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The University of Manchester Research
Perspectives of patients and healthcare professionals onmHealth for asthma selfmanagementDOI:10.1183/13993003.01966-2016
Document VersionAccepted author manuscript
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Citation for published version (APA):Simpson, A., Honkoop, P., Kennington, E., Snoeck-Stroband, J. B., Smith, I., East, J., Coleman, C., Caress, A-L.,Chung, K. F., Sont, J. K., Usmani, O. S., & Fowler, S. (2017). Perspectives of patients and healthcareprofessionals on mHealth for asthma selfmanagement. European Respiratory Journal, 49(5), [1601966].https://doi.org/10.1183/13993003.01966-2016Published in:European Respiratory Journal
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Download date:28. Oct. 2020
1
PerspectivesofpatientsandhealthcareprofessionalsonmHealthforasthmaself-
management
AndrewJSimpson1,PersijnJHonkoop2,ErikaKennington3,JiskaBSnoeck-Stroband2,Ian
Smith2,JessicaEast3,CourtneyColeman3,AnnCaress1,KianFanChung4,JacobKSont2,Omar
Usmani4,StephenJFowler1.
1DivisionofInfection,ImmunityandRespiratoryMedicine,SchoolofBiologicalSciences,The
UniversityofManchesterandUniversityHospitalofSouthManchesterNHSFoundationTrust,
UK
2Dept.ofMedicalDecisionMaking,LeidenUniversityMedicalCenter,Leiden,theNetherlands
3AsthmaUK,London,UK
4NationalHeartandLungInstitute,ImperialCollegeLondon&NIHRBiomedicalResearch
Unit,RoyalBrompton&HarefieldNHSTrust,London,UK
Correspondenceto:DrAndrewSimpson,DivisionofInfection,ImmunityandRespiratory
Medicine,UniversityHospitalofSouthManchester,EducationandResearchCentre(2nd
Floor),SouthmoorRoad,[email protected]
Takehomemessage
PeoplewithasthmaandhealthcareprofessionalsprovidestrongsupportformHealthfor
asthmaself-management.
2
ABSTRACT
Rationale:mHealthhasthepotentialtorevolutionisetheself-managementoflong-term
medicalconditionssuchasasthma.Auser-centreddesignisintegralifmHealthistobe
embracedbypatientsandhealthcareprofessionals.Objective:Determinetheperspectivesof
individualswithasthmaandhealthcareprofessionalsontheuseofmHealthforasthmaself-
management.Methods:Asequentialexploratorymixedmethodsdesignwasused;focus
groupsinformedthedevelopmentofquestionnaires,whichweredisseminatedtoindividuals
withasthmaandhealthcareprofessionals.Results:Focusgroupparticipants(18asthma
patientsandfivehealthcareprofessionals)identified12potentialusesofmHealth.
Questionnaireresultsshowedthatindividualswithasthma(n=186)mostfrequently
requestedamHealthsystemtomonitorasthmaovertime(72%)andtocollectdatatopresent
tohealthcareteams(70%).Incontrast,asystemalertingpatientstodeterioratingasthma
control(86%)andadvisingthemwhentoseekmedicalattention(87%)wasmostfrequently
selectedbyhealthcareprofessionals(n=63).Individualswithasthmawerelesslikelythan
healthcareprofessionals(P<0.001)tobelievethatassessingmedicationadherenceand
inhalertechniquecouldimproveasthmacontrol.Conclusion:Ourdataprovidestrong
supportformHealthforasthmaself-management,buthighlightfundamentaldifferences
betweentheperspectivesofpatientsandhealthcareprofessionals.
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INTRODUCTION
Asthmaaffectsapproximately300millionpeopleworldwide[1].Inmanycasesasthma
controlremainssuboptimalandavoidabledeathsarestilloccurring[2].Asthmaself-
managementhasbeneficialhealthoutcomessuchasreducedhospitaladmissions,betterlung
function,fewerasthmasymptomsandlessuseofrescuemedication[3-6].Asthmaguidelines
recommendthatallpeoplewithasthmareceiveeducationonasthmaself-management[7,8].
Traditionalasthmaself-managementprogramsutilisepersonalasthmaactionplans,which
involvethemonitoringofsymptomsand/orpeakflow,withawrittenactionplandetailing
howtorecogniseandrespondtoworseningasthma.This‘penandpaper’approachis
burdensomeandtimeconsumingandneitherpatientsnorhealthcareteamsareenthusiastic
abouttheiruse[9].Furthermore,actionpointsbasedonrudimentarydata,suchassymptoms
andpeakflow,maybelesseffectivethanactionpointsbasedonmultiplepersonalised
parameters[10].Despiteimportantbenefitsofself-management,only27%ofadultswith
asthmareceiveanasthmaactionplan[11]andpatients’adherencetowrittenactionplansis
poor[12].
Web-basedsystemsofferlessburdensomeself-managementsupport,whichmayimprove
asthmaoutcomes[13].Nowadays,smartphoneshavebecomeanintegralpartoflifeand
mobilehealthcare(mHealth)systemsarepromisingtoolsthatmayrevolutioniseasthmaself-
management.Thereareover200mobilephoneapplicationsforasthma[14]and
supplementarywearableandinhalerbaseddevicesarewidelyavailable[15].Currently,
however,theutilityofmHealthforasthmaself-managementisunknownandarecent
Cochranereviewwasunabletoadvisecliniciansandthegeneralpublicontheirefficacy[16].
