interactive applications for patient education and behaviour change in asthma
DESCRIPTION
Interactive applications for patient education and behaviour change in asthma. Introduction to Medicine Class 16 2006-2007. Summary. Introduction Aim Methods Study Design Definition of population Clinical outcomes evaluated Search strategy – Query Inclusion/Exclusion criteria Results - PowerPoint PPT PresentationTRANSCRIPT
Interactive applications Interactive applications for patient education for patient education and behaviour change and behaviour change
in asthmain asthma
Introduction to Introduction to MedicineMedicineClass 16 2006-2007Class 16 2006-2007
SummarySummary IntroductionIntroduction
AimAim MethodsMethods
Study DesignStudy Design Definition of populationDefinition of population Clinical outcomes evaluatedClinical outcomes evaluated Search strategy – QuerySearch strategy – Query Inclusion/Exclusion criteriaInclusion/Exclusion criteria
ResultsResults DiscussionDiscussion Limitations of our studyLimitations of our study ConclusionConclusion Gantt ChartGantt Chart Site MapSite Map
IntroductionIntroduction
IntroductionIntroductionASTHMAASTHMA chronic disease chronic disease recurrent breathlessness and recurrent breathlessness and
wheezingwheezing high prevalence all over the worldhigh prevalence all over the world undesired clinical outcomesundesired clinical outcomes
treatment strategiestreatment strategies improve asthma outcomesimprove asthma outcomes
World Health Organisation (WHO)World Health Organisation (WHO)Gina Report: Global Strategy for Asthma Management Gina Report: Global Strategy for Asthma Management
and Preventionand Prevention
IntroductionIntroduction• StrategiesStrategies : : acquire self-efficacy and acquire self-efficacy and informationinformation
• Patient education with interactive applicationPatient education with interactive application
• Interactive applications (IA) - computer-based, usually web-based, information packages for patients combine health information, social support decision, or behaviour change
Guevara J.P., BMJ. 2003Guevara J.P., BMJ. 2003Clark NM, BMJ. 2000Clark NM, BMJ. 2000
Murray E., CDSR 2005Murray E., CDSR 2005
• Overcome difficulties
Introduction - AimIntroduction - Aim
• To summarize the results from published studies about the use of interactive applications for education of children and/or adults with asthma;
• Research Question: Are clinical outcomes achieved with
the use of interactive applications better than with usual care?
MethodsMethods
Study DesignStudy Design
Systematic Review:Systematic Review:
Combine the available Combine the available evidence from published evidence from published studies to draw more reliable studies to draw more reliable and generalised conclusions.and generalised conclusions.
Definition of the Definition of the PopulationPopulation
Articles indexed in MedLine inclusively, Articles indexed in MedLine inclusively, identified through a identified through a sensitivy query sensitivy query related to the use of IA in asthma carerelated to the use of IA in asthma care
VariablesVariables
Number of people with outcomesNumber of people with outcomes
Clinical outcomes Clinical outcomes evaluatedevaluated
Score of quality of lifeScore of quality of life Lung functionsLung functions Frequency of symptoms Frequency of symptoms Hospital admitionsHospital admitions Absenteeism to work/schoolAbsenteeism to work/school Emergency room visitsEmergency room visits Asthma knowledgeAsthma knowledge Self-managementSelf-management MedicationMedication Physician consultationPhysician consultation
Search Strategy - QuerySearch Strategy - Query
AND ((interactive[All Fields] AND ("communication"[MeSH Terms] OR AND ((interactive[All Fields] AND ("communication"[MeSH Terms] OR communication[Text Word]) AND applications[All Fields]) OR computerized[All Fields] communication[Text Word]) AND applications[All Fields]) OR computerized[All Fields] OR (telemedicine[MeSH Terms] OR telemedicine[Text Word]) OR (("computers"[TIAB] OR (telemedicine[MeSH Terms] OR telemedicine[Text Word]) OR (("computers"[TIAB] NOT Medline[SB]) OR "computers"[MeSH Terms] OR computer[Text Word]) OR NOT Medline[SB]) OR "computers"[MeSH Terms] OR computer[Text Word]) OR ("internet"[MeSH Terms] OR internet[All Fields]) OR ("software"[MeSH Terms] OR ("internet"[MeSH Terms] OR internet[All Fields]) OR ("software"[MeSH Terms] OR software[Text Word]) OR ("multimedia"[MeSH