Smartphone and tablet self‐management apps for asthma

Abstract

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the effectiveness, cost‐effectiveness and feasibility of using smartphone and tablet apps to facilitate the self‐management of individuals with asthma.

Background

Asthma is a common, chronic disorder of the airways characterised by paroxysmal and reversible obstruction of the airways in response to an inflammatory trigger (Van der Meer 2009). It is one of the most common chronic diseases worldwide, estimated to affect approximately 235 million individuals (WHO 2011). Historically prevalent in high‐income countries, it has increasingly become more common in low‐income countries; as a result, the global increase in prevalence of asthma has been estimated at 50% per decade (Braman 2006; Pearce 2000). This high burden of disease places significant pressure not only on health systems but also on patients and their families (Masoli 2004).The treatment of chronic asthma has traditionally followed a pharmacological approach. Inhaled bronchodilators form the main component of this approach and are complemented by anti‐inflammatory corticosteroids, leukotriene receptor antagonists and other drug classes in more severe cases of the condition (BTS‐SIGN 2011). Pharmacological treatment is usually delivered in a stepwise manner that aims to control symptoms, prevent acute asthma exacerbations and improve lung function (BTS‐SIGN 2011). Under a paternalistic framework however, this approach results more often than not in patients not being able to achieve good asthma control (Foster 2007; Wilson 2010).Recent developments in healthcare delivery have seen a gradual shift towards partnership models of care (Foster 2007). These models advocate self‐management programmes as a means to encourage the active engagement of patients in their own healthcare (Foster 2007). Self‐management programmes can increase a person’s self‐efficacy; for long‐term conditions requiring pharmacotherapy, increased self‐efficacy coupled with effective self‐monitoring strategies can lead to changes in health behaviours including better treatment adherence (Foster 2007; Wilson 2010). Self‐management programmes can thus help reduce the demand for, and increase the capacity of, health care resources whilst improving clinical outcomes for patients (BTS‐SIGN 2011). In the context of asthma, self‐management programmes have been associated with improved asthma control; improved asthma‐related quality of life; and a reduction in the number of unscheduled healthcare visits and hospital admissions (Partridge 2008; Powell 2009).

Clinical guidelines now recommend the inclusion of self‐management education in the routine management of patients with asthma (BTS‐SIGN 2011; Powell 2009). There is a certain degree of variability across different self‐management programmes, however, they all should cover structured asthma education, self‐monitoring of asthma symptoms or peak flow, regular medication review and written asthma action plans (BTS‐SIGN 2011; Partridge 2008; Powell 2009).

Despite the recommendations, implementation of self‐management programmes at a population‐level is still very poor (Partridge 2008). Even when implemented, patient adherence to self‐monitoring strategies and treatment recommendations is unsatisfactory (Kaya 2009; Lahdensuo 1999; Verschelden 1996; Weinstein 2005). The current state of affairs calls for innovative approaches to the implementation of self‐management programmes.

The rapid evolution of technology over the past few decades provides new opportunities for the design and delivery of self‐management initiatives (Charles 2007; Pinnock 2007). Of particular interest is the use of consumer mobile electronic devices (cMEDs) for these purposes, operating within a field that has come to be known as mHealth (Estrin 2010; Istepanian 2005).

The term cMED is reserved for consumer devices that are handheld, mobile, instant‐on, and general purpose (see Table 1). Smartphones (i.e. mobile phones with advanced computing and connectivity features) and tablet computers (i.e. general purpose computers contained in a single panel and usually operated through a touch screen) are amongst the most popular and widespread types of cMEDs (mHealth Alliance 2010). Over 70% of all contract phones sold in the UK in June 2010 were smartphones and 27% of British adults now claim to own one (Ofcom 2010; Ofcom 2011). In the United States, a report by the Pew Research Center revealed that approximately 35% of all adults own a smartphone (Smith 2011). Similarly, approximately 11% of American adults own a tablet computer (Mitchell 2011). Of all the mobile phones sold worldwide in 2010, approximately 22% were smartphones (mobiThinking 2011). As retail prices continue to decline, ownership of these devices is likely to continue to increase (Ofcom 2010).