InvestigationsintosuccessfulmHealthsystemspointtouser-centreddesignpractices[17].In
termsofasthma-selfmanagementhowever,thereislittleevidenceofuser-centreddesign
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practicesandnodataexploringtheperspectivesofbothend-users(i.e.,patientsand
healthcareprofessionals).
ThecurrentinvestigationispartofthemyAirCoachproject,supportedbytheEuropean
Union’sHorizon2020FrameworkProgramforResearchandInnovation.Thisprojectaimsto
createauser-centredmHealthtooltosupporttheself-managementofasthma.Understanding
patients’andhealthcareprofessionals’perspectivesisafundamentalstepinthedevelopment
ofuser-centredmHealthsystems.Therefore,thepresentstudywasconductedtodetermine
theperspectivesofindividualswithasthmaandhealthcareprofessionalsontheuseof
mHealthsystemstosupportasthmaself-management.Specifically,weaimedtodetermine
end-user:i)experiencesandperceivedusesofmHealthsystemsforasthmaself-management;
ii)viewsofwhatmeasurementswouldbeusefulinmanagingasthma;andiii)perspectiveson
theacceptabilityofandbarrierstousingmHealthsystemsforasthmaself-management.
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METHODS
Studydesign
Weemployedasequentialexploratorymixedmethodsdesign[18],inwhichqualitative
exploration(usingfocusgroups)informedinstrumentdevelopmentforasubsequent
electronicquestionnaire,withfindingsfrombothdatasourcesintegrated.
Focusgroups
Onemoderatorguidedeachfocusgroup,followingtheapproachfromGreenbaum[19],
accordingtoastructuredscheduleoftopics(table1);thecontentofwhichwasdetermined
viaconsultationwiththemyAirCoachcollaborators(www.myaircoach.eu)andapatient
advisorygroup.Threefocusgroupswereconductedwithindividualswithasthma,in
Manchester(UK),London(UK)andLeiden(theNetherlands),andonefocusgroupwas
conductedwithhealthcareprofessionalsinManchester(UK).Thefocusgroupswerevideo-
recorded,transcribed,translatedwhereappropriateandunderwentFrameworkAnalysis
[20].Dataweregroupedunderemergentthemesandintegratedintothreepre-determined
corecategories,relatingtotheresearchaims.DatamanagementwassupportedbyNVivo
qualitativeanalysissoftware(Version10).
Individualsaged≥18yearswhowerepatientswithdoctor-diagnosedasthmaorahealthcare
professionalinvolvedinthetreatmentofasthmawereeligibletoparticipateinthefocus
groups.PatientswererecruitedfromrespiratoryclinicsinManchesterandLeiden,andvia
advertisementsplacedonlineatAsthmaUK’swebsite.Healthcareprofessionalswere
recruitedfromhospitalrespiratorydepartmentsinManchester.
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Table1.Focusgrouptopicguideforpeoplewithasthmaandhealthcareprofessionals
Topic1.ExperiencesandperceivedusesofmHealthforasthma− Exampleprompts:HaveyoupreviouslyusedmHealthsystemstohelpmanage
your/yourpatients’asthma?WhatwouldyouconsiderwouldbeausefulpurposeofamHealthsystemwithregardstoyour/yourpatients’asthma?
Topic2.PotentialusefulmeasurementsformHealth− Exampleprompts:Whatphysiological,behaviouralandenvironmentalmeasurements
couldhelpyoumanageyour/yourpatients’asthma?Topic3.BurdenandbarriersofmHealth− Exampleprompts:WhatwouldpreventyoufromusingmHealthsystems?Topic4.Alertsandreminders− Exampleprompts:Isthereanypartofyour/yourpatients’asthmamanagementthatis
oftenforgotten?Topic5.Userfeedbackandsupport− Exampleprompts:Whattypeofsupportwouldyoulike?Examplesinclude;intuitive
interfaceswithinformationaboutasthma,FAQs,accesstoGP,specialistasthmanurse,speaktootherusers
Topic6.Privacy− Exampleprompts:Howwouldyoufeelaboutpersonalmedicaldatabeingstoredona
mobiledevice/beingdatasharedwithyourhealthcareteamand/ormedicalresearchers?
Topic7.Productdesign− Exampleprompts:Whatdesignaspectswouldyouaccept/findunacceptable?Would
youconsidercarryinganadditionaldevice(s)?
Questionnaires
Along-listofquestionswasgeneratedfollowinganalysisofthefocusgrouptranscripts.The
clinicalresearchteamandmembersofthehospital’spatientandpublicinvolvementteam
(includingapatientrepresentative)assessedthequestionsforfacevalidityandbias.The
importanceofeachquestionwasthenrankedandthenumberofitemsreducedtogeneratea
20-itemquestionnaireforpeoplewithasthmaand10-itemquestionnaireforhealthcare
professionals.Thequestionnairesweredifferentforpeoplewithasthmaandhealthcare
professionals,butcontainedsomeidenticalquestionstoallowcomparisonsbetweengroups.
AsmHealthsystemsmayprovidemultiplefunctionsrelevanttopatientsandhealthcare
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professionals,wedidnotimposeanyrestrictionsonthenumberofresponsesthatcouldbe
selectedbyparticipantsandallresponsesweregivenequalweighting.