Terms] OR multimedia[Text Word]) OR software[Text Word]) OR ("multimedia"[MeSH Terms] OR multimedia[Text Word]) OR ("hypermedia"[MeSH Terms] OR hypermedia[Text Word]) OR (www[All Fields] OR ("hypermedia"[MeSH Terms] OR hypermedia[Text Word]) OR (www[All Fields] OR web[All Fields] OR online[All Fields]) OR e-health[All Fields] OR video[All Fields] OR web[All Fields] OR online[All Fields]) OR e-health[All Fields] OR video[All Fields] OR digital[All Fields] OR ("television"[MeSH Terms] OR television[Text Word]) OR digital[All Fields] OR ("television"[MeSH Terms] OR television[Text Word]) OR video[All Fields] OR audio[All Fields])video[All Fields] OR audio[All Fields])
(("asthma"[MeSH Terms] OR asthma[Text Word]))(("asthma"[MeSH Terms] OR asthma[Text Word]))
AND ((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical trials[MeSH Terms] AND ((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical trials[MeSH Terms] OR clinical trial[Publication Type] OR random*[Title/Abstract] OR random OR clinical trial[Publication Type] OR random*[Title/Abstract] OR random allocation[MeSH Terms] OR therapeutic use[MeSH Subheading])allocation[MeSH Terms] OR therapeutic use[MeSH Subheading])
AND ((("patient education"[MeSH Terms] OR patient education[Text Word]) OR AND ((("patient education"[MeSH Terms] OR patient education[Text Word]) OR (educational[All Fields] AND interventions[All Fields]) OR (psycho-educational[All (educational[All Fields] AND interventions[All Fields]) OR (psycho-educational[All Fields] AND interventions[All Fields]) OR ("self care"[TIAB] NOT Medline[SB]) OR Fields] AND interventions[All Fields]) OR ("self care"[TIAB] NOT Medline[SB]) OR "self care"[MeSH Terms] OR self management[Text Word]) OR prevention[Text Word]) "self care"[MeSH Terms] OR self management[Text Word]) OR prevention[Text Word]) OR (behavioral[All Fields] AND change[All Fields])OR (behavioral[All Fields] AND change[All Fields])
Inclusion CriteriaInclusion Criteria
Controled studies that evaluate the Controled studies that evaluate the eficacy of interactive aplication for eficacy of interactive aplication for asthma pacient educationasthma pacient education
Exclusion CriteriaExclusion Criteria
Articles that were not in English, Articles that were not in English, Portuguese and Spanish.Portuguese and Spanish.
Non-access to the Non-access to the full text of the full text of the articles after : Library Search, Web articles after : Library Search, Web search, contact withauthor and field search, contact withauthor and field experts;experts;
General description of methodsGeneral description of methods
We formulated a query and conducted an We formulated a query and conducted an exhaustive search in PubMed;exhaustive search in PubMed;
The articles were distributed by groups of two The articles were distributed by groups of two people;people;
The title and abstract of articles were read and The title and abstract of articles were read and it were applied the inclusion and exclusion it were applied the inclusion and exclusion criteria in order to exclude or non-exclude it;criteria in order to exclude or non-exclude it;
If the two elements of the group did not reach a If the two elements of the group did not reach a consensus, the article is evaluated by a third consensus, the article is evaluated by a third element;element;
General description of methodsGeneral description of methods
In a second step the full articles In a second step the full articles were were distributed by groups of two people;distributed by groups of two people;
Full text of articles were read and the Full text of articles were read and the inclusion and exclusion criteria were inclusion and exclusion criteria were applied;applied;
In cases that the two elements of the In cases that the two elements of the group did not reach a consensus the group did not reach a consensus the article was evaluated by a third element;article was evaluated by a third element;
Analysing Full TextsAnalysing Full Texts
Which clinical outcomes were evaluated?Which clinical outcomes were evaluated? What was the method of evaluation of the What was the method of evaluation of the
outcomes?outcomes? How long was the intervention?How long was the intervention? What and how was the intervention?What and how was the intervention? Which results were obtained?Which results were obtained? What is the main message of the article?What is the main message of the article?
