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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

Link to publication record in Manchester Research Explorer

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,ManchesterM239LTAndrew.Simpson-2@manchester.ac.uk

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.

3

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

4

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.

5

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.

6

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

7

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.

8

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.

9

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.

11

SomeoftheproposedusesformHealthsystemsthatoriginatedinthefocusgroupdiscussions

receivedlesssupportfromthequestionnaires.Inthefocusgroupsseveralpatientsvoiced

frustrationsaboutattendingroutineasthmacheck-upsandproposedmHealthasapossible

replacement,quote1.7.However,inthesurveysonly25%ofpatientsand33%ofhealthcare

professionalsindicatedthattheywouldlikeorfinditusefulforamHealthsystemtoreplace

routineasthmacheck-ups.

12

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).

13

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]

14

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.

16

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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