Individualswithasthmaandhealthcareprofessionalscompletedthequestionnairesviaan
onlinesurveyplatform(www.surveymonkey.com),overatwo-weekperiodinDecember
2015.AhyperlinktotheonlinesurveywasincludedonadvertsplacedonlineatAsthmaUK
andtheEuropeanCommissionwebsitesandviaAsthmaUK’sandEuropeanFederationof
AllergyandAirwaysDiseasesPatients’Associations(EFA)socialmediachannels.Healthcare
professionalsfromtheNorthWestSevereAsthmaNetworkandtheNorthWestrespiratory
postgraduatecontactlistwereinvitedviae-mailtocompletetheonlinequestionnaire.For
purposesofcharacterisingthesample,individualswithasthmacompletedtheAsthmaControl
Questionnaire(ACQ);ascoreof≥1.5defineduncontrolledasthmaand<1.5wasclassifiedas
controlledorpartlycontrolledasthma[21].Chi-squaretestsidentifieddifferencesinresponse
frequencybetweenindividualswithasthmaandhealthcareprofessionalsandbetween
individualswithcontrolled(includingpartly-controlled)anduncontrolledasthma,usinga
statisticalsoftwarepackage(SPSS,version22.0).SignificancewassetatP<0.05.
Dataintegration
Qualitativefocusgroupdataandquantitativeresultsfromthequestionnaireswereintegrated
underthreecorecategories.Focusgroupquotesrelatingtoquestionnairedatawere
identifiedandusedtoilluminateandcomplementand/orcontrastthequantitativeresults.
Ethics
AnNHSresearchethicscommittee(15/EM/0360)andtheethicscommitteeofLeiden
UniversityMedicalCentre(P15.195)approvedthisstudyandparticipantsgaveinformed
consent.
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RESULTS
Participantcharacteristics
Eighteenindividualswithasthma(ninefemales)andfivehealthcareprofessionals(two
medicaldoctors,twoasthmanursesandaphysiologist)participatedinthefocusgroups.One
hundredandeighty-sixindividualswithasthmacompletedthequestionnaire;mean±SDage
40±16years,135females,and91withuncontrolledasthma.Sixty-threehealthcare
professionalscompletedthequestionnaire,including31generalpractitioners,13hospital
doctors,eightasthmanurses,and11fromotherhealthcaredisciplines.
Corecategory1:ExperiencesandperceivedusesofmHealthforasthmaself-management
TheexperiencesofindividualswithasthmaofusingmHealthvariedconsiderably,withsome
participantsreportingnoexperienceofusingmHealthfortheirasthmaandafewparticipants
reportingconsiderableexperiencewithmultipledevices.Healthcareprofessionals’
experienceswithmHealthsystemswerelimitedtotheiruseduringresearchprojects.The
typesofmHealthsystemsthatparticipantshadexperiencewitharepresentedintable2.
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Table2.Emergentthemesidentifiedinfocusgroupswithpeoplewithasthma(n=18)andhealthcareprofessionals(n=5)integratedundercorecategories Emergentthemes
Corecategory1 ExperienceofmHealth Experiencewithapplicationsfor:nutritionanalysis,inhaler(medication)monitoring,activitylevelmonitoring,
lungfunction(peakflow)monitoring,mentalhealth,environmentalmonitoring(e.g.,pollutionandpollen),andasthmadiary.
PotentialusesofmHealth
Replacecheck-ups,advisewhentoseekmedicalattention,monitorasthmaovertime,collectdatatopresenttohealthcareteam,alertstodeteriorationinasthmacontrol,useasanasthmaactionplan,provideeducationmaterials,instructionsonhowtomanageanasthmaattack,asystemtocallforemergencyhelp,asystemtoupdatemedicalrecords,asystemtorecordside-effectsandasystemtodeterminemedicationeffectiveness.
Corecategory2 Usefulmeasurements Environmentconditions(e.g.,pollution,allergens(pollen),temp),lungfunction(e.g.,peakflowandmeasurements
ofairwayinflammation),breathing(e.g.,breathingrateanddetailsofhowoftenyoucough),heartrateandactivitylevels,stresslevel,medicationadherence,inhalertechnique,diet,qualityofsleep,self-reportedsymptoms.
Usefulalerts Medicationrunninglow,usingtheirmedicationtoomuch,theyhavenottakentheirinhaler,theyareusingtheirinhalerincorrectly,lungfunctionisgettingworse,pollutionlevelintheirareaishigh,pollen/allergenlevelsintheirareaarehigh,temperature/humidityintheirareaishigh/low
Corecategory3 Acceptabilityandbarriers
Usability,productdesign,privacy,time,personalisability,humancontact,datausefulness(e.g.,reliability,interpretationandsubjectivity),cost,mobilecompatibility,medicationcompatibility.
10
FocusgroupparticipantsidentifiedtwelvepotentialusesofmHealthsystemsforasthmaself-
management(table2).Theseproposedusesweredevelopedintoanitemoneach
questionnairerelatingto:i)functionsindividualswithasthmawouldlikefrommHealth;and
ii)functionsthathealthcareprofessionalsbelievedwouldbeuseful(table3).