General description of methodsGeneral description of methods
We extracted the data from the We extracted the data from the selected articles and inserted it on selected articles and inserted it on SPSS;SPSS;
We conducted a data analysis;We conducted a data analysis; We interpreted and discussed our We interpreted and discussed our
results;results;
ResultsResults
Selection of participantsSelection of participants
Selected Articlesn = 586
(in PubMed search)
Article’s revision by Title and/or Abstract
Excluded Articles: n = 14
Reasons for exclusion:
Full text not available: n = 10Articles not primarily about asthma: n = 1Articles not related to Interactive Applications: n = 1Not controlled Studies: n = 1Articles that did not evaluate the efficacy of the method: n = 1
Revision of the remaining Articles by
full text(n = 27)
Articles Included in the Systematic
Reviewn = 13
Excluded Articles: n = 559
Reasons for exclusion:
Articles not primarily about asthma: n = 502Articles not about children/adults: n = 3Not controlled Studies: n = 11Articles not related to Interactive Applications: n = 41Reviews: n = 2
Included Vs Excluded ArticlesIncluded Vs Excluded Articles
AddAdd
Frequency Frequency Percent Percent
Valid Valid Excluded Excluded
Opponent Opponent
Included Included
Total Total
557557
22
27 27
586 586
95,1 95,1
0,3 0,3
4,64,6
100,0 100,0
Lesser exclusion motiveLesser exclusion motive
FrequencyFrequency PercentPercent
Isn´t primarily about asthmaIsn´t primarily about asthma 502502 85,785,7
Isn't about children/adultsIsn't about children/adults 33 ,5,5
Isn´t a controlled studyIsn´t a controlled study 1111 1,91,9
Isn''t about interactive Isn''t about interactive applicationsapplications
4141 7,07,0
Is a reviewIs a review 22 ,3,3
TotalTotal 559559 95,495,4
Missing Missing SystemSystem 2727 4,64,6
Total Total 586586 100,0100,0
Agreement between evaluatorsAgreement between evaluators
Reviewer1 * Reviewer2Reviewer1 * Reviewer2
CrosstabulationCrosstabulation
Count Count
Symmetric MeasureSymmetric Measure
a. Not assuming the null hypothesis.a. Not assuming the null hypothesis.
b. Using the asymptotic standard error assuming the null hypothesis.b. Using the asymptotic standard error assuming the null hypothesis.
ValueValue Asymp.Asymp.
Std. Std. ErrorErroraa
Approx. TApprox. Tbb Approx. Approx. Sig.Sig.
Measure of Agreement KappaMeasure of Agreement Kappa
N of Valid CasesN of Valid Cases
0,9620,962
586586
0,0260,026 23,30023,300 0,0000,000
Reviewer2 Reviewer2 TotalTotal
ExcludedExcluded IncludedIncluded
Reviewer1 Reviewer1 ExcludedExcluded
IncludedIncluded
557 557
11
11
2727
550550
2828
TotalTotal 558 558 2828 586586
Analysing full textAnalysing full text
Interactive application usedInteractive application used Three types of interactive applications were more frequently used: Three types of interactive applications were more frequently used:
computer programs, video games, web-based education program.computer programs, video games, web-based education program.
