this study.

ACKNOWLEDGMENTS:

We would like to express our gratitude to the Centre for Higher Education Funding and Assessment (PPAPT) of the Ministry of Higher Education, Science, and Technology of the Republic of Indonesia, and the Indonesia Endowment Fund for Education (LPDP) for their funding support through the Indonesia Education Scholarship (BPI) grant number 202209090899.

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Received on 17.07.2025 Revised on 13.11.2025

Accepted on 04.01.2026 Published on 01.07.2026

Available online from July 04, 2026

Research J. Pharmacy and Technology. 2026;19(7):3046-3052.

DOI: 10.52711/0974-360X.2026.00433

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Object	Testing	Input	Output	Result
Main menu	Education icon	Clicking the icon	Go to the education page	Valid
	Discussion forum icon	Clicking the icon	Go to the discussion forum page	Valid
	Health condition	Clicking the icon	Go to the health condition page	Valid
	Medication reminder	Clicking the icon	Go to the medication reminder page	Valid
	Healthcare and hospital location	Clicking the icon	Go to the healthcare and hospital location page	Valid
Education page	List of educational material	Clicking the thumbnail	Go to the specific page containing the education	Valid
Discussion forum page	List of discussion page	Clicking the thumbnail	Go to the page containing the discussion forum text	Valid
Health condition	Health condition form page	Fulfilling the form	Go to the list of health conditions page	Valid
Medication reminder	Medication taking schedule form page	Fulfilling the form	Go to the list of the medication-taking schedule page	Valid
Healthcare and hospital location	Healthcare and hospital location	Clicking the thumbnail	Go to the page containing the healthcare and hospital location map	Valid