PatientsmostfrequentlyrequestedanmHealthsystemtomonitorasthmaovertime(72%)
andtocollectdatatopresenttohealthcareteams(70%),table3.Thismayrelatetodifficulties
thatpatientshaverecallingsymptomsandconveyingthesetotheirhealthcareteams,as
illustratedbyquote1.1(table4).Discussionswithhealthcareprofessionalsrevealedthatifa
patientpresentedthemwithdataonanmHealthsystemthattheywouldfindthisusefuland
onehealthcareprofessionalsuggestedthatitmightempowertheirpatients,quote1.2(table
4).
Functionsalertingpatientstodeterioratingasthmacontrol(86%)andadvisingwhentoseek
medicalattention(87%)weremostfrequentlyselectedbyhealthcareprofessionals(table3).
FocusgroupdatahighlightedthatmHealthcouldpromptpatientstoseekmedicalattention
sooner,quote1.3(table4).Supportforthesefunctionsamongstindividualswithasthmawas
alsohigh(table3)andcommentsinthefocusgroupdiscussionswerebroadlyalignedwith
thoseofthehealthcareprofessionals,quotes1.4and1.5(table4).
Arecurringthemeinthefocusgroupdiscussionswasthepotentialtoincorporateasthma
actionplansintomHealth.ThepreferenceofmHealthoverthetraditional‘penandpaper’
approachmaybelinkedtotheincreasedconvenience/accessibilityofmHealth,quote1.6
(table4).Inthequestionnaires,46%ofpatientsand79%ofhealthcareprofessionals
(P<0.001)answeredthattheywouldlikeorfinditusefultohaveanasthmaactionplan
incorporatedintoamHealthsystem.Thereasonbehindthegreatersupportfromhealthcare
professionalswasnotapparentinthefocusgroupdiscussions.
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SomeoftheproposedusesformHealthsystemsthatoriginatedinthefocusgroupdiscussions
receivedlesssupportfromthequestionnaires.Inthefocusgroupsseveralpatientsvoiced
frustrationsaboutattendingroutineasthmacheck-upsandproposedmHealthasapossible
replacement,quote1.7.However,inthesurveysonly25%ofpatientsand33%ofhealthcare
professionalsindicatedthattheywouldlikeorfinditusefulforamHealthsystemtoreplace
routineasthmacheck-ups.
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Table3.Questionnaireresults:whatindividualswithasthmawouldlikefromamHealthsystemandwhathealthcareprofessionalsbelieve
wouldbeusefulfunctions
Responseoptions Asthma
(%)
HCPs
(%)
P Asthma P
Uncontrolled
(%)
Controlled
(%)
Adevice/systemthatcouldreplaceroutine(e.g.,annual)asthmacheck-ups 25 33 0.21 12 40 <0.001
Adevice/systemthatoffersadviceregardingwhenadditionalmedicalattentionshouldbesought
49 87 <0.001 56 44 0.12
Adevice/systemtohelppatientsmonitortheirasthmaovertime 72 81 0.14 77 66 0.12Adevice/systemtocollectdatathatpatientscanshowtheirdoctor/healthcareprofessional,todemonstratehowtheirasthmahasbeen
70 78 0.30 71 67 0.57
Adevice/systemthatdetectsandalertspatientsand/orhealthcareprofessionalstoadeteriorationintheirasthmacontrolbeforetheywouldnormallynotice
69 86 0.01 75 64 0.18
Adevice/systemforpatientstouseastheirasthmaactionplan 46 79 <0.001 53 40 0.08Adevice/systemtooffereducationalmaterialsaboutasthma 22 73 <0.001 25 17 0.21Adevice/systemthatprovidesinstructionsonhowtomanagetheirasthmainanemergency
45 81 <0.001 47 44 0.68
Adevice/systemthatcanbeusedtocallforemergencyhelpduringanasthmaattack
49 52 0.69 52 49 0.71
Adevice/systemthatcantakemeasurementsandupdateapatient’smedicalrecord
53 51 0.80 56 49 0.34
Adevice/systemtorecordtreatmentside-effects 44 37 0.29 46 44 0.79Adevice/systemthatcantellifchangestopatient’sasthmamedicationhasimprovedtheirasthmacontrol
36 76 <0.001 45 28 0.02
Asthma,peoplewithasthma(n=186);HCPs,healthcareprofessionals(n=63);Uncontrolled,individualswithanasthmacontrolquestionnaire
(ACQ)score≥1.5(n=91);Controlled,individualswithACQscore<1.5(n=86).