0 1 2 3 4 5 6 7
GSM /SMS
home telephone
w eb based education programme
video game
computer programe
Inte
ract
ive
appl
icat
ion
Number of studies
Follow up timeFollow up time
0 5 10 15 20 25
Runge C, et al 2006
Lieberman DA, 2001
Huss K, 1991
Huss K, 2003
Ostojic V, 2005
Bartholomew LK, 2000
Rasmussen LM, 2004
McPherson AC, 2006
Ross Shegog, 2001
Homer C et al, 2000
Sundberg R, 2004
Guendelman S, 2002
Krishna S, 2003
Aut
hors
Months
Number of individuals of the population per study
0 50 100 150 200 250 300 350 400 450 500
Ostojic V, 2005
Lieberman DA, 2001
Huss K, 1991
Ross Shegog, 2001
Sundberg R, 2004
Huss K, 2003
McPherson AC, 2006
Guendelman S, 2002
Homer C et al, 2000
Bartholomew LK, 2000
Krishna S, 2003
Rasmussen LM, 2004
Runge C, et al 2006
Auth
ors
Number of individuals of the population
ArticleInteractive application
studied
lung function
asthma severity
physician consultations
Medicationhospital
admissionemergency
visits
school/work absence
self-manegement
asthma knowledge
quality of life
Runge C, et al 2006
Web-based education program
+
+
+ +
+
Rasmussen LM, 2004
Web-based education program
+
0 0
Ostojic V, 2005
GSM and SMS + +
McPherson AC, 2006
Computer program
+
+
Krishna S, 2003
Computer program
+ +
+ +
+
Huss K, 1991Computer program
+
+
Ross Shegog,
2001
Computer program
+
Homer C et al, 2000
Computer program
-
-
+
Sundberg R, 2004
Computer program
-
0
Lieberman DA, 2001
Video game + +
Bartholomew LK, 2000
Video game +
0 +
+
Huss K, 2003 Video game 0 -
0 0
Guendelman S, 2002
Program connected to a
home telephone - + +
+
+
-
0
Significantly improvement of the treatment group vs control group*
Significantly improvement of the control group* vs treatment group
Not significantly differences between the two groups
*The control group also have a paralell intervention (not interactive)
Summary of results of the studiesSummary of results of the studies
Only in one study the allocation of patients to Only in one study the allocation of patients to control and exposed groups was not random.control and exposed groups was not random.
Six of thirteen studies evaluated acquisition of Six of thirteen studies evaluated acquisition of asthma knowledge and five of this observed asthma knowledge and five of this observed better results on intervention group compared better results on intervention group compared with control group while one did not observed with control group while one did not observed significantly differences.significantly differences.
Ten out of the thirteen studies generally Ten out of the thirteen studies generally concluded that the outcomes of individuals using concluded that the outcomes of individuals using interactive applications were better than in interactive applications were better than in control groups.control groups.
DiscussionDiscussion
Interactive applications often achieve Interactive applications often achieve positive outcomes in the target populationspositive outcomes in the target populations
Computer programs is the type of Computer programs is the type of interactive application most investigated.interactive application most investigated.
Web-based programs are less studied but Web-based programs are less studied but have better results in most patients’ have better results in most patients’ outcomes.outcomes.
The results of other interactive The results of other interactive applications are inconsistent.applications are inconsistent.
DiscussionDiscussion
Computer programComputer program:: There is some heterogeneity in the results, but the There is some heterogeneity in the results, but the
majority of the cases lead to several majority of the cases lead to several improvements.improvements.
However, since some articles show that the control However, since some articles show that the control group had better results than the intervention group had better results than the intervention group, it is necessary to evaluate this intervention group, it is necessary to evaluate this intervention in more studies so as to lead to solid conclusions. in more studies so as to lead to solid conclusions.
DiscussionDiscussion
Video gameVideo game:: There are contradictory results, so more studies There are contradictory results, so more studies
about this method must be performed in order to about this method must be performed in order to have a better evaluation.have a better evaluation.
Web-based education program:Web-based education program: Although only two articles are currently available, Although only two articles are currently available,
significant improvements were observed in the significant improvements were observed in the target population.target population.
DiscussionDiscussion
GSM and SMS GSM and SMS :: More studies are necessary since the only article More studies are necessary since the only article
with this interactive method reported good results with this interactive method reported good results in pulmonary function and self-management.in pulmonary function and self-management.
Program connected to a home Program connected to a home telephone:telephone:
Only one article was found, moreover its results Only one article was found, moreover its results were not consistent, with improvements in were not consistent, with improvements in emergency visits, school absence and quality of emergency visits, school absence and quality of life but with negative results as for hospital life but with negative results as for hospital admissions.admissions.