Open in table viewer

Table 1. Criteria and definitions of a cMED
Handheld A single device with integrated display and input mechanisms that weighs less than 1 kg and measures less than 300 mm along its largest dimension
Mobile Operates wholly or substantially without requiring a physical connection to an external power source or other entity
General purpose Supports computing functions requiring arbitrary software code
Instant‐on Features are available for use immediately after turning the device on
Consumer Available for purchase, by buyers acting within a market, without modification other than to install specific software

Increasingly sophisticated computing features mean that both smartphones and tablet computers are capable of supporting self‐management functions. The combination of technical capabilities and broad coverage makes cMEDs ideal candidates to deliver these functions at a population‐level. Self‐management functions can be offered within software extensions that users add to their devices, popularised under the term ‘apps’ (short for applications).

Description of the intervention

Asthma health apps are software designed for cMEDs, such as smartphones and tablets, which aim to promote or support one or more asthma self‐management skills. These apps act as an optional add‐on to the device in its default interaction form with the user via a set of interfaces (e.g. visual user interface)

Health apps are best characterised as a medium with broad capabilities to communicate information, provide interactive experiences and collect information from patients. They provide a platform for the delivery of self‐management interventions that are highly customisable, low cost and easily accessible.

How the intervention might work

Apps can potentially overcome some of the major limitations of traditional methods of delivering asthma self‐management education, thus facilitating and improving the delivery of such education. Due to the wide uptake of mobile phone technology around the world, health apps can reach a significantly larger proportion of the population (in this particular case, of individuals with asthma). Furthermore, the majority of individuals tend to always carry their mobile phones with them and tend to have them always on. Therefore, asthma self‐management apps could make these interventions more accessible and convenient, and thus facilitate adherence. Electronic diary functions may support monitoring of symptoms, lung function, or both and alert an individual about deterioration of their condition, prompting them to seek timely care. Reminders linked to an electronic diary could help address non‐adherence caused by forgetfulness.

Health apps would allow the presentation of educational material through a variety of multimedia modalities. Additionally, the user may be able to customise the content of educational material according to their learning needs. This feature could also make structured education more accessible for illiterate patients or those with certain learning disabilities (e.g. dyslexia).

Smartphone and tablet apps currently support the collection and immediate transfer of real‐time data. For those who implement this capability, the transfer to a healthcare provider of personal health data recorded on a smartphone or a tablet computer might simplify the regular medical reviews. These data could potentially provide an objective measure of asthma severity and a more approximate indicator of patient adherence.

In low‐income settings, the use of health apps for the self‐management of asthma could potentially help to overcome some of the barriers to reducing the burden of asthma, such as poor infrastructure, poor access to care, distance from healthcare facilities and illiteracy (Masoli 2004).

Adverse effects of the intervention

Poor usability and technical difficulties with a mobile health app, or the hardware on which it operates, may negate the efficacy of a self‐management intervention and negatively affect health outcomes. Despite their popularity, certain smartphone or tablet apps may fail to adhere to evidence‐based recommendations, which might question their utility as a supplement to asthma treatment.

Smartphone and/or tablet adoption is usually associated with particular socio‐demographic groups. In the United States of America, for example, higher than average levels of smartphone adoption are seen amongst the wealthy and well‐educated; individuals younger than 45 years; and urban and suburban residents (Smith 2011). Therefore, the use of health apps to support asthma self‐management might result in the exclusion of important sectors of the population.

Why it is important to do this review

There is a large body of literature supporting the beneficial effect of self‐management education on defined outcomes in individuals with asthma (Boyd 2009; Gibson 2008; Gibson 2009; Tapp 2007; Welsh 2011; Wolf 2008). The majority of systematic reviews in this field however, have preceded the widespread adoption of health apps to support asthma self‐management practices. As a result, the use of apps to support the implementation of asthma self‐management strategies has not yet been explored in a systematic review. Instead, other technologies have been considered in these systematic reviews. For example, Bussey‐Smith 2007 and Sanders 2006 assessed the effectiveness of computer‐based asthma self‐management programmes. More recently, McLean 2010 conducted a systematic review to evaluate the effectiveness of a number of different technologies supporting the delivery of asthma care, including the Internet, telephone, videoconferencing, text messages and other networked systems.

Apps for asthma have the potential to reach a considerable proportion of the population, make self‐management interventions more accessible and convenient, and improve patient adherence. A review of this technology is therefore warranted in order to address the current gap in knowledge and to tease out the potential benefits (or harmful effects) of health apps in asthma self‐management.