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Table4.SelectionofsupportingquotesQuoteNo Selectedquotes Corecategory1
1.1 “Itwouldbehandyhavinganappsothatyoucanmonitor(asthma)yourself…toshowyourconsultantandrespiratorynurseexactlyhowyourasthmahasbeen…becauseoftenwhentheyaskyoucan’tremember”.[Patient#7,London]
1.2 “It'saverypowerfultooltobeabletoshow(patients)thedataandsaythisiswhatishappening…ratherthanjustsayingyou'vegottokeeptakingyourmedication...youareempoweringthemwiththeirtreatment”.[HCP#3]
1.3 “Alittlebitofaprompttosaythatattheselevelsmaybeyoushouldbeseekingmedicalattention,thiswouldbehelpfulbecausethentheymayattendtheaccidentandemergencydepartmentalittlebitsooner”.[HCP#2]
1.4 “ThingssometimesgetworseandIdon’tnecessarilynoticethemand,therefore,Iletthemgetworse.ItwouldbeniceifIcouldmonitoritandseetrendsindifferentthingsandaddressthem”[Patient#4,London]
1.5 “Ihavehadthatmoment,whereyouthinkatwhatpointdoIcallanambulance...Iwouldliketobeabletohitabuttonanditsaysthisiswhatyoushouldbedoing”[Patient#3,London]
1.6 “Ifyoucouldhaveyourasthmacheck-upandpluginyourasthmaactionplanvaluesintosomething...that’samuchbetterwayofhelpingpeoplestayincontrolthanapieceofpaper,thatwhentheycomebackfromthedoctorstheyputdownanddon'ttouchagainuntilthenextasthmacheck”[Patient#3,Manchester]
1.7 “Ireallydislikegoingtomyasthmacheck-upwhenIamprettysureitisfairlywellcontrolledanyway….IgoandtheytellmewhatIalreadyknow…itwouldbeniceifadevicecouldfeedbacktothenurseandtheycouldletmeknowwhenIshouldgetacheck-up”.[Patient#2,London]
Corecategory22.1 “MypeakflowtendstogodownandthenIgetworse…evenifIdon’tfeelbad,mypeakflowwillbelowerthanitshouldbe”[Patient#7,London]2.2 “Onthewrittenasthmaactionplans,itsaysifmypeakflowdropsbelow‘X’thenIshoulddothiswithmymedication...soitisusefulforthat”[Patient#3,
London]2.3 “Ifit’sgoingtobeahighpollencount,Iwillarrangetogooutintheeveningorveryearlyinthemorningandavoidthatpartoftheday...airqualityis
somethingthat’sabitmoredifficulttoavoid,butit’susefultoknowandmayinfluencewhetherIgoforaruntodayorwhetherIwaituntiltomorrow”[Patient#4,Manchester]
2.4 “TheamountoftimesIrushthroughit[takingmyinhaler]…Idon’tfeellikeIamgettingthebenefitfromit”[Patient#4,London]2.5 “Patientsareonstepfourorfivetreatmentbutcan'ttakeaninhalercorrectly…itisfrighteningthattheyarebeingreferredtousformoreinvasive
treatments”[HCP#1] Corecategory3
3.1 “Notalloftheasthmaticpatientshavethesamesymptoms…Ithinkyouneedtoindividualisethesymptomsandwhatismeasuredtoeverypatientseparately”[HCP#5]
3.2 “Idon’twanttomeasureallthosethings…ifitisoneormaybetwothingsImight,orifyoucouldpersonaliseittowhatisrelevanttoyou,butI’mnotgoingtomeasureallofthosethings”[Patient#2,London]
3.3 “Ifitisautomaticallyonyourinhaleranditmeasuresandgivesyoufeedback,perfect…ifIhavetogetaseparatedeviceouttomeasureit,thenIwouldprobablyuseitless”[Patient#7,Leiden]
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3.4 “Ijustdon’tlikesubjectivequestions.Idon’trememberhowbad‘bad’waslasttimeIselectedbad”[Patient#2,London]3.5 “Ifsomethingiswearableanddiscreet,Iwoulddefinitelygoforsomethinglikethat.Ifitisbulkyandveryvisible,thenmaybenot”[Patient#4,London]HCP,healthcareprofessional
15
Corecategory2:Usefulmeasurementsformanagingasthma
Thefocusgroupdiscussionshighlightedmanymeasurementsthatparticipantsbelievedcould
providesupportfortheself-managementofasthma(table2);theseweredevelopedinto
itemsonthequestionnaires(table5).
Lungfunctionmeasurements(71%)werecommonlyidentifiedasbeinghelpfultomaintain
asthmacontrol(tables5).Thiswaslinkedwithpatients’perceptionofaconnectionbetween
asthmacontrolandlungfunctionandwhentotakeappropriateaction,quotes2.1&2.2(table
4).Additionalphysiologicalparametersidentifiedasbeingusefulforasthmacontrolincluded:
restingheartrate,breathingrate,stresslevels,sleepqualityanddiet.Thesemeasurements
weregivenvarying,butusuallymodest,supportfromthequestionnairedata(table5).
Measurementsregardingenvironmentalconditionswerebelievedtobehelpfulforasthma
self-managementby71%ofindividualswithasthmaand68%ofhealthcareprofessionals
(table5).Focusgroupdatasuggestthatenvironmentalalertsmayaffectindividuals’
behaviours,quote2.3(table4).
Bothindividualswithasthmaandhealthcareprofessionalsidentifiedthenegativeimpactof
incorrectinhalertechniqueandprovidedsupportfortheirintegrationintomHealth,quotes
2.4&2.5(table4).However,surveydatahighlightedanotablecontrastintheresults,witha
significantlyhigherproportionofhealthcareprofessionalscomparedwithpatientsbelieving
measuringinhalertechnique(87%vs.43%,P<0.001)andmedicationadherence(89%,vs.
48%,P<0.001)wouldbehelpfulforasthmacontrol.
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Table5.Questionnaireresults:Whichofthefollowingmeasurementsdoyouthinkcouldhelpyou/yourpatientsachievebetterasthmacontrol?