DiscussionDiscussion In general, the outcomes with more considerable improvements In general, the outcomes with more considerable improvements
were knowledge about asthma, absenteeism and the need of were knowledge about asthma, absenteeism and the need of medication. medication.
This can be explained since these applications, by using methods This can be explained since these applications, by using methods like games that are more attractive to a young population, may like games that are more attractive to a young population, may allow them to learn more efficiently with this kind of approach.allow them to learn more efficiently with this kind of approach.
The adult’s population is not so open to these interactive The adult’s population is not so open to these interactive methods.methods.
On the contrary, as for the more practical results such as asthma On the contrary, as for the more practical results such as asthma severity, quality of life or even emergency visits, there is not, in severity, quality of life or even emergency visits, there is not, in general, a significant improvement. This may seem a paradox general, a significant improvement. This may seem a paradox since the theoretical knowledge has improved.since the theoretical knowledge has improved.
It was not possible to perform a It was not possible to perform a comparison among some studies comparison among some studies because there were articles that studied because there were articles that studied the same interactive aplications but the same interactive aplications but whose outcomes evaluated were whose outcomes evaluated were different.different.
It is also important to mention that some It is also important to mention that some of the articles that studied the effect of of the articles that studied the effect of computer programs had a time of computer programs had a time of intervention superior than others.intervention superior than others.
Limitations of our studyLimitations of our study
Limitations of our studyLimitations of our study
Relatively to the number of Relatively to the number of participantsparticipants::– there was a discrepancy among there was a discrepancy among
some studies and there was not a some studies and there was not a strong representation of the whole strong representation of the whole asthmatic population since 9 asthmatic population since 9 studies were about young children studies were about young children and only 4 about adults.and only 4 about adults.
Limitations of our studyLimitations of our study
Having in mind cited limitationsHaving in mind cited limitations
Is not possible at this time to Is not possible at this time to establish the usefulness of establish the usefulness of
interactive methods for education interactive methods for education and behaviour change of asthma and behaviour change of asthma
patients.patients.
ConclusionConclusion
The theme of this systematic review is a recent subject The theme of this systematic review is a recent subject and still has many limitations:and still has many limitations:
It is necessary to find ways of increasing adherence of It is necessary to find ways of increasing adherence of participants in the studies and, as interactive applications participants in the studies and, as interactive applications are widely used by younger people, this can affect the are widely used by younger people, this can affect the results when we compare studies with adults results when we compare studies with adults versusversus studies with children. studies with children.
The results from the articles included in this The results from the articles included in this systematic review are very diversesystematic review are very diverse
ConclusionConclusion The use of interactive applications seem to be promising The use of interactive applications seem to be promising
for improving patient education and promoting behaviour for improving patient education and promoting behaviour change, but more studies on the best options and on its change, but more studies on the best options and on its effects in asthma outcomes are necessary.effects in asthma outcomes are necessary.
Moreover, more studies about the use of interactive Moreover, more studies about the use of interactive applications that account for the specific needs of each applications that account for the specific needs of each individual could be the purpose of new studies. individual could be the purpose of new studies.
Asthma can severely affect the patients’ lives in different Asthma can severely affect the patients’ lives in different manners. In consequence, every effort maid with the aim manners. In consequence, every effort maid with the aim of improving patient education and promoting behaviour of improving patient education and promoting behaviour change (increasing self-management) is meaningful and change (increasing self-management) is meaningful and necessary. necessary.
GanttGantt ChartChart
Site MapSite Map
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AuthorsAuthors Almeida P, Caetano F, Carvalho A, Almeida P, Caetano F, Carvalho A,
Fernandes S, Gaspar J, Loureiro M, Fernandes S, Gaspar J, Loureiro M, Marques C, Neves N, Rollo A, Sousa Marques C, Neves N, Rollo A, Sousa C, Sousa C, Sousa S.C, Sousa C, Sousa S.
SupervisorsSupervisorsFonseca, MD, PhDFonseca, MD, PhD