Responseoptions Asthma(%)
HCPs(%)
P Asthma PUncontrolled
(%)Controlled
(%)Measurementsofenvironmentconditions(e.g.,pollution,allergens,
temperatureandhumidity)70 68 0.81 75 65 0.16
Measurementsoflungfunction(e.g.,peakflowandmeasurementsof
airwayinflammation)71 75 0.58 71 70 0.82
Measurementsofbreathing(e.g.,breathingrateanddetailsofhow
oftenyoucough)64 60 0.60 68 60 0.29
Measurementsofheartrateandactivitylevels 46 37 0.18 49 43 0.39
Measurementsofstresslevels 53 37 0.03 57 49 0.27
Measurementsofmedicationadherence 48 89 <0.001 52 44 0.32
Measurementsofinhalertechnique 42 87 <0.001 43 43 0.98
Measurementsofdiet 32 32 0.94 36 24 0.09
Measurementsofqualityofsleep 54 44 0.20 58 48 0.16
Measurementsofself-reportedsymptoms 34 57 <0.001 40 30 0.19
Asthma,peoplewithasthma(n=186);HCPs,healthcareprofessionals(n=63);Uncontrolled,individualswithanasthmacontrolquestionnaire(ACQ)score≥1.5(n=91);Controlled,individualswithACQscore<1.5(n=86).
17
Corecategory3:AcceptabilityofandbarrierstousingmHealthsystemsforasthmaself-
management
Table2summarisesperspectivesontheacceptabilityofandbarrierstotheuseofmHealth
systems.TheabilitytopersonalisemHealthsystemswasaconsistentsubcategoryacrossall
focusgroups.Discussionshighlightedthatdifferentpopulations,e.g.,children,theelderlyand
peoplewithdifferingasthmaseverity,havedifferentuser-requirements.Furthermore,itwas
proposedthatmHealthsystemsmayneedtobepersonalisedatanindividuallevel,quote3.1
(table4).Oneparticipantwithasthmasuggestedthatmeasuringnumerous‘irrelevant’
parametersmightdiscouragetheircompliancewithmHealth,quote3.2(table4).Similarly,
patientshighlightedthatiftheburdenofinputtingdatawastoomuchthentheywouldnotbe
willingtocomplywiththedeviceandemphasisedthatmHealthshouldbeasautomatedas
possible,quote3.3(table4).
Thetopicofdatausefulnesswascommonacrossallfocusgroupsandincludedcomments
regardingthereliabilityofdata,datasubjectivityandtheinterpretationofdata.Individuals
withasthmahighlightedconcernswithsubjectivemeasurements,suchasself-reported
symptoms,quote3.4(table4).Theinterpretationofthedata,eitherbyautomatedsystemsor
bytheindividualsthemselves,washighlightedasasourceofpossibleerrorandanimportant
consideration.Consequently,only12%ofpatientsrespondingtothequestionnaireindicated
thattheywouldacceptallrecommendationstochangetheirmedicationbasedonfeedback
frommHealth.Thisvalueincreasedto30%ifdatasupportingtherecommendationwasalso
presentedtothepatientandto41%ifthepatient’sdoctorendorsedthemHealthsystem.
Similarly,only21%ofhealthcareprofessionalswouldbecomfortablefortheirpatientsto
changetheirmedicationbasedonmHealthfeedback.Thisvalueincreasedto46%ifthe
healthcareprofessionalcouldseepatientdataandapprovethechanges.Furthermore,22%of
18
healthcareprofessionalswouldliketoseethepatientinpersonbeforetheyrecommended
anychangestotheirmedication.
Datasecurityanddatausewasacommonthemeacrossfocusgroups.Patientsexpressed
opposingviewswithregardstodatasecurity,withsomepatientsunconcernedwithhowtheir
datawasmanagedandsomeinsistentthatdatasecurityisofupmostimportance.Participants
ofthefocusgroupsexpressedunanimoussupportfortheirdatatobeusedinananonymous
formatforresearchpurposes,whilstquestionnaireresultssuggestjustoverhalf(58%)of
patientswerehappyforanonymousdatatobeusedforresearchpurposes.
Physicalpropertiesrelatingtoproductdesignandcompatibilitywerediscussedasimportant
considerationsformHealth.Questionnaireanalysisrevealedthat76%ofindividualswith
asthmawouldbewillingtocarryorwearatleastoneadditionaldeviceand72%wouldbe
willingtokeepanadditionaldeviceathome.However,discussionsinthefocusgroups
indicatethatthismightdependontheproductdesign,quote3.5(table4).
19
DISCUSSION
TheeraofmHealthoffershugepotentialtoenhanceconventionalhealthcare.Asthmaisan
idealcandidateconditionformHealthdevelopments,beingalong-termconditionthat
requirescontinuousattentionfrombothhealthcareprofessionalsandpatients.IfmHealth
systemsaretobeutilisedinroutinepractice,theywouldneedtobeembracedbybothend-
users.Thisisthefirststudytocomprehensivelyexplorepatients’andhealthcare
professionals’perspectivesontheuseofmHealthfortheself-managementofasthma.There
weresignificantdifferencesinopinionswithregardstoexpectationsbetweenhealthcare
professionalsandpatients,howeverbothend-usersprovidesubstantialsupportformHealth
forasthmaself-management.
Allpeoplewithasthmashouldreceiveapersonalasthmaactionplan,aspartoftheirasthma
self-managementstrategy[7,8].However,onlyaroundaquarterofindividualswithasthma
receivesuchaplan[2,11].Ourfindingssuggestthatalargeproportionofhealthcare
professionalsbelievethatincorporatingapersonalasthmaactionplanintoamHealthsystem
wouldbeausefulfunction.Thissentimentwascommonlysharedbyindividualswithasthma
andvividlyportrayedinthequalitativedata,withoneparticipantrecallingthefeelingof
distressandindecisionabouthowtotreattheirasthmaandatwhatpointtoseekemergency
attention.Neitherpatientsnorhealthcareprofessionalsareenthusiasticaboutusingwritten
asthmaactionplans[9]andourdatasuggesttheconvenienceofmHealthmakesitan
appealingalternative.
Anaccurateinitialassessmentandon-goingreviewofpatients’asthmaseverityandcontrolis
crucialfortheappropriatemanagementofthedisease[2].Ourdatasuggestthatpeoplefindit
difficulttoexpressasthmaseverityandcontroltotheirhealthcareteams,andindeeditis
knownthatpatientsoftenunderestimatetheirasthmaseverity[22,23].Suchdiscrepancies
betweenperceptionandobjectiveasthmaseveritycouldhavedrasticconsequencesinthe
20
managementofthedisease.TheUKNationalReviewofAsthmaDeaths(NRAD)suggeststhat
poorrecognitionofasthmaseveritybypatientsandtheirhealthcareteams,andsubsequent
long-termunder-treatment,areavoidablefactorsrelatedtoasthmadeaths[2].Oneproposed
useofmHealththatwaswellsupportedbybothend-users,wasasystemthatcollectsdata
overtime,toassistpatientsindemonstratingtheirasthmacontrol/severitytotheir
healthcareteams.Theselectionofwhichparameterswouldbeusefulforthispurposemerits
carefulconsideration.
Weidentifiedavarietyofphysiological,environmentalandbehaviouralmeasurementsthat
individualswithasthmaandhealthcareprofessionalsbelievecouldsupportasthmaself-
management.Individualswithasthmamostcommonlyrespondedthatmeasurementsoflung
functionwouldbeusefulformaintainingasthmacontrol.Thesuccessoftraditionalasthma
self-managementprograms,relyingonregularpeakflowmeasurements[5],wouldsupport
theirbelief.Otherphysiologicalparametersthatwereidentifiedasbeingusefulincluded
measurementsofheartrate,respiratoryrateandsleepquality.Giventhatheartrate
variabilitymaybeassociatedwithasthmacontrol[24],thatrespiratoryratevariabilityduring
sleepmaydifferbetweenindividualswithandwithoutasthma[25],andthatnocturnal
wakeningisacommoncomplaintofindividualswithasthma,thepotentialforthese
measurementstoprovidesupportforasthmaself-managementwarrantsfurther
investigation.
Eachyear5.5milliondeathscanbeattributedtopoorairquality[26],whilstairpollution
exposureisassociatedwithincreasedfrequencyofasthmaattacksinchildrenandadults[27].
Alargeproportionofindividualswithasthmaandhealthcareprofessionalsrespondingtoour
surveybelievemeasurementsofenvironmentalconditionscouldhelpachievebetterasthma
controlandshouldbeincorporatedintomHealth.
Asthmaisnolongerseenasasingledisease,butasyndromewithheterogeneouspresentation
21
andnumerousphenotypesandendotypes[28].Participantsidentifiedthatthecomplexand
heterogeneousnatureofasthmameansthatindividualswillhavedifferingrequirementsfrom
mHealth.Whilstitisunrealistictoexpecthealthcareprofessionalstobetrainedintheuseof
multipledifferentmHealthsystems,itwasproposedbyourparticipantsthatpatientsand
theirhealthcareteamsshouldbeabletocustomiseapanelofrelevantfunctionsand
parametersforeachpatient.ThisposesacomplexandchallengingproblemformHealth
developers,whoshouldworkinclosepartnershipwitharangeofpatients,withdifferent
levelsofasthmacontrol,andwithhealthcareprofessionalstoensureallend-user
requirementsaremet.
SharpcontrastswerenotedinthesupportforsomemHealthfunctionsbetweenpatientsand
healthcareprofessionals.Intriguingly,thefunctionsthatreceivedlesssupportfrompatients
appeartorelatetoaspectsthatpatientsmaybeinherentlyawareofandthereforeseenoneed
formHealthfeedback;e.g.,measurementsofmedicationadherence,inhalertechniqueand
self-reportedsymptoms.Onthecontrary,thewell-supportedfunctionsrelatetoaspects
wherebythepatientwouldbesomewhatblindtotheinformationwithoutsuchfeedbacke.g.,
environmentalandlungfunctionmeasurements.Itwouldseemareasonableinterpretation
thatpatientsadvocatefunctionsthatrelatetoacquiringinformationthatwouldotherwisebe
unknowntothem,notsimplymonitoringparametersthattheycouldalreadybeawareof.In
contrast,functionsthatinclude‘bigbrother’monitoringofpatients,suchasmedication
adherenceandinhalertechnique,werewellsupportedbyhealthcareprofessionals.Thisis
reasonablegiventhathealthcareprofessionalsneedtoknowthatmedicationhasbeentaken
asprescribedinordertoassesstreatmentefficacy,andadherencetotreatmentisknowntobe
variable[29].
Thisresearchbenefitsfromamixedmethodsdesign,permittingthemesidentifiedinthefocus
groupstobequantifiedinthesurveyandintegratedintheanalysistoacquirea
22
comprehensiveunderstandingoftheperspectivesofpatientsandhealthcareprofessionalson
mHealthforasthmaself-management,However,severalmethodologicallimitationsdeserve
consideration.Participants’responsestothequestionnairesweregivenequalweightinginthe
analysis.Thismethodfailstotakeintoaccountthestrengthoftheiropinions.Thisstudymay
thereforehavebenefittedfromtheabilityforparticipantstoranktheirresponsesinorderof
preference.Thisstudymayhavealsobenefitedfromanotherroundoffocusgroup
discussions,toprobefurtherintotheresultsfromthequestionnaire.Themajorityofthe
participantsinthesurveylikelycamefromthosewhovisitAsthmaUK’swebsiteorfollow
AsthmaUKsocialmediachannelsand,therefore,arelikelytobemoreactiveandwell-
educatedinthemanagementoftheirasthma.Thepossibilityofselectionbiasshould
thereforebeconsideredduringtheinterpretationoftheresults.
Inconclusion,asthmaisanidealcandidateformHealthdevelopmentsandrecenttimeshave
seenameteoric,butratherhaphazardandoftenill-informed[30]riseinmHealthsystemsfor
asthmaself-management.Auser-centreddesignofmHealthisintegralfortechnologytomeet
end-users’expectationsandmayimproveadherenceandhealthoutcomes.Thisresearch
providesoverwhelmingsupportformHealthtoassistasthmaself-management,byboth
individualswithasthmaandhealthcareprofessionals,buthighlightsfundamentaldifferences
inpreferredfunctionsbetweenthedifferentend-usersandidentifiednumerousfactorsthat
wouldneedconsiderationduringthedevelopmentofnewmHealthdevices.Developersof
newmHealthsystemsshouldconsidertheseopinionsduringthedevelopmentofnewuser-
centredmHealthsystemstoaidtheself-managementofasthma.
23
ACKNOWLEDGEMENTS
Credits
WewouldliketothankJokeDeVochtforhersupportinorganisingthepatientadvisorygroup
andreviewingthefocusgrouptopicguides.Wewouldalsoliketothankthemembersofthe
patientadvisorygroupfortheirvaluableinsightandguidanceindevelopingthetopicguides.
Financialcontribution
ThisprojecthasreceivedfundingfromtheEuropeanUnion’sHorizon2020Framework
ProgrammeforResearchandInnovationundergrantagreementNo643607.Thefunderhad
noinputinthestudydesign;inthecollection,analysis,andinterpretationofdata;inthe
writingofthereport;andinthedecisiontosubmitthearticleforpublication.
Sponsor
TheUniversityHospitalofSouthManchesterNHSTrustsponsoredthisstudy.Thesponsor
hadnoinputinthestudydesign;inthecollection,analysis,andinterpretationofdata;inthe
writingofthereport;andinthedecisiontosubmitthearticleforpublication.
Competinginterests AllauthorshavecompletedtheICMJEuniformdisclosureform
atwww.icmje.org/coi_disclosure.pdf(availableonrequestfromthecorrespondingauthor)
AS,PH,EK,JS-S,IS,JE,AC,CCandSF,havenoconflictinginterests,financialorotherwise;
OUreportsgrantsfromAstraZeneca,Chiesi,GlaxoSmithKlineandEdmondPharmaand
personalfeesfromBoehringerIngelheim,Chiesi,Aerocrine,Napp,Mundipharma,Sandoz,
Takeda,ZentivaandCipla,outsidethesubmittedwork;JSreportsgrantsfrom
GlaxoSmithKlineNLandChiesiNL,outsidethesubmittedwork;KCreportsgrantsfromPfizer,
GSK,MRC,EUIMIandNIHandpersonalfeesfromGSK,AstraZeneca,Novartis,Teva,
BoehringerIngelheim,J&JandMerck,outsideoftheworksubmitted.
Detailsofcontributors
AS(guarantor),PH,EK,CC,KC,JS,OUandSFwereresponsiblefortheconceptionanddesign
oftheresearch;AS,EK,JS-S,ISandJEplannedandconductedthefocusgroups;AS,JE,EKand
SFproducedthequestionnaire;ASandSFanalysedresults;AS,SFandACinterpretedthe
results;ASdraftedthemanuscript;AS,PH,EK,JS-S,IS,JE,CC,AC,KC,JS,OUandSFeditedand
24
revisedthemanuscript;AS,PH,EK,JS-S,IS,JE,CC,AC,KC,JS,OUandSFapprovedthefinal
versionofthemanuscript.
Transparencydeclaration
AShadfullaccesstoallthedatainthestudyandtakesresponsibilityfortheintegrityofthe
dataandtheaccuracyofthedataanalysis.ASaffirmsthatthemanuscriptisanhonest,
accurate,andtransparentaccountofthestudybeingreported;thatnoimportantaspectsof
thestudyhavebeenomitted;andthatanydiscrepanciesfromthestudyasplannedhavebeen
explained.